Inside the September 2003 print edition of Canadian
Feature Report: Internet and connectivity trends
Canada Health Infoway
begins a new round of funding
To kick off its third round of investments,
the Canada Health Infoway has partnered with organizations constructing
region-wide Picture Archiving and Communication Systems (PACS)
in Southwestern Ontario and British Columbia.
An $8 million pilot project in Trois-Rivieres
and Shawinigan is enabling physicians and other healthcare professionals
to quickly access lab, diagnostic imaging and medication information
about patients on browser-like systems.
The Interior Health Authoritys integration
of 19 different business systems into a unified entity involved
an investment of $3.2 million but has led to annual savings of
In a large-scale project spread across many
U.S. states, insurance companies have been compensating physicians
for delivering healthcare to patients using the Web. The project
has benefits for patients, doctors and payors.
Ultrasound technology has rapidly improved
in recent years, delivering better imaging quality and enhanced
features. The size of the machines has also decreased, enabling
technologists such as John Peacock to fly into remote communities
to provide U/S services.
PLUS news stories, analysis, and features and more.
Canada Health Infoway begins a new round of funding
By Jerry Zeidenberg
TORONTO To kick off its third round
of investments, the Canada Health Infoway has partnered with
organizations constructing region-wide Picture Archiving and
Communication Systems (PACS) in Southwestern Ontario and British
The investments are of an undisclosed size details are
still being worked out and the final contributions to the projects
will likely be announced this fall.
The projects are part of Infoways latest wave of partnerships
that will see the agency invest $135 million in a total of nine
diagnostic imaging and pharmaceutical systems.
The two regions that won funding the Thames Valley group
of hospitals in Southwestern Ontario and the Fraser Health Authority
in British Columbia are seen as prototypes for shared
services projects that can bring the benefits of electronic
medical images across wide geographical areas.
Theyre also seen as purveyors of cooperative governance
structures that could be replicated in other regions of Canada.
For its part, Infoway would like to see the creation of a pan-Canadian
system of interoperable health records in five to seven years.
The network, as envisioned, will connect various types of healthcare
providers, including hospitals, physicians and continuing-care
centres. And if all goes according to plan, the system would
consist of various components, such as medication histories,
lab reports and diagnostic imaging results.
Infoway has so far been funded with $1.1 billion by the federal
government. Its using the money to seed the growth of electronic
health-record projects that show great potential for improving
patient care and whose methods could be transferred to other
sites across the country.
Regarding the planned investments in Southwestern Ontario and
British Columbias Fraser Health Authority, These
are optimal places for us to help put diagnostic imaging networks
in place, said Myrna Francis, interim president and CEO
of the Canada Health Infoway.
Theyve already had experience with a shared services
model, theyre widely dispersed geographically, and theyve
got large enough populations to adequately test the systems and
produce meaningful results.
Theyve also had a good deal of experience with change
management, and they both have physician leadership thats
supportive of the projects.
Ms. Francis explained that Infoway favours geographically large
projects as a way of extending the benefits of electronic systems
which to date have largely been concentrated in large,
urban hospitals to medical centres across the country.
PACS in particular is quite an expensive technology,
she said. Yet, most of this country is comprised of small
hospitals. A shared services approach allows you to bring the
technology and all of its benefits into the smaller centres.
She noted that with hospitals assembled into shared services
organizations, the overall cost of the systems can be reduced,
as well, much in the way that a buying group can obtain steep
She agreed that technology is only one component of an IT project,
and that the human factors support, training and change
management are critical to the success of any implementation.
If the technology goes in, and people arent using it for
one reason or another, the project can hardly be deemed a success.
Thats why 20 percent of the amount contributed by Infoway
will be dedicated to areas such as change management and knowledge
Ms. Francis said that a good deal of on-going assessment and
monitoring has been built into the business plans of the projects,
to ensure that the networks meet their expectations at each step
of the way and that taxpayers money has been invested
She stressed that the funding is gated, meaning that
project managers must meet certain agreed-to targets such
as end-user adoption and impact on care in order to receive
the next tranche of funding. We dont want a situation
where the systems are implemented and no one is using them,
For its part, the Southwestern Ontario group of hospitals
which includes London Health Sciences Centre and St. Josephs
Health Care in London will link eight hospitals into a
PACS network over the next 18 months. Its preliminary plan anticipated
an investment of $35 million, but part of the funding includes
updated modalities such as digital x-ray systems
for some of the hospitals.
Thats because getting full benefits out of a computerized
network for diagnostic images means that hospitals must be able
to quickly send digital images. Older equipment in some locations
still relies on film.
Its yet to be decided how much of the investment will be
contributed by Infoway, but in any case, the project can be considered
a large-scale investment in digital imaging systems. Its
also slated to get even bigger, as the plans call for extending
the shared service to a total of 22 regional hospitals in a subsequent
phase, noted Diane Beattie, vice president and chief information
officer for LHSC and St. Joes.
On first glance, the most difficult part of a project of this
size might appear to be coordinating the partners especially
in Ontario, which hasnt regionalized its hospitals
into formal groups or health authorities. As a result, provincial
hospitals in some cases guard their independence.
However, Ms. Beattie observed that in the case of the eight hospitals
launching the PACS network, the CEOs had already decided to cooperate
on a wide variety of issues and meet monthly as the Thames Valley
group of hospitals.
When working together in groups, small hospitals are always
worried that the big hospitals will dominate, but at the same
time, the larger hospitals are wary of the small centres
they worry that they will bear the total cost and responsibility
to establish systems across the continuum of care.
She said that the Thames Valley hospitals have been working on
procedures that make all parties comfortable. Were
developing a mutual understanding and lessons that can be passed
on to others, she said.
Ms. Beattie is a member of the Thames executive coordinating
committee, and notes that it already had plans in place to create
common IT platforms before winning the Infoway funding. Diagnostic
imaging is just the start of where we want to go, she said.
Were planning common platforms in business and clinical
She noted that cooperation and technology transfer has already
worked between London Health Sciences Centre and St. Josephs
Health Care, London. Recently, LHSC established its PowerChart
results viewer for lab and radiology at St. Josephs
Acute Care site. We put 1,200 new users onto the system
at St. Joes, in addition to more than 8,000 who are using
it at LHSC, she said. It was all done in four months,
even with the SARS crisis in full force, and the project still
went through smoothly.
Now, said Ms. Beattie, the technology transfer will flow the
other way. St. Josephs has been using a PACS, and the know-how
gained with it will be transferred to LHSC and the other partners.
She pointed out that the Thames Valley hospitals already have
a secure, high-speed network called LARGnet that can be used
to transmit radiological studies, along with other files. When
the PACS is expanded further to reach an additional 14 hospitals,
the plan is to use the government of Ontarios Smart Systems
for Health network.
At the Fraser Health Authority, in British Columbia, there was
agreement among executives and staff at the 12 hospitals that
a region-wide PACS was the way to go. Were well past
the stage of trying to convince people that PACS is a good thing,
said Bill Dow, administrative director, medical imaging. People
here know that we need it from clerical staff to senior
radiologists. Theyre totally excited about it happening.
Mr. Dow noted that theres also a good deal of support from
physicians in many departments such as emergency and family
physicians. For these doctors, images will be available much
faster in the emergency department, and reports will be accessible
more quickly for general practitioners.
For its part, the Fraser Health Authority which conducts
some 600,000 diagnostic imaging exams a year is seeking
to implement a PACS as cost effectively as possible, while striving
for the best quality obtainable. To do this, its making
Web technologies a big part of the solution.
RIGIC project allows quick access to a variety of patient
By Jerry Zeidenberg
TROIS-RIVIERES, QUE. Few healthcare
professionals would turn down the chance to access patient lab
results, radiology reports and medication information from a
single computer workstation. Especially if the data could be
reached quickly and easily using the point-and-click techniques
of a browser.
It would mean that instead of waiting for paper reports that
often take hours or even days to arrive, doctors could rapidly
obtain the information they need to order the next round of tests
or therapies for their patients.
While many hospitals and health regions are talking about implementing
this kind of integrated system that provides fast-access to various
types of computerized information, the Centre hospitalier regionale
de Trois-Rivieres now has a solution up and running.
About 50 physicians, nurses and other professionals in the oncology
department have been using the system to reach lab, diagnostic
imaging and medication information about their patients on a
browser-like system. Doctors can also order lab tests. In the
future, they hope to add radiology tests and medication orders
to the system, as well.
At the moment, its mainly available in oncology,
but it could easily be expanded to the rest of the hospital,
said Dr. Christian Carrier, chief of hematology/oncology service
and a director of the information technology project. Cardiologists,
internists, family physicians and others are all asking for access.
Called the Clinical Portal, the $8 million pilot project was
developed by the hospitals in Trois-Rivieres and Shawinigan,
in partnership with MediSolution Inc., with the involvement of
the Regie Regionale de la Mauricie et du Centre du Québec
and with partial backing from Health Canadas CHIPP
the Canada Health Infostructure Partnerships Program.
Using the portal, oncologists in Trois-Rivieres can access patient
information from any point in their two-campus hospital, and
also from the Centre-de-la-Mauricie in Shawinigan. Dr. Carrier
says the system could easily be expanded so that clinicians at
area hospitals in Athabaska and Drummondville have access, too.
Systems could be connected using Quebecs high-speed network,
the RTSS, which currently links all of the provinces hospitals.
For its part, MediSolution had a team of 50 persons working on
the project at its peak, commented Diane Bouchard, vice president.
That figure is currently at about 20. The company installed its
MediVisit regional master patient scheduling product, and MediResult,
an order entry and results information application, and did a
great deal of integration with existing systems.
We worked closely with staff at the hospital, who also
have a great deal of expertise in computer technology,
said Ms. Bouchard. She noted that as part of the project, 17
new servers were added and 38 interfaces were created between
The integration project in Trois-Rivieres and Shawinigan is formally
known as RIGIC short for Reseau Integre de Gestion des
Informations Cliniques. It was officially begun in the fall of
2002, and runs until the end of 2003. A process of evaluation
will then be completed, and the project managers are optimistic
they will be able to launch a second phase.
A key feature for the users, stressed Dr. Carrier, is ease of
use. While doctors and nurses can tap into lab results, radiology
reports and other systems, they dont have to know how to
operate these particular applications.
I dont have to learn the RIS (Radiological Information
System) or the laboratory information system, noted Dr.
Carrier. I can get all of the information just by using
If the RIGIC project gets the go-ahead for an additional phase,
Dr. Carrier said the management team would like to add access
to diagnostic images to the mix, to complement the text-based
radiology reports that are currently available. This would involve
a tie-in to the Picture Archiving and Communication System (PACS).
In addition, the team would like to build drug orders into the
This is a natural application for us, said Dr. Carrier.
When youre doing chemotherapy, youre using
drugs that are complicated, costly and dangerous if you make
mistakes. If you use computers, you can become more efficient.
Dr. Carrier noted that RIGIC makes use of a patient registry
thats an important part of the system: It ensures
that the right data always goes with the right patient.
He added that security has been a major concern in the development
of the system. We pay rigorous attention to all the confidentiality
issues. We use a double identification system, with user name
and PIN, and all accesses are journalised.
Dr. Carrier said that along with physicians and other healthcare
professionals, patients have also given RIGIC the thumbs
up: Patients feel safer when they see that their physician
can guide the decisions regarding their healthcare with all the
Interior Health reaps the rewards of a large-scale I.T. implementation
By Tara Wyllie
In a climate where the reins on spending are
pulled tight, the task of embarking on a large, healthcare I.T.
initiative can be fraught with risk management issues.
That challenge faced the Interior Health Authority, when five
health regions and 14 health councils with 19 different business
systems needed to operate as a single organization.
Following a sound project management methodology and using a
common sense, business-case approach, Interior Health has proven
its I.T. expenditure to be a worthwhile investment.
The need for integration became critical as the I.T. department
tackled the variances within this new organization. The solution
was to integrate 19 different business systems and over 100 non-integrated
financial applications into one, while providing internal control,
a consolidated financial statement, and standardization for consumable
products and business processes.
This enterprise-wide system needed to meet the operational and
information needs of financial services, purchasing, logistics
and facilities planning and involve accounts payable, e-mail,
fixed assets, general ledger, materials management and payroll
Pat Ryan, chief information officer and Mal Griffin, director,
applications & information development for Interior Health
spearheaded this project. Keenly aware that many IT projects
are typically over budget and behind schedule, they realized
that this initiative required enterprise-wide support and accountability.
Their business objectives were clear; invest $3.2 million into
a 14-month project and deliver $4.3 million in annual savings
back to the organization.
They applied project management methodology (PMM) stressing communication,
efficiency, teamwork, and issue resolution throughout the process.
Many of the team members came to the project as representatives
of their specific program areas. Mal Griffin handled the business
of aligning the expectations and contributions from each of these
Project accountability was established by a governing steering
committee which reported to the executive sponsor, Chris Mazurkewich,
chief operating officer, strategic & corporate services.
The steering committee included managers, directors and key executives
from integral departments including: accounting services, purchasing,
logistics & facilities development, purchasing & capital
planning, information & technology, accounts payable and
This committee met bi-weekly to review project progress. Project
progress reports were prepared monthly and distributed to the
project teams, steering committee, directors of business support
and the executive sponsor. Quarterly project updates were distributed
and presented to the board finance committee.
The project was organized by business area (e.g., accounts payable,
e-mail, payroll, inventory, etc.) with each assigned a business
That business manager then assembled a project team (technical/applications
and training specialists) who were responsible for implementation
and training of their respective project area. These teams met
weekly and sometimes daily through the duration of project planning
and execution. Communications, targeted to executives, facility
administrators, managers and staff were frequent and focused.
The project objectives were SMART (specific, measurable, attainable,
realistic and timely) and documented before the project was initiated.
Changes to the scope of the project were reviewed and approved
by the steering committee only when absolutely necessary and
critical to the success of the project. Costs were controlled
and overruns prevented through ongoing reviews by the initiative
project manager, Mal Griffin.
Griffin combined this project management approach with key software
vendor partnerships to accomplish project objectives (The partners
included Meditech, Microsoft and Total Care Technologies.) The
total project investment was $3.2 million and was completed $0.5
million under budget.
The execution of this project was virtually seamless and the
result is a single business system that now generates permanent
annual savings of $4.3 million which can now be redirected to
direct patient care.
This integration has resulted in cost and time savings and efficiency
improvements, for example: pay statements are now distributed
to more than 13,000 employees using confidential e-mail, management
reports are distributed to more than 1,200 managers using internal
e-mail, 106 pre-existing bank accounts have been effectively
closed and now operate out of one. Interior Health has also benefited
from this implementation with improved organizational effectiveness
and customer service to its employees and departments.
The Interior Health Integrated Business Systems Implementation
demonstrates that large IT projects can be completed successfully,
on time, on budget, and providing direct benefits that reach
across the entire organization.
The key, says Ryan, is having great people, applying practical,
common sense approaches and working hard to ensure I.T. alignment
with all levels of the organization. What were really doing
is laying a foundation for business intelligence to support the
organization as a whole.
Interior Health certainly seems to have accomplished this. The
business system inventory now includes accounts payable, e-mail,
general ledger, materials management, fixed assets, payroll and
staff scheduling. Accounts receivable, human resources and data
repository are the only remaining elements to be integrated into
Project leader Griffin says, Our business systems implementation
was an enormous task. We were successful because we had executive
commitment, healthy vendor partnerships and the expertise of
our internal partners. We went to work and built a smart and
practical solution that boasts savings of $4.3 million annually.
These savings are now being applied to direct patient care. Our
launch was ahead of schedule and executed seamlessly.
More information about Interior Health is available at
Tara Wyllie is an independent consultant based in
Westbank, B.C., specializing in marketing and web content management.
Ultrasound machines ever-smaller, offering higher resolution
and more features
By Andy Shaw
Greater mobility and sharper resolution
theyre two trends in ultrasound that have been constantly
improving since the technology first emerged in the 1970s from
under the hulls of ships for submarine detection and were deployed
as effective tools for diagnostic imaging.
Since then, few have lived with those trends as closely as John
Peacock. For nearly nine years now, Peacock, an independent ultrasound
technologist who is based in Sioux Lookout, Ont., has been servicing
the diagnostic imaging needs of 18 fly-in only communities in
the wilds of northern Ontario. As many as three times a week,
every week, rain or shine or snow, Peacock grabs his SonoSite
180Plus portable ultrasound machine and jumps into a small airplane.
In single hops as short as 15 minutes and as long as an hour-and-a-half,
he wings his way to work in remote community nursing stations
that are as far flung as Fort Severn near the shores of Hudsons
Its the only program of its kind that I know of in
the country, says Peacock, who first came north for only
a three-month assignment not long after graduating as a sonographer
from Mohawk College in Hamilton, Ont.
The radiologist at the time in Sioux Lookout was from McMaster
University, and he had worked in Nicaragua and Africa. He was
a man with a conscience, says Peacock. He had started
doing x-rays in the fly-in communities where they were badly
needed, but he thought it would be much more useful if we could
get an ultrasound program going for them. So, he was looking
for someone who had some training in high-risk obstetrics, and
of course, he was also looking for an ultrasound machine small
enough to fit in an airplane.
He found both in Peacock and the now venerable Hitachi 405.
So we began with the Hitachi, which was a fine machine
for its day, says Peacock. But since then mobile
systems have been getting much smaller and much better. Back
then, no mobile machine had spectral Doppler, or colour Doppler,
or tissue harmonics, or directional M-mode capabilities because
the software to run them just didnt exist. Now it does,
so now they do.
Those new capabilities means Peacock can do a much wider range
of work than when he first started out.
I was originally brought up here only to do obstetric ultras.
And that made sense since the birth rate in the communities I
serve is about two-and-a-half-times the national average. But
now I can do much, much more, says Peacock who is also
trained to do gynecological, abdominal, and neurological examinations.
Wider still are the range of ultrasound uses these days in the
largely urban setting of Ontarios golden triangle. There
Dr. Alex Hartman is chief radiologist for RDS Diagnostics Ltd.,
a company that runs community diagnostic imaging centres stretching
from the towns of Markham in the east to Cambridge in the west,
with a lot of Toronto in between.
Dr. Hartman is an expert in the recent trend of using injected
substances to enhance the sharpness of detail in an ultrasound
image. But he is struck most by the built-in capabilities and
diminishing size of todays most advanced machines.
Its worth a quick review of the basic function of
an ultrasound machine to appreciate how far they have come,
says Dr. Hartman. In simple terms, sound is sent out from
a transducer usually embedded in a handheld device. It goes into
the body and is reflected off different types of tissues at different
speeds. Judging from those speeds, the machines built-in
computer has a way of figuring out the depth and composition
of what was hit and thus can differentiate between different
types of tissue.
As the sophistication of the software inside the ultrasound computer
has grown, so too has the resolution of the machine.
The machines can convey incredible resolution nowadays,
says Dr. Hartman, to the point where if there is something
in there as small as one fiftieth of a millimetre, I can probably
see it. Things are now that good.
Even the simplest of todays ultrasound machines are good
for another reason: they capture images in two directions.
Essentially, an ultrasound, like some other modalities,
takes pencil-thin cross-section images of whatever the transducer
is aimed it. But that is all along one plane. Standard machines
today also take another image along another plane at 90 degrees
to the first. These are todays two dimensional or 2D machines.
The two images taken at right angles enable the trained viewer
to get a sense of the three-dimensional shape of a soft tissue
object by combining the two in their minds eye. Now 3D
machines have come along in the last year or so to remove the
inevitable inaccuracies of that mental gymnastic.
As electronics have miniaturized, the number of transducers in
the business end of an ultrasound machine has risen from one
in the early days to as many as one thousand today. That many
more sonic ears in a 3D ultrasound enables the machine to assemble
more sophisticated pictures.
In 3D machines, the software inside builds a three-dimensional
model, explains Dr. Hartman.
But those 2D and 3D images take some time to emerge from the
machine as pictures. So its not hard to guess what has
just loomed over the ultrasound horizon 4D, as some call
The very newest machines have added the fourth dimension
of time, says Dr. Hartman, explaining that 4D ultrasound
allows sonographers to see the form and motion of structures
inside the body including the fetus in expecting women.
Companies like GE in their most advanced ultrasound equipment
have added the ability to see a moving 3D image in real time
as you scan the body.
But both 3D and 4D are barely out of their infancy as ultrasound
developments. Hartman reports that RDS has only obtained four
3D machines to complement the 50-60 2D machines now in their
Diane Protz, vice president of operations for RDS, says 2D is
here to stay for some time: Its still the mainstay
of ultrasound. And with 3D theres quite a steep learning
curve for the operator. So I dont think youll see
people for the next little while at least running out to replace
their meat-and-potatoes machines.
But as a technology, ultrasound may be on the verge of replacing
other imaging modalities.
Ultrasound can do cross section imaging like CT scanning
and MRI and can examine a very tiny and precise area, says
Hartman. But [CT and MRI scanners] can be 10 times and
more the cost and are very big machines. Theyre not at
all portable. Consider, too, that the next generation of ultrasound
machines will be the size of a Palm Pilot.
Theyre even wearable.
Master Sgt. Cheryl Vance of the United States Air Force has helped
develop an ultrasound vest that she and other instructors
are now using to train military sonographers and other technicians.
Soon it will move out for use on the battlefield and likely from
there to civvy street.
The vest Vance wears in class has a central processing unit stitched
in and connected to an ultrasound wand and a wristband keyboard
as well as a hand-held mouse and a single, head-mounted eyepiece.
Jointly developed by the Air Force and two private companies,
the US$36,000 device will have this kind of mobility and utility
in the field: a military sonographer will be able to take a sonogram
of an injured soldier and immediately transmit the image by satellite
to a radiologist for interpretation who is perhaps a continent
away. And since the vest-born CPU is running Windows, it is also
a regular computer, so the specialist can send back an interpretation
by e-mail, which the user can read in his or her eyepiece.
One can also picture what vest-borne ultrasound might mean to
a civilian hospital: no more wheeling a big ultrasound cart into
an already overcrowded room and scurrying around for a convenient
plug-in. The examining sonographer can simply strap on the battery-driven
vest, go immediately to bedside, and from there wirelessly download
the images to hospital network storage.
Meanwhile in a Cessna high over northern Ontario, John Peacock
will likely be bringing back his ultrasound images on a storage
system he helped devise. Working with Sonoplex, a Brantford,
Ont. company, and its Medical Imaging Digital Archiving System
(MIDAS), Peacock developed an adaptation of the program for mobile
use. With a stroke of his Print key on a laptop attached
to his SonoSite machine, MIDAS downloads his sonograms, which
can then be sent down the Internet for a remote radiologist.
More often, Peacock packs the images into what he describes as
a ruggedized U.S. military lunchbox unit filled with
digital storage hardware by a London, Ont. firm and plied with
software by Sonoplex especially for him.
Peacocks innovation is part of a larger trend that is taking
ultrasound out of its analog origins and into the wider and rapidly
expanding digital world.
Last fall in Chicago, for instance, Esaote, the Italian-based
ultrasound machine maker and one of the worlds largest,
unveiled its SuperDAM digital storage and compression system.
It eliminates the need for tape, film, or even CD storage of
ultrasound images. Sonograms are stored digitally on the system,
so that when they are recalled by radiologists and sonographers,
they can instantly jump to any point in the examination without
having to watch it play through to that point. Also, with the
click of a button, they can compress their ultrasound images
to a fraction of their original size and without any appreciable
loss of image quality, making storage and transmission that much
Such technological advantages, of course, come at a cost. But
there is a pay back. Peacock, for example, estimates that for
the approximately $80,000 a year needed to keep him flying and
making sonograms, the region he serves probably saves over $500,000
It means, for example, that a woman does not have to find
baby sitters or get off work and be flown out of her community
for two days stay just for a pre-natal examination, says
And while much of his work still does involve babies and their
aftermath, ultrasounds traditional use, the technology
is broaching new diagnostic frontiers elsewhere.
RDSs Dr. Hartman says ultrasound, because of its increasing
portability and resolution, is moving beyond its traditional
grounds in obstetrics and gynecology.
As you can see on some of the hospital TV shows, theyre
depicting quite accurately how ultrasound is rolled into the
ER and used to detect free fluid in the abdomen and other internal
catastrophic injuries that might not be obvious. Youre
also seeing increased use of it to diagnose sports injuries.
In neurosurgery and in spinal cord operations, there are some
tumours and tissue that can only be evaluated by imaging once
you are in the operating room. And you just cant wheel
in other modalities like CT or MRI, but ultrasound you can. Cardiologists
are also now swearing by it to produce echocardiograms, which
are basically ultrasounds of the heart. Its also being
used to assess the danger of blood clots in the legs or elsewhere.
Recently, Dr. Hartman was mightily impressed by another possible
use that was presented by researchers from France ultrasound-based
angiograms. A non-invasive, painless, risk-free angiogram that
would no longer have to snake through the arteries would indeed
be a medical breakthrough and keep ultrasounds stock rising.