Inside the January/February 2003 print edition of Canadian
Feature Report: Developments in diagnostic imaging
departments, universities, give birth to new technologies
Hospitals, universities and government think-tanks
have made remarkable contributions to DI.
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
Ontario to launch patient safety and waiting-list projects
Ontarios Hospital e-Health Council announced
plans for two province-wide projects that will dramatically enhance
the quality of care received by the public.
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.
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.
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
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.
Canadas DI departments, universities, give birth to
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 doesnt 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.
Lets 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 theyre 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. Well have more to say about
Dr. Smith and the IBDs innovative approach later. But beforehand,
lets 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
With backgrounds not only in medical imaging but also physics,
computer systems, image-guided surgical planning, as well as
electrical and biomedical engineering, Intelerads founders
had all the necessary backgrounds to be imaging innovators.
Chris Henri, now the executive vice president and an Intelerad
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 didnt 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 couldnt
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. Brets 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 didnt 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 eFilms chief technology officer working out of
the companys Toronto office.
Now, Intelerad and Merge eFilm are in effect PACS competitors.
But they remain friendly. Intelerad even distributes the eFilm
We have slightly different strengths, says Henri.
Intelerads strengths are definitely in the technical
back end for handling archiving and distribution. And were
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
companys 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, Intelerads 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 dont
pay for the tangible IntelePACS product. In effect, its
free. What you pay for, besides the off-the-shelf hardware needed,
is Intelerads standard support package for the first year.
It includes round-the-clock remote technical support, daily system
watch-dogging by Intelerads proprietary InteleMonitor system,
any software updates, and follow-up onsite visits after installation.
Intelerads current client list of over 20 hospitals and
other users spans three continents and stretches from the Perth
Radiological Clinic on Australias west coast, to Radiology
Imaging Associates in Denver, Colo., St. Pauls Hospital
in Vancouver, the University Health Network and Mount Sinai Hospital
in Toronto, the McGill University Health Centre and the Centre
Hospitalier de lUniversité de Montréal (CHUM)
and on over to the Ernest Müller Research Institute in Bern,
Meanwhile, in Manitoba, theres an alternative approach
to diagnostic spin-offs thats also in the picture. At the
Institute for Biodiagnostics (IBD) in Winnipeg, theyre
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.
IBDs 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. Novadaqs 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
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
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.
IBDs 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 IBDs top medical technology
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. Theyre interested in 1000s-off. They cant
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 didnt 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, heres 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
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 outfits
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.
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
The technology also enables the physician to gauge how far cancers
have developed, and to determine the best course of therapy for
Its 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
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
For his part, Dr. Nijhawan is thrilled that his hospital is able
to offer the advanced technique to patients. Its
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
Endoscopic ultrasound can tell us what type of lesions
were 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 its 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. Its 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 its 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: Its an excellent
method of determining whats going on inside the GI tract,
and for making an accurate diagnosis.
Ontario to launch patient safety and waiting-list projects
By Jerry Zeidenberg
TORONTO Ontarios 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
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 councils 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.
Its hard to sell the public on unique patient identifiers,
said Mr. Closson. Its 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
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 Ontarios
citizens. Mr. Closson noted that its already being done
in British Columbia and Alberta, and said theres no reason
why it couldnt be accomplished in Ontario.
The government has all kinds of drug records for seniors
that arent being made use of, from agencies like the Ontario
Drug Benefits Program, he said. Theyre 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
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 & Womens
College Health Sciences Centre, said in an interview that it
wont be difficult to get the patient safety system up and
running, as most of the components are already in place. Its
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 provinces 155 hospitals.
Moreover, the ODBP database will likely be moved over to the
SSH data warehouse.
Its 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
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 wont do the job, as many Ontarians dont
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 Im puzzled why
Building and expanding telehealth. Systems like Ontarios
North Network, which connect specialists in facilities like Sunnybrook
and Womens 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
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
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 havent seen a consumer survey of this type before,
said Mr. Closson. It suggests that its not the public
that is holding us back. Were holding ourselves back,
he asserted to an audience of hospital managers.
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
thats been overlooked quite often by telehealth enthusiasts
in the past.
Were 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
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 projects results will be measured
on an ongoing basis.
If youre not clear at the beginning about how youre
going to evaluate your program, youll scramble at the end
to do it, commented Gebran. And when that happens,
the quality of the evaluation is usually poor. Its 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
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.