The trials and tribulations of a middle-aged PACS consultant,
father, and garage sale junkie as he engages in his
never-ending search for sanity in an insane world.

Tuesday, September 14, 2010

I'm Incensed!

Those who know me know there are a lot of things that incense me. At the top of the list are women with entitlement issues, one that is so prevalent in my age group it rankles the mind. That is also one of the primary reasons I remain single nine years post-divorce. Don’t get me wrong, I’m met some very interesting people along the way but the “You’re lucky to have me” and “I deserve only the very best and will settle for nothing less” attitudes I just can’t deal with. It’s about having an anti-narcissistic attitude, living life instead as it comes instead of expecting life to take care of you along the way.

Included in my long and varied list of things that incenses me are people who refuse to accept responsibility for their actions. This is something I have drummed into my kids time and again. It’s not bad to make a mistake- if anything it’s good, especially if you learn from it- but above all you need to accept responsibility for your actions.

I’ve been dealing in PACS for nearly three decades now and have seen and heard it all. In three decades I can count on one hand the number of times a vendor has said “It’s our fault, we accept responsibility for it, and we will make it right. “ In contrast, I need two hands to count the number of times I have said that in the past month alone. Maybe I’m just more screwed up than everyone else, but hey, at least I acknowledge it.

Standards, or a lack thereof, are responsible for most of the serious issues we face in PACS today. Yes, we have DICOM, HL-7, and now IHE, not to mention the ACR Standards and others but is adherence to them mandatory? No. Are there penalties that are enforceable if these “standards” aren’t followed? No. Do I blame the vendors? No. True, few vendors will try and get around saying they support the “standards” but the level of adherence varies widely. Everyone says they support DICOM, but whereas Baskin Robbins has (or at least had) a mere 31 flavors, DICOM has 31,000 flavors that can be embraced all that require a conformance statement to interpret just how they support it.

So why am I getting on my high horse again? I just faced this with “make it work” situation yet again in trying to establish a vendor neutral archive (VNA) for one of my clients. I asked two major vendors the same exact question and both came back with nearly the same answer- we can’t do it but hey, it’s not our fault. Yes, we have proprietary software. Yes, it will be a while before we open up our kimono to others. But then everyone does it so….. And oh yeah it’s not our fault…there is no requirement that dictates we had to do this so we didn’t. And you know what? They are right.

I thought implementing a VNA would be a fairly simple, straightforward task. Wrong…The vendors say “We want to do this- we really do- but it’s not our fault we can’t” The latest rationale I was given as to why a vendor couldn’t share what they call “our data” (but really belongs to the customers) is that “until the IHE makes some headway with the MIMA (Multiple Image Manager/Archive), these issues will be very real world challenges that limit interoperability.” O.K., I fully understand it now- it’s not your fault, it’s IHE’s fault.

But IF the IHE DID make headway with MIMA (which sounds like something your kids would call their grandmother, by the way) and you didn’t follow the guideline (not a standard) then whose fault would it be then? IHE’s? Nope. The vendors? Nope. Huh? Once again vendors have no legal requirement to follow standards because no one enforces standards.

What about moral and ethical requirements? Please don’t go there. The vendors will claim buyers don’t have to buy a system from a vendor who doesn’t support standards but then frankly the truth is we wouldn’t be buying ANYTHING now because to date there isn’t a single ^*&(%#$ vendor in the market who supports VNA standards. Why? Well for one it’s because no true standards for VNA’s exist and even if they did there is nothing enforcing their use. This will change by RSNA with a few pending announcements from a few progressive companies but still…it’s sad that we have gotten to this sorry state…

Rarely will a vendor ever admit it’s their fault even if it clearly is. But in this case it’s not their fault. It’s everyone’s fault and no one’s fault. We all share the blame. When “standards” like DICOM, HL-7 and IHE were developed we thought they had to be adhered to. Never in our wildest dreams did we imagine support of them they would be made optional or that there be so many ways to both support it and not support it at the same time. We never demanded that standards be developed. Instead we allowed them to be developed by the same wolves that guarded the henhouse. And don’t hand me that bull that we had to make the standards open or no one would support it. Someone should have stood up like my father did 35 years ago when I wanted to come in at 3 a.m. and he wanted me home by 1. “My house, my rules”. Guess what? I was home by 1. Thirty five years later I too have turned into my father as well saying the same thing to my own kids. Guess what? They follow the rules…and dad is up above smiling at me too…

We trusted. No, we weren’t lied to, we just weren’t told the entire story. Mom used to say a lie by omission is still a lie but…but what if we didn’t know what to ask? It’s like that guy on Real TV- “Are you on parole?” No.” “We just ran your profile- you are on probation. Why did you lie to us?” “You asked if I was on parole, not probation.” It’s a matter of semantics. “Do you support IHE?” “Yes.” “Do you follow the IHE protocols for...?” “Well, um…..”The answer no doubt can and will be completely different.

So what now? We require. We demand. We add contract language that very specifically states what we want and need- in no uncertain terms. Fred Astaire died in 1987 so unless you are Singing in the Rain please save the tap dancing for somewhere else… Nebulous words like could, would, and should, need to be replaced with can, will, and does. Timelines are established with significant penalties for not meeting them. And nothing, but nothing, proprietary can or will ever be used in the system design.

We have trusted too long and been hurt by our trusting ways. It’s time we took back the night.


  1. Well we've just had a modality upgrade (One of the biggest vendorS) that resulted in the modality unilaterally redefining a DICOM field from type 1C to type 1 in MWL transactions & the engineer quite happy to say "well we didn't require it before. We do now!".

    What is needed is a central, open and independent database of DICOM inconsistencies in a form (and language) that is accessible by people making decisions.

    As for VNA? We need a definition first. I'm still not sure exactly specifically _what problem_ VNAs are intended to address.

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  3. set up a T-Party: Call it an F-Party for "Follow" the standard, "Full" compliance, or F'd up if not interoperable.

    You can be a male Sarah Palin for this party.

  4. Remember the line from Animal House about trusting....

  5. I suppose (and realize I'm a babe in the woods), that vendors what to do more than the standard specifies. So the solution is to have vendor specific fields. I'm not disagreeing with anything said here though; the basics really need to be there. But vendors should have the option of having vendor-specific features, knowing that these features are by definition not compatible with other vendors. Little things though, not big stuff that will completely break a pacs system.