Thursday, August 28, 2008

Is the winter of discontent with CDs finally upon us ?

It is not news that I have been whining about systems that produce non-DICOM and non-PDI compliant CDs for a long time now. Yet some folks continue to believe that it is acceptable for vendors and sites to create proprietary CDs with proprietary viewers on board, despite the fact that these offer no advantage over standard CDs. I am often criticized for harping on this subject to the exclusion of all others (most recently in response to a comment on Sam's blog), but I make no apologies about it, since I believe it is indeed the primary interoperability issue facing the digital imaging community at the present time.

Well, those of us who have been focusing on the radiology-centric aspects of this mess have now been joined in battle by the community of physicians out there in the real world who have been struggling to deal with this nonsense.

The American Medical Association, as a consequence of complaints initiated by the American Association of Neurological Surgeons with respect to viewing MRIs, has produced a report from their board of trustees that resulted in a resolution with respect to "Development of Standards for MRI Equipment and Interpretation to Improve Patient Safety". Note that the discontent being expressed by the AMA is not confined to neurosurgeons, but involves everyone who receives CDs. Further, the emphasis is on safety, specifically, if media is unreadable or unusable or takes to long to use, then the safety of the patient may be at risk. This activity has been going on for several years, though few people outside of the groups involved have been aware of it.

Yesterday, I attended an interesting meeting in DC at the AMA office, which involved many of the stakeholders mentioned in the resolution, including vendor representatives from MITA (NEMA) as well as the ACR. Those referring physicians present made it abundantly clear that swift, dramatic and effective action by industry and by radiology facilities is expected without delay, and that delay will result in engagement of the regulators and the legislators.

During the course of that meeting we came to the consensus that emphasis would be placed on establishing that the standard of care will be compliance with the IHE PDI specification, and in the absence of any explicit enforcement mechanism, promulgating this as an AMA principle may suffice. Woe betide anyone who then expects to get paid for producing non-compliant CDs (since payers might not pay for less than the standard of care when they become aware of the issue), or who expects to prevail in the civil courts in the event of a negligence action caused by an unfortunate outcome from inability to read a CD.

The other outcome of the meeting was acceptance of the goal of defining a set of minimal functional requirements for a "simple viewer" that would set the lower bounds on what such a viewer would do (and to some extent, how it would do it). An IHE effort, with evaluation of compliance performed by users (not radiologists or engineers) was proposed as the mechanism to implement this.

There was debate, but not consensus, about actually standardizing aspects of the user interface, including what icons should be used and what they should look like. Though this may seem impractical, given the installed base and the investment by each vendor in their own look and feel, the matter arises because physicians faced with a completely unknown and unexpected interface have great difficulty figuring out how to make a viewer perform even basic tasks. This problem needs to be solved somehow.

Regardless, the writing is on the wall for proprietary media, and vendors who create it, or permit their users to create it, and sites that provide it. Let them all be "in the deep bosom of the ocean buried".



joeyb said...

Welcome words, David.

Stephan said...

Hi David,

here in Germany, the German Radiological Society launched a Media Exchange Certification Project.

Based on the PDI (with some extensions), a catalog of criterias has been consented. Vendors can get a certificate for their CDs to show they create "good" media.

More info here:

Best regards,


Carlão said...

Hi David. I trust that DICOM is concise and smart and is the right standard for medicine but what about the definition of a default viewer in the standard for every modality?
By definition I mean how buttons are placed, which functions they have, even in sketch.

:) Best Regards!

David Clunie said...

Hi Carlão

Ask and ye shall receive:

IHE Basic Image Review Profile