Monthly Archives: November 2007

Overseas Reading

There was quite a flutter of conversation this year at RSNA over having Indian radiologists pre-read  studies and having those findings delivered to a US radiologist. Dalai has a post about it. In general almost everyone that I have talked to is completely opposed to overseas reading from radiologists. It will not shock some of my readers to learn that I am not.

So when I was a researcher we conducted numerous reader studies under controlled conditions. For those of you not familiar when researching the impact of new technologies or methodologies on the accuracy of radiologist findings we display carefully selected cases in a controlled manner. There is a specific task such as identify the cervical spine fractures. There is a set of normal cases with no pathology included in the dataset. The process is extremely onerous and tedious. However you get quantifiable data on the radiologists accuracy. So what’s good accuracy? I would say above 80% and the radiologist is quite good. Very few people will cross the 90% barrier.

Now to determine what a good US radiologists accuracy should be obviously you would need a much larger study. But lets for the sake of argument say that the average radiologist is correct 75% of the time. What if an Indian radiologist could show that he was also correct 75% of the time. Why should he not be allowed to read?

A potentially much more valuable but much, much harder to obtain metric would be tying the findings and recommendations of a radiologist to patient outcomes. This is much harder to prove since patient care is a very complicated animal with many players all of whom get to make decisions that may conflict with one another. I just feel that I have to mention this since this would be a truer measure of quality than simply accuracy.

So where does that leave us? Will this happen? No. It would not matter if the Indian radiologist was right 90% of the time over a large number of studies. The ACR would simply say that they were not US trained and could not be as good as American radiologists. As an across the board statement that is most probably true. However I do consider it to be unprovable since I don’t know where the data would come from. If someone else wants to contest that view please do so.

It turns out that it is easy to say that the Indian radiologist would do a bad job. It sounds true to main street America. And more importantly it helps people feel good, which it turns out is more important than being right.

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Why scalability should concern you when you are small

Scalability is a topic often ignored by small companies. We will get to it later. We don’t have enough traffic. We don’t have the time or resources. Well that’s all well and good until something happens. Maybe that something is you becoming successful. Now your service is in demand. Your database is being pounded. Adding web servers isn’t a problem but getting them data is. Your database server thrashes in agony. And then you get upset. How could this happen? We bought big beefy machines from Dell. We paid a lot of money for them.

Engineering scalability does matter. You don’t need to have all the hardware you need to stay up when TechCrunch links to you. I would even say just having your developers model what they would do is good thing. Then at least you have a plan that has been tested. You know what you will do as traffic increases. People who know me have heard me talk about playbooks. I don’t always advocate doing exactly what your playbook says but I strongly recommend having one since it gives you a place to start. Think of it like a business plan. You won’t follow your business plan exactly but it gives you a place to start.

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Update on Emageon

I blogged about Emageon recently. Their third quarter was less than stellar. I continue to believe that the mid sized PACS companies will have a difficult time in todays market. They have very little to differentiate them from the major players other than they are smaller. I reiterate that I do believe that the quants are wrong and the fact that these companies have departed from the mean is a sign of a difficult market for them, not because the stock is undervalued. Anyone else have thoughts on this?

Check out the institutional holdings for Emageon.

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