A radiologist’s wish list for 2016

Eric Postal, MD

With all the changes occurring in the PACS administrator’s environment this past year, PARCA eNews decided to take a lighter approach to the final Q&A of 2015. We thought we’d talk to Eric Postal, MD, a practicing radiologist, to see what may be on his wish list for 2016. Dr. Postal is a board-certified radiologist at Virtual Radiologic (vRad), based in Eden Prairie, Minnesota. vRad is a leading national teleradiology services and telemedicine company with over 350 U.S. board-certified and eligible physicians, 75 percent of whom are subspecialty trained. vRad interprets and processes patient imaging studies on the world’s largest and most advanced teleradiology PACS for more than 2,100 client hospital, health system and radiology group facilities in all 50 states. Dr. Postal has more than 15 years of experience in academic, hospital and private practice settings. He writes a blog from a radiologist’s perspective for DiagnosticImaging.com.

Q. In a recent blog post, you talked about the frustrations of DICOM viewers that fall far short of being universal viewers. Would a truly universal DICOM viewer be on your wish list for 2016?

A. Since I wrote that column, someone helpfully posted comments about a viewer called Osirix. It was the first I'd heard of something available to the public, but unfortunately, it is not for PCs. But that did inspire me to search around and find a PC-friendly DICOM viewer (it’s called RadiAnt) that I was able to download and use. It was a happy day for this radiologist – worlds better than the one included on the CD I'd been sent that I referenced in my post. 

Q. What other devices or tools would you like to see from a PACS system that would make your work easier?

A. Let me take the opposite tack first. Before coming on board with vRad back in 2011, I worked in a couple of different hospital radiology departments and a couple of private practices. Spending extra money on their software was not a routine practice in those places; the thinking was generally to spend as little as they could. I was accustomed to working with zero bells and whistles, and it was a good day when it didn't crash. 

Coming on board with vRad was a dramatic change. They have built what is now the largest PACS in the world that is continually being invested in, upgraded, and modified in response to what its radiologists find useful. So there were things I encountered with vRad’s PACS that were pleasantly surprising. I am still actually mystified these sorts of things that we use every day aren't being widely used in all practices. 

For instance, one that leaps to mind immediately is vRad’s second input device that works alongside the mouse. Anywhere I had been prior to vRad, you'd have one hand on the mouse and the other ready to use the keyboard with whatever keyboard shortcuts there were. vRad has modified a device originally designed for video games when vRad acquired it from the original manufacturer. They called it the “Grip.” 

Essentially you have the mouse in your right hand, and your left hand fits on this grip that has indentations for your fingers with at least one button, sometimes more than one for each finger. You more than double the number of controls you have over the screen without reaching out for the keyboard and looking for which button to press or dragging down menus. Much like on a mouse, the buttons on the Grip are mappable, so you can readily customize it to the way you work. 

vRad has a philosophy that the more time radiologists can spend with their eyes on the images, rather than looking at the keyboard or a menu, the more time they are doing what radiologists should be doing – being doctors and interpreting images for the referring physicians and patients who are eagerly awaiting their reports. Optimizing the amount of time I spend looking at the images means I can work faster and more accurately.

The Grip is part of the standard bundle of equipment that all vRad radiologists receive, along with the hi-res monitors and a keyboard – it is just standard equipment for getting the job done. And as you might imagine these things get quite a bit of use, so when they begin to wear out, vRad is quick to send out replacements.

Q. You mentioned PACS software at previous places you work, is there something you’d wish for from PACS vendors?

A. I've been in radiology for 15 plus years, and I have yet to meet any radiologists who have been approached by anybody in the PACS industry saying, “We have some software that we'd be interested in hearing your take on,” or on the preprogramming level, “what would you like to see in a piece of software,” or for that matter, “here's a beta version, would you be interested in looking at some sample cases and telling us what you think our strength and weaknesses are?”

The only people who seem to be approached are the senior partners, department chairs, or other folks who are in a position to make purchases or give serious recommendations to the powers that be. That is understandable, of course, since that's where the money is coming from, so that is where the industry looks. But the problem is the further up the chain of command you go, the less those people are actually in the trenches reading lots of studies. So they are going to be further and further removed from knowing what the people reading the studies are going to find useful or relevant.

Q. What about ergonomics, is there anything you’d wish for in terms of greater comfort in a workstation?

A. That is one thing you would get feedback on if the industry reached out to radiologists. As I said before, the key to getting good useable feedback would be to have a broad base of different types of radiologists. You want to have academicians, private-practice radiologists, and you definitely would want to have teleradiologists because they read more cases than anyone—it is a growing field of radiology. 

You also want different subspecialties—musculoskeletal, neuro, pediatrics – because they literally look at things differently. What a pediatric radiologist wants to see in a workstation is a going to be different from what a neuroradiologist wants. And if you have a broad base of feedback, you get a lot of people commenting on the ergonomics, as well as what is in the software and how customizable it is. 

As I mentioned, vRad’s Grip is very customizable. There are lots of toolbars at the top of the screen you can move around or minimize if you don't use them. So I think reaching out more to radiologists who are doing the actual work will provide a great amount of information. As a matter of fact, vendors would find themselves in a triage situation, and they would need to ask themselves “what are we going to act on first here?”

Q. Any wishes in terms of workflow?

A. Workflow feeds into another issue we spoke about earlier. At vRad I've got three screens, two strictly for PACS purposes and the third is for the RIS, which gives me all the non-image related stuff along with communication channels with vRad’s Operations Center in Minnesota. So if I have a critical finding, I need to get a referring physician on the phone right away. vRad built its software suite on radiologists’ needs, which includes improving efficiency. So I can push a single button that immediately sets off a chain reaction of events, and the next thing you hear is your virtual phone ringing with that referring physician on the line. Again, it’s about spending more time being a doctor and less time on all the administrative interruptions that can distract from patient care.

Q. Are there any wishes regarding passwords?

A. There absolutely is. One blog I wrote a few months ago was about my first computer-programming class back in high school. It was amusing to me, then, that the teacher had a pocket-sized notebook for all his passwords, and I thought, come on, how hard can it be to remember a password? Fast forward a couple of decades and, what do you know, I have a pocket-sized notebook of my own. 

Everyone has a different set of rules about what is a legitimate password, how frequently you have to change it and even how you change it. So even if all of your passwords were the same initially, they migrate over time and suddenly you have a notebook full of them. 

When I started at vRad, one welcomed peripheral was a fingerprint scanner. You couldn't use it for everything, but it did save you a fair amount of time. Unfortunately, some software didn't play nicely with the fingerprint scanner so it went away, but I really hope it comes back some day.

Q. What about integration, is there something you’d like to see in terms of reading imaging from multiple institutions?

A. That is an ongoing challenge. At vRad, there is a lot that goes on behind the scenes that I don't see, but you've got hospitals all over the country that have different types of equipment and software behind it – and there are different local regulations. Every now and then you have something new and complex such as ICD-10 documentation requirements – and one hospital is adapting well and another one isn’t. vRad spent a lot of time and work to minimize those differences by standardizing imaging ordering data to the new 70,000 ICD-10 codes across all of its 2,100 client facilities. As an example, different institutions will call the same study by different names, or one will send a scan with contrast, while another will send the exact same study but call it “with or without contrast.”

Q. So you’d like to see more standardization?

A. Absolutely, but I understand it is a little like herding cats. vRad's approach is to have as much built into its own platform and software, so instead of having all these outside entities speaking different languages at the radiologist, it is all boiled down and standardized. It is sort of like merging lanes on a highway, so that by the time it gets within your own system it is all one. 

For example, let’s say you have ten different order types for a head CT scan that all mean the same thing. vRad's order management system is always looking for ways to streamline things to have them run smoother.

(updated 12-8-2015)