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Inside the January/February 2003 print edition of Canadian Healthcare Technology:


Feature Report: Developments in diagnostic imaging


Canada’s DI departments, universities, give birth to new technologies

Hospitals, universities and government think-tanks have made remarkable contributions to DI.

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Imaging technique combines U/S and endoscopy

York Central Hospital in Richmond Hill, Ont., is among the first in Canada to offer endoscopic ultrasound to patients.

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Ontario to launch patient safety and waiting-list projects

Ontario’s Hospital e-Health Council announced plans for two province-wide projects that will dramatically enhance the quality of care received by the public.

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E-procurement

Five hospital groups, consisting of 21 hospitals, have now signed on to the Canadian Health Marketplace (CHM). The burst of activity comes after a 12-month test run at the Lakeridge Healthcare Corp., a five-hospital alliance in Ontario.


Assessing telehealth

The Edmonton-based Capital Health Authority has developed a new business-case template to evaluate the viability of clinical telehealth projects. It measures both medical merits and financial soundness of proposals.

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U.S. docs take to handhelds

A new study finds that 72 percent of U.S. physician offices have at least one doctor using a handheld computer for clinical purposes. Most employ the devices for portable drug reference.


Small town, big PACS

Dr. Harry Nath, radiologist at the hospital in Peace River, Alberta, has led the creation of a sophisticated PACS implementation that ties together images from CT, digital fluoroscopy, CR, and ultrasound. Hospitals of all sizes can learn from his example.


PLUS news stories, analysis, and features and more.

 

Canada’s DI departments, universities, give birth to new technologies

By Andy Shaw

Diagnostic imaging, since its early X-ray days, has had a remarkable impact on medicine – enabling physicians to diagnose diseases more effectively and thereby hastening treatments. But better imaging doesn’t show up all by itself. Extensive investment, research, and development are needed. So is testing and commercialization. This process is by no means easy nor does it happen overnight.

So how does it happen?

Often in Canada, the investment comes from government, the research from hospital-connected universities, and the development usually involves partnership with a private sector company.

Interestingly enough, a fair bit of this is happening in Canada when it comes to diagnostic imaging. Indeed, the country has a long and distinguished history of innovation in this area. Let’s look at some recent developments in DI, and how Canadian hospitals, universities and research institutes are generating technologies and companies.

“There might be as many as 25 companies that spring up in a year, but they’re like fruit flies, hard to see, and most die off quickly,” says Dr. Ian Smith, Director General of the Institute for Biodiagnostics (IBD) in Winnipeg.

The IBD, a National Research Council spin-off itself, has taken a different tack from the universities and in its 10 years of existence, the IBD has spun off five diagnostic imaging companies that are in business today. We’ll have more to say about Dr. Smith and the IBD’s innovative approach later. But beforehand, let’s take a look at how two successful diagnostic imaging companies were spun-off by hospitals in Montreal and Toronto.

The imaging systems now being sold by Intelerad Medical Systems Inc., in Montreal, and Merge eFilm in Toronto, grew first from research and development done on filmless Picture Archiving and Communication Systems between 1995 and 1999 by a team at the Montreal General Hospital, one of several McGill University teaching hospitals.

With backgrounds not only in medical imaging but also physics, computer systems, image-guided surgical planning, as well as electrical and biomedical engineering, Intelerad’s founders had all the necessary backgrounds to be imaging innovators.

Chris Henri, now the executive vice president and an Intelerad founder, explains:

“In 1995 I was working as a physicist in the department of diagnostic radiology at McGill, where the chief radiologist was Dr. Patrice Bret. When a computer systems administrator left our department, I was delegated the task of finding his replacement and ended up hiring a very talented computer engineer from McGill named Robert Cox.

“We hit it off very well, and one of the things we became involved in was trying to get an ultrasound mini-PACS, which had been purchased before we arrived, off the ground and working. It had never really worked. But we had at our disposal some software from the medical physics unit that had been developed by researchers for viewing images on Macintosh computers. In a very short period of time we were able to enhance this software and demonstrate to Dr. Bret that it could do, basically, what the commercial system was supposed to do. He was very excited about that and immediately launched a clinical trial. Within two months, the Radiology department was operating and managing the ultrasound images completely digitally.

“So without really intending to, we had become PACS developers. About six months later, we were asked if we could do the same for CT and MRI. We realized that the software we had patched together for the Macintosh ultrasound PACS would not hold up for those two, so we started looking and landed on Linux.

“We went with Linux at the time because it was free and we really didn’t have a budget for developing PACS. It ran on PC hardware, which was much less expensive than something like a Sun server,” says Henri. “Linux was also very flexible and it had the ability to mimic some Macintosh capabilities. That was important because back then, our diagnostic imaging department was entirely Macintosh-based.

“We used Linux and some public-domain software to re-develop our server architecture for acquiring, storing, archiving, and retrieving images. And by February of 1997 the department had gone live, filmless in CT and MRI. We literally ripped out all the laser cameras that were used to print film. So there was no turning back.

“But eventually we got to the point where the hospital administration said that the hospitals are in the business of providing healthcare, and not operating a research and development shop, so they couldn’t afford to grow our group anymore. They said that they were grateful for the work we had done and wanted us to simply maintain it. They, in fact, encouraged us to step outside of the hospital and form a company that would allow us to continue our development efforts and grow through commercial sales. And they assured us that they would be our first client.”

Thus was born Intelerad.

In the meantime, Dr. Bret had been attracted by the University Health Network (UHN) in Toronto to become its chief radiologist – and had expressed the desire to build a similar team at the UHN that would share the Montreal software and continue PACS software development. Dr. Bret’s first hire for the Toronto group was Gregory Couch, PhD. He spent his first month on the job in Montreal picking the brains of Henri and his colleagues.

“Gregory then developed what was the missing piece of the puzzle,” says Henri. “Partly by putting it on the Internet for other developers to add to, he developed an application called eFilm that was darn near as good as anything you could get commercially, but it was for free, and you didn’t need to buy a six-figure workstation to run it. He really shook the foundations of the imaging world with that.”

For more than a year, the development groups in Montreal and Toronto tried to form a single business entity in order to bring their systems to market. But by February of 2000 they agreed to go their separate ways. Since then, a Milwaukee-based company has bought control of the Toronto interests, with Couch serving as Merge eFilm’s chief technology officer working out of the company’s Toronto office.

Now, Intelerad and Merge eFilm are in effect PACS competitors. But they remain friendly. Intelerad even distributes the eFilm software.

“We have slightly different strengths,” says Henri. “Intelerad’s strengths are definitely in the technical back end for handling archiving and distribution. And we’re focused on 24-hour-a day support.”

On the other hand, Merge eFilm developers have produced what they regard as a quantum leap in the flexibility, scalability, and workflow capacity of a PACS system at the front end. The company’s Fusion Server 1.0 is a single software platform that minimizes the hardware needed while delivering clinical quality PACS, as well as teleradiology and Web distribution. It readily integrates databases and image storage with a whole range of overriding HIS applications. As such, the company says its software is a stepping-stone to both a filmless environment and a fully electronic patient record.

For its part, Intelerad’s IntelePACS is a highly scalable, fault-tolerant system that works on PCs or workstations running Linux and that conforms with the DICOM 3.0 standard. But more importantly to its developers, it is affordable.

Somewhat like “buying” certain cell phones, you don’t pay for the tangible IntelePACS product. In effect, it’s free. What you pay for, besides the off-the-shelf hardware needed, is Intelerad’s standard support package for the first year. It includes round-the-clock remote technical support, daily system watch-dogging by Intelerad’s proprietary InteleMonitor system, any software updates, and follow-up onsite visits after installation.

Intelerad’s current client list of over 20 hospitals and other users spans three continents and stretches from the Perth Radiological Clinic on Australia’s west coast, to Radiology Imaging Associates in Denver, Colo., St. Paul’s Hospital in Vancouver, the University Health Network and Mount Sinai Hospital in Toronto, the McGill University Health Centre and the Centre Hospitalier de l’Université de Montréal (CHUM) and on over to the Ernest Müller Research Institute in Bern, Switzerland.

Meanwhile, in Manitoba, there’s an alternative approach to diagnostic spin-offs that’s also in the picture. At the Institute for Biodiagnostics (IBD) in Winnipeg, they’re spinning off companies based on research in four core areas: magnetic resonance imaging, spectroscopy, physiology, and bioinformatics. The stated goal of the National Research Council (NRC)-backed IBD is to develop non-invasive diagnostic instruments and techniques that can be commercialized. IBD is not associated directly with any university or hospital.

IBD’s best known spin-offs sound like a trio of space aliens: Novadaq, IMRIS, and MRV. Scientists and programmers at IBD spent three years developing the cardiac imaging system now commercialized by Novadaq Technologies Inc. Novadaq’s SPY(tm) Imaging System enables cardiac surgeons to check the outcomes of coronary artery bypass procedures on the fly. SPY can instantly spot kinks or twists restricting blood flow in new artery grafts. SPY is awaiting FDA approval in the United States but is already on sale in Canada and Europe .

Similarly, IBD researchers conceived the original design for the patented IMRIS inter-operative magnetic resonance imaging system made for neurosurgeons. The IMRIS magnet at the heart of the system can move repeatedly over the patient and then retract to allow surgeons unrestricted access to the patient. Brain surgeons are currently using an IMRIS system at the Foothills Hospital in Calgary.

The magnetic resonance technology used by MRV Systems is specifically designed for use on our four-footed friends. Winnipeg veterinarian Dr. Gordon Goodridge triggered IBD interest in developing an affordable MRI to meet the strong demand for veterinary diagnostic imaging.

Traditionally, the cost of owning MRI equipment and being trained in its use has been too high for veterinary clinics and hospitals. So they have had to negotiate with regular hospitals for after-hour access to MRI or use lower resolution X-ray and ultrasound systems.

Nonetheless, the estimated North American spending on pet examinations, pregnancy testing of livestock, and soundness evaluation of race horses is nearly $700 million annually. To exploit this major market, MRV has on trial in Saskatoon a mobile veterinary MRI that is about a tenth the cost of a fit-for-humans model.

IBD’s ability to spin-off new companies received a further boost last year when the NRC announced a $10 million contribution as part of its nation-wide innovation program. The money will help finance a new Industrial Partnership Facility (IFP). To be built alongside the IBD building, the IFP will be a small business incubator for IBD diagnostic spin-offs and other start-ups. The entrepreneurs of those fledgling companies will be able to draw on and work alongside IBD’s top medical technology researchers.

Smith believes the dedicated nature of the IBD is more productive in creating spin-off companies than either the hospital/university or big company environments.

He says university researchers are focused mostly on their individual career paths and getting them to collaborate on research is challenging at the best of times, never mind getting them to go all the way and form a new company. And the large-scale market leaders in diagnostic imaging keep their focus on the large scale.

“These guys are not interested in one-offs, two-offs, three-offs or even 10-offs. They’re interested in 1000s-off. They can’t make money unless they have a large volume,” says Smith. “But the real breakthroughs are made by the small companies like ours doing one- to three-offs. Then when they have demonstrated that it works in a hospital or two, they sell it to a Siemens or a GE, who say we didn’t want to invest in it before because it was too risky. But now that you have shown that it works, we want to buy it off you.”

Smith says there are exceptions out there to his rule of thumb, citing the development work being done at Sunnybrook Hospital in Toronto and the spin-offs created by the Robarts Institute in London, connected with the University of Western Ontario.

“I would rank Robarts right behind us” says Smith.

As to other sources in future for spinoffs, here’s one hitherto off-the-beaten-track spot to watch: Saskatoon. For two reasons: first, it is the site of the soon to be operational synchrotron at Canadian Light Source Inc. And, in case you have to ask, a synchrotron is an accelerator that spins atomic bits about the circumference of a 400-metre loop and is used for a wide variety of research.

Among its talents, the synchrotron can spin-off and focus the X-ray end of the light spectrum with unequalled clarity and brilliance.

The other reason to keep an eye on the place is the outfit’s newly appointed president.

In a remarkable recruiting coup, Dr. Bill Tomlinson was snared from the European Synchrotron Radiation Facility in Grenoble, France, where he was head of the medical research group. During earlier research in his distinguished career, Dr. Tomlinson helped invent and patent a diffraction-enhanced imaging technique.

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York Central among first in Canada to use endoscopic ultrasound

By Jerry Zeidenberg

RICHMOND HILL, ONT. – A gastroenterologist trained at the Mayo Clinic in Minnesota is now using endoscopic ultrasound technology at York Central Hospital, in Richmond Hill, Ont., to more accurately diagnose lesions found in the GI tracts of patients.

The technology also enables the physician to gauge how far cancers have developed, and to determine the best course of therapy for patients.

“It’s an excellent way of identifying cancers and other illnesses – quickly, accurately, and in a non-invasive manner,” said Dr. Pardeep Nijhawan, who recently completed a five-year residency and research fellowship at the Mayo Clinic, specializing in gastroenterology.

While EUS is used in many medical centers in the U.S., York Central Hospital is one of the first facilities in Canada to employ the technology. Like other forms of diagnostic imaging, it may become a standard practice across the country as word of its effectiveness spreads.

For his part, Dr. Nijhawan is thrilled that his hospital is able to offer the advanced technique to patients. “It’s nice to see that a community hospital can take the lead in introducing this to Canada,” he said.

Endoscopic ultrasound (EUS) works by attaching an ultrasound probe to the tip of a narrow catheter, which is carefully guided through the digestive system of the patient. The ultrasound device not only creates images of structures on the surface of the GI tract, but also identifies problems in the walls of the stomach, duodenum and intestines.

Moreover, it can be used to image nearby structures, such as major blood vessels, the pancreas, liver, gallbladder and lymph nodes.

“Endoscopic ultrasound can tell us what type of lesions we’re dealing with, even if they are submucosal (beneath the surface layer),” said Dr. Nijhawan, who has been using the technology to diagnose patients at the hospital since August, after the hospital acquired a $220,000 EUS system in July.

He said endoscopic ultrasound is most useful for patients who have had a regular endoscopy, during which a lesion was found. An EUS can help the specialist determine the nature of the mass without the need for exploratory surgery.

“It can tell us if it’s a benign or malignant cancer, a pool of blood vessels or even a fat collection,” explained Dr. Nijhawan. In each of these cases, the images will appear differently on the computer screen, which the physician watches as he or she performs the procedure. “It’s a matter of pattern recognition,” noted Dr. Nijhawan.

The technology is also extremely useful for cancer staging, he said. “If you can look at the lesion using ultrasound, and you see that it’s in an advanced stage, you might decide that extensive surgery is unnecessary for the patient.”

For example, in cases of advanced esophageal cancer, removal of a large part of the esophagus could be more traumatic to the patient than foregoing the surgery and allowing the person to live out his remaining days, months or years with the ability to eat and drink relatively normally.

Dr. Nijhawan predicts that enhancements to EUS technology will appear in the near future, such as narrower catheters, making it easier for the patient to swallow and reducing the risk of tearing the GI tract. As well, he foresees developments in the area of fine needle aspirants – the devices that allow physicians to take tissue biopsies while they are conducting the endoscopic ultrasound. All in all, Dr. Nijhawan says endoscopic ultrasound is an extremely useful technology: “It’s an excellent method of determining what’s going on inside the GI tract, and for making an accurate diagnosis.”

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Ontario to launch patient safety and waiting-list projects

By Jerry Zeidenberg

TORONTO – Ontario’s Hospital e-Health Council announced plans for two province-wide projects that will dramatically enhance the quality of care received by the public – a medication safety system and a waiting-list management network for cancer patients.

In addition to providing solutions to these pressing problems, the projects should also raise general awareness of information technology and computerized networks as an effective method of improving the delivery of healthcare services.

If the success of the two projects can generate greater public support for e-health, council members believe the stage will be set for additional IT solutions that will boost the quality of care in Ontario.

A recent Ipsos-Reid poll conducted in conjunction with the Ontario Hospital Association found that Ontarians rate under-funding, staff shortages and waiting lists as the most urgent healthcare problems today.

“These were the top concerns, not information technology,” commented Tom Closson, CEO of the Toronto Hospital and chair of the Hospital e-Health Council. Mr. Closson presented the results of the survey and also outlined the council’s future direction at the recent OHA annual convention, held in Toronto last November.

“Most members of the public have no idea of what e-health is,” said Mr. Closson. However, he pointed out that, “80 percent respond positively when e-health is explained to them.”

Mr. Closson noted that concepts like unique patient identifiers, privacy legislation and even electronic medical records have little meaning for the public – unlike the need for more nurses or additional MRI machines.

“It’s hard to sell the public on unique patient identifiers,” said Mr. Closson. “It’s not an exciting issue.”

However, instead of pleading with consumers to support various technical components of e-health, council members say it makes more sense to demonstrate concrete cases of how e-health can solve real world problems – such as medication errors and waiting lists.

When it comes to medication error, the Hospital e-Health Council plans to give physicians – and at a later date, patients – access to databases containing drug histories about Ontario’s citizens. Mr. Closson noted that it’s already being done in British Columbia and Alberta, and said there’s no reason why it couldn’t be accomplished in Ontario.

“The government has all kinds of drug records for seniors that aren’t being made use of, from agencies like the Ontario Drug Benefits Program,” he said. “They’re currently not available to ERs or anybody else.”

The ODBP tracks drug usage by seniors, a group that accounts for 38 percent of all prescription drug expenditures in the province. Seniors are also major users of hospital emergency departments.

Mr. Closson noted that such records could be extremely useful to doctors treating patients in hospital ERs. Quick access to their drug histories – especially in the evening, when most family practices are closed – would help emergency physicians to make faster, more accurate diagnoses and start treatments sooner.

They could do this with less risk of triggering an adverse drug event if they can determine which medications the patient has been taking – information that could be supplied by databases.

Sam Marafioti, vice chair of the Ontario Hospital e-Health Council, and vice president of e-Health at Sunnybrook & Women’s College Health Sciences Centre, said in an interview that it won’t be difficult to get the patient safety system up and running, as most of the components are already in place. It’s now an issue of tying them all together.

He explained that the system will make use of the Systems for Smart Health secure data network, which has now been connected to approximately 90 percent of the province’s 155 hospitals. Moreover, the ODBP database will likely be moved over to the SSH data warehouse.

“It’s a matter of using the resources that we have in place,” said Mr. Marafioti. “Little funding is required, and it could be done in months.”

The e-Health Council hopes the project will be up and running in 2003, and is currently awaiting approval from the Ontario Ministry of Health and Long-Term Care.

On the waiting list front, the Hospital e-Health Council intends to work with Cancer Care Ontario (now headed by former Toronto Hospital CEO Dr. Alan Hudson) to build province-wide registries with electronic access.

The system will show patients and doctors the backlog for cancer-care services at hospitals across the province. It will also identify openings for care at various hospitals – facilities where patients could be directed for faster treatment.

Physicians with long waits for treatment in Toronto, for example, may discover that greater capacity exists in Kingston or Hamilton, and could request service in these other centres.

But a good deal of work needs to be done in building master patient indexes and data repositories. “We currently have no idea in this province of how long people are waiting for cancer surgery,” said Mr. Closson. “We do know that in our organization (the University Health Network, consisting of the Toronto Hospital, Toronto Western Hospital and the Princess Margaret Hospital), the wait has increased from 38 days to 56 days in the last year.”

An electronic network for waiting lists could greatly improve the workings of the provincial cancer care system, he observed.

The proposed waiting-list management solution would also make use of the Systems for Smart Health secure network, connecting hospitals to Cancer Care Ontario. It would include hospital laboratories, which conduct cancer pathology testing and help determine staging strategies for physicians.

Once developed, a waiting-list management system for cancer could also serve as a model for waiting lists and referrals in other areas, said Mr. Marafioti. “A secure, network-based system for cancer care could serve as a foundation and provide a tool set for many disease states, including cardiac care, dialysis, orthopedics, and others,” he commented.

The Hospital e-Health Council is now one of several such councils that operate under the umbrella of the Ontario e-Health Council. The latter organization is chaired by Lorelle Taylor, chief information officer at the Ontario Ministry of Health and Long-Term Care.

There are other e-health councils for physicians and community care.

For its part, the Hospital e-Health Council has identified six key issues, and has established working groups for each of them:

• The need for a common, unique patient identifier for all Ontarians. Mr. Closson noted that Ontario Hospital Insurance Plan numbers won’t do the job, as many Ontarians don’t have an OHIP card.

• Privacy and security legislation from the provincial government, the lack of which is holding back some institutions from going forward with computerized solutions to healthcare problems.

• Province-wide electronic patient records. EPRs could provide major benefits to both patients and care-providers. They offer an accurate account of medical encounters, drug histories, tests and allergies, and can be quickly sent to the various facilities visited by patients. Doctors can make decisions more promptly, and patients can start treatments faster.

• E-Pharmacy networks that connect hospitals with pharmacies, delivering the drug histories of patients. Such networks can help reduce the incidence of adverse drug interactions. Said Closson: “Many provinces have it, and I’m puzzled why Ontario doesn’t.”

• Building and expanding telehealth. Systems like Ontario’s North Network, which connect specialists in facilities like Sunnybrook and Women’s College Health Sciences Centre with physicians in northern Ontario, can help bring expertise in dermatology, psychiatry, ER medicine and other specialties to rural areas.

• Waiting list management systems.

Mr. Closson commented that the two projects being launched by the council – patient safety and waiting list management for cancer – involve many of these priorities.

Survey: When e-health was explained to them, members of the public responded favourably to the idea of electronic patient records (EPRs), e-pharmacy systems, waiting list management systems and expanding telehealth.

The Ipsos-Reid researchers polled 800 Ontarians about these issues in September 2002. “Electronic patient records, of the four areas, has the greatest priority with the people of Ontario,” said Mr. Closson. He noted that 69 percent of the respondents agreed that EPRs would have a somewhat better or much better effect on their own personal health. It was explained that an EPR meant that their records could be moved easily from place to place, including emergency rooms, giving doctors more information. This in turn leads to faster, more accurate diagnoses and earlier treatments.

Some 60 percent to 70 percent of respondents thought that telehealth initiatives would lead to real improvements in healthcare delivery. Mr. Closson said that e-pharmacy and e-waiting list management scored high, as well.

“I haven’t seen a consumer survey of this type before,” said Mr. Closson. “It suggests that it’s not the public that is holding us back. We’re holding ourselves back,” he asserted to an audience of hospital managers.

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Capital Health Authority applies rigorous assessment to telehealth

By Jerry Zeidenberg

The Edmonton-based Capital Health Authority is using a new business case template to assess the viability of clinical telehealth projects. It makes sure that projects not only justify the clinical merits of a telehealth solution, but that all of the costs are accounted for – something that’s been overlooked quite often by telehealth enthusiasts in the past.

“We’re starting to receive applications for telehealth projects from all parts of the integrated health region,” commented Joseph Gebran, Regional Director of Telehealth and Simulation at Capital Health, and leader of the team that put the template together. “We thought we should have a structured way of looking at applications to experience the best possible success on each project.”

Gebran noted that often enough, groups get fired up with a telehealth solution that does appear to solve a clinical or administrative problem. But they often underestimate the true costs.

For example, capital costs for a project might be quite low to get a project off the ground in its first year. But if equipment upgrades are required in subsequent years, to keep up with current technology, the ongoing costs can become quite high.

And in many cases, a vendor will contribute a limited amount of equipment for free to help launch a pilot project. But to expand further can require major expenditures.

To create the telehealth business case template, he and the other team members researched how technology projects are assessed around the world. They adapted the findings to the particular needs of Capital Health.

Gebran noted that new telehealth projects in the region must be approved by a telehealth steering committee, which is made up of 26 members from different parts of the integrated health region.

So far, two new projects have been approved using the new method, and six others are under consideration. The programs that got the green light use telehealth to connect caregivers at a major Alberta referral center to others at rural hospitals and clinics for renal care follow-up and lung-cancer triage and follow-up.
Quite naturally, the Capital Health telehealth business case template requires applicants to state the goals of their project, and how it will provide benefits.

But it also asks how the project’s results will be measured on an ongoing basis.

“If you’re not clear at the beginning about how you’re going to evaluate your program, you’ll scramble at the end to do it,” commented Gebran. “And when that happens, the quality of the evaluation is usually poor. It’s much better if you work out a plan beforehand.

“We want to make sure that people are thinking about how to assess their program right from the start.”

The template also requires that a telehealth project have a champion – someone who is willing to act as the main representative of the project, and is able to drive the initiative forward. The champion is also the prime problem-solver, a person who is ready and willing to put in the extra hours to make sure that people, technology and processes all work together in the way they should.

Among other factors, the template covers topics such as the effect of the project on stakeholders, policies and procedures affected, logistics that must be addressed to implement the solution (i.e. space, equipment, training), project risks, costs, performance indicators, innovation and sustainability.

Gebran commented that telehealth is in a state of change, with new technologies coming to the fore. There are more desktop solutions, which bring videoconferencing and the use of instruments to the workplace of the doctor, nurse or administrator. In the past, cart-based telehealth equipment was the standard.

 

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