Sun Young Park: Designing Health Technology to Empower Patients

Sun Young Park:  Designing Health Technology to Empower Patients

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[Music] welcome everyone to the honeystands [Music] [Applause] welcome to the penny stamp speaker series i'm silva lindner associate professor in the school of information and faculty affiliate with the stamp school of art and design at the university of michigan it is my great honor to introduce today's presenter design researcher and interaction designer dr zhunyan park dr park is an internationally recognized expert in design and human computer interaction whose interdisciplinary research brings into dialogue insights from health care information science and human factors of computing as a designer and design researcher she has collaborated with professionals in the fields of engineering computer science dentistry health emergency and oncology at the university of michigan ucla ucsd and drexel these interdisciplinary collaborations have received a generous support and funding from the national institute of health drawing from ethnographic research dr park works with and supports vulnerable populations such as people with chronic illness and pediatric patients with cancer in understanding and gaining access to their health data coping strategies and proactive adaptation blending design with humanistic and social science research methods dr park's research envisions and builds technologies that can be otherwise this work is utmost important and timely as data-driven technologies have come to increasingly shape the most intimate aspects of our everyday lives our health our bodies and our well-being dr park is the pi on two prestigious grants from the national science foundation a strong recognition of the social impact and intellectual merit of her work her research is published in interdisciplinary venues such as the acm conference on human factors of computing chi designing interactive systems and computer-supported cooperative work in social computing in 2017 dr park was selected as one of 46 international members of the inaugural class of the acm future computing academy a high caliber organization of young computer science and design professionals who work together to making the future of computing more just and equitable i personally have had the great privilege to know dr park as a friend and co-conspirator in the worlds of design and ethnography of technology practice for over a decade we first met as graduate students in the laboratory of ubiquitous computing at the university of california irvine where we bonded over our shared passion not only for the social life of technology but also for food and travel i very much look forward to dr park's talk today and i'm pleased you're joining us remotely thank you for the nice introduction sylvia hello everybody this is very unusual time because i have a microphone here and i'm in my place despite this is happening during pandemic i'm still very excited to be part of penny stem series i'm a designer and i work at the intersection of design health and information and technology my aim is to understand and investigate opportunities for designing technology that improve people's ability to manage their health and illness today i'm going to talk about a couple of my research projects that focuses on designing health systems that help people feel more empowered in their care so by end of this talk i hope you have a better understanding of not only my work but also the importance and value of focusing a patient individual's experience strategy and adaptation so let me tell you a little bit about how i got here in 2009 former president barack obama said this in his speech we'll make the immediate investment necessary to ensure that within five years all of america's medical records are computerized this was a huge initiative by the government and policy maker as a result numerous hospitals made substantial changes to their practice with the hope that information technology would provide solutions to a variety of problems such as improving efficiency patient safety accountability billing and more around the time i was starting my phd study in human computer interaction this is the field that studies the design and use of computer technology focusing on interfaces between people and computers so for me it was such a great time to study how such a large-scale health system could support successfully healthcare work in a complex work environment like a hospital these photos were taken from my anthropographic field study in an er at uc irvine medical center in 2010 at that time papers were dominantly used in clinical settings as you can see in these photos paper-based patient charts were kept in many different places there were piles everywhere literally after the electronic health record ehr system a computer system for the collection of patient health information everything became electronic instead of using paper charts clinicians now use electronic md notes in ehr system by typing everything on their computers these ehr systems used in hospitals are very very expensive and they're also very very interesting to me at least and so i started going to the er and studying this fancy computer system with clinicians late one evening when i entered er for my another field observation i experienced a really disturbing moment i looked around edie and so a lot of patients were sitting around waiting left out from the process i saw a disconnection between what patients were experiencing and what the ehr system was designed to support this fancy computer system which was largely designed to support providers and administration's work that holds the promise of saving more lives and ensuring patient safety seem to completely fail to serve patients needs here's what a real a few real patients said about their experience in the er waiting room and at their best side after the first encounter with the nurse i didn't see her another few two hours i was broke here in bed around 11 pm and nobody came here till 4 5 a.m so i couldn't really ask questions while clinicians were busy documenting charts putting in orders checking status on their computer many patients in the er were not getting any help or were not able to ask questions er patients were left vulnerable worried and left out not knowing what was wrong with them or what was going to happen i noticed the patient's struggles and i thought about what how technology could help improve their situations this was my turning point and what led me to study those who are in vulnerable healthcare situations where there's no proper support resources or access to their care related information i'm going to share with you what i discovered in my studies but before i do i'd like to briefly give you a some background information about healthcare field and share my research approach the past few years have been fascinating time for medicine and healthcare with the advancement of various technological applications we now have more sophisticated clinical treatment our healthcare providers use clinical decision support tools for more effective decision making smartphones and wearable devices with sensors allow us to monitor and track our health related information and help us reflect on and change our behaviors for better managing our health right now you may even be wearing a smart watch or device to let you know that let you track your pulse or other health related data recent artificial intelligence and machine learning technology provide more exciting opportunities by uh providing us insightful or predictive information about our health despite this excitement around technology advancement i like to point out the key challenges and problems in health technology design and deployment that i observed through my work first even though the system designers designed very carefully it's very challenging to design a perfect information technology for a healthcare environment that's because the successful implementation of a health system such as ehr system is not just about technology but requires an understanding of the human thought and work processes underlying the system implementation and the complex relationship in the organization using the system for instance one article from wire magazine in 2016 reported on a potentially fatal mistake that happens at uc san francisco hospital where a 16 year old boy was given 38 times the dosage of his prescribed antibiotic this accident occurred because of not only the problematic future interface of the system but because the system lacked understanding of the physician's thought process and the unique work practice at uc san francisco hospital that does not have a max dosage limit set in the system because many of their patients with rare disease often need what might otherwise be considered as overdose so this pediatric patient in the article ended up being in icu because the mistake almost killed him this shows how serious the consequence can be when designing a health technologist technology without a comprehensive understanding of the complex nature of healthcare work the second challenge is that existing health technology oftentimes do not account for collaborative aspect of care by that i mean the multiple stakeholders involved such as patients patients family members other care givers physicians and care team members with different roles perspective and needs instead they mostly focus on the primary users only this lack of consideration on collaborative aspect leads to unintended consequences of healthcare health system deployment for example when ehr systems were initially implemented in hospitals because the system was primarily designed to streamline the billing and administrative work it increased the time and efforts the physicians spent documenting patients information on their electronic charts as a consequence the physicians actual physical time to interact with their patients and nurses was significantly decreased the third problem is that health systems do not account for the needs of individuals with vulnerabilities successful chronic illness management requires active patient participation and effective communication however this can be difficult especially for more vulnerable patients who may lack self-knowledge sufficient communication skills or appropriate information access like the elderly young child patients people with low health literacy or those living in marginalized communities such patients needs in consequence are not often recognized and their capacity to understand their care related information is often misjudged by their caregivers and their providers this leads to an imbalance in participation and decision making in patient care eventually affecting significantly on a patient empowerment identifying these challenges in designing and deploying health technology i found that it's crucial and necessary to understand the inextricable interplay between social and technical aspects of health system this means that we have to consider designing a social technical system to not make a purely technical system but one can meet the diverse needs of all different people involved in patient care especially those who are often overlooked because of their vulnerabilities my overall research goal is to evaluate and design health information technologies that empower individuals with vulnerabilities to have more effective communication and collaborative decision making in their care using a social technical approach so let me briefly share with you the research approach i took to achieve this goal in terms of my mythology i employ social technical approach by leveraging methods from multiple disciplines including design human computer interaction and social science this social technical approach has let me tackle the complexity of healthcare problems by gaining a thorough understanding of people technology and information use and context through my research i discovered this intersection where user strategy and annotation come together this user strategy annotation provides a lens through which to learn how users patients in most cases face and realize their challenges in managing their health or using healthcare system and also cope with such challenge by changing how they do things their physical environment or even their perceptions this finding is particularly crucial to understand patients needs empower patients in their care and draw valuable insights for designing and implementing a complex health health technology i will talk about this adaptation process in more details as i discuss my research so moving on to an overview of my project i'm going to talk about patient adaptation through two case studies that represent patient from the vulnerability the first case study involves patients in the emergency department who are experiencing vulnerable situations and the second case study focuses on young pediatric patients with cancer who are already vulnerable due to their young age i found that these two different vulnerable patient populations showed similar patterns of adaptation behaviors ed patients and pediatric cancer patients both adapt to a care environment that did not properly acknowledge their needs or support their needs by actively developing coping strategies so let's start with the first case study the first one is on emergency department patients just to be clear edie is a former term for er or emergency room patients in the ed suffer from not only the uncertainty of their physical symptoms but significant information depreciation rely heavily on their providers or others to make decisions about their care so my study aimed to investigate the design space for patient-centric health systems or technology in the clinic setting to improve patients vulnerable situations where information about their care is not readily available or accessible specifically i started with these research questions what information do patients need in order to communicate with their providers and provide to understand their care situation what strategies and effort do patients make to seek and obtain information what are opportunities for designing technology to address their needs based on these questions i conducted a qualitative field study in the ed at uc irvine medical center including institute field observation of 43 patient needed visits and follow-up interviews and we also conducted ed provider interviews and then we later on conducted qualitative data analysis for our interview data my investigation identified there there were several types of information breakdowns patients encountered during their stay in the ed first delay and unavailable information about their care second information overload which means that they receive of an overwhelming amount of information during their consultation with physicians and information that was either inaccessible or unpredictable during their edit stay and finally information that was inconsistent and confusing received from multiple different care team members i also identified the corresponding strategies patients develop and use to cope with such information breakdowns in the interest of time i would only talk about the first breakdown when patients experience delay or loss in receiving their care related information and i will explain this by using a one patient case study a case observed in my field study the patient a 32 year old woman named yasmin came to the ed for an eye infection after multiple consultations with the ed providers and eye doctor she was informed that she will be discharged once she took some prescribed medication yasmin sat in the eye exam room waiting for her medication two hours passed and she was still waiting finally she was asked to leave the room since another patient needed to use the room and she was in the process of being discharged anyway so she's sat in the waiting room waiting for her medication after another two hours of waiting had passed yes men started to worry that her care team members had forgotten her as she saw there are more trauma patients coming to the ed so she decided to ask an uh an ed staff member passing by in the hallway to remind her previous best signers that she was still waiting for her medication after some still more waiting yes man finally learned that her medication had to be compounded by the pharmacy which was a lot more time consuming than simply getting getting it from a shelf it turned out the bedside nurse who was occupied with several inpatient incoming patients had now received this information from the resident who was also busy with multiple trauma patients until yasmin asked for it in this story there were three breakdowns moments in the information delivery to the patient the information that the medication would take longer time to be made should have been delivered from the pharmacy to the physician to the bestsellers and finally to the patient yes men however the information got lost in the middle due to the busy schedule physician who didn't let the nurse and then the nurse was too busy with other patients to follow with the resident and almost forgot that yes man was still waiting this is an example of information breakdown many ed patients often experience where care related information gets delayed or lost we found that there were multiple factors that could cause these information breakdowns the main factor is due to the nature of ed providers work which is very impromptu and reactive to what is happening at the moment instead of being pre-planned other factors are related to time-related dependency of medical care activities in the eda much of the required information for ed care activities is only available after the execution of prior active prior activities that often involved units outside of the ide during the patient treatment process for instance ad physicians had to wait for a confirmation from a surgeon a pharmacy approval or bad availability of one of the inpatient unit in the hospital which could all cause further delay in these cases patients had to simply wait for hours suffering in pain without proper information update to deal with this information delay we found that many patients in the ed developed and used various coping strategies in this episode yes man actively observed her surroundings and the other people around her to figure out the current ongoing situation and then she actively approached and reminded the clintons of her needs by doing this she was able to figure out why the information was delayed and what she could do and ultimately expedited her own care processes yasmin's experience is just one example of what my study identified as the patient's development of coping strategies for handling breakdowns through a process of active patient engagement and adaptation to their care context within the information poor environment the current health i.t design in the ed as well as ed practice treats patients as a passive recipient of care in that it does not consider their needs or take them into account as a potential users however my study uncovered that patients are actually active adapting agent who are trying to figure out workable system rather than passive recipient by actively developing coping strategies patients try to ensure their own safety by preventing or alleviating the potential impacts of information breakdowns on their care this patient engagement adaptation in fact improve overall healthcare quality in a larger context so in my study i asked where can health information technology help here and here are the key takeaways first is the importance of designing patient-centric health i.t systems

for clinical setting for example a real-time digital information display can be implemented in the patient room to provide the most updated status care status information in the real time by aggregating multiple information sources including ehr system and multiple care team members who might have a different level of updated information just like a food delivery app or uber that shows where your requested information is standing in the entire timeline of the delivery process and update the status information in real time this can foster effective information sharing among patients caregiver and other care team members also extending the prior work on patient behaviors and roles i argue that the patient's adaptation process driven by their design thinking can offer valuable insight to the design community to improve or redesign patient care environment since the way patients reconfigure their own care environment can complement design insights in a way that designers cannot predict i believe this is more necessary for patients experiencing different vulnerabilities in their care so far i talk about ed patient subtition and now let's move on to my second case study which focuses on how young pediatric patients with cancer adapt to their care environment to provide a brief background more than 11 000 kids that are diagnosed with cancer every year in us specifically leukemia is the most common cancer in childhood especially among those aged 14 and younger there are several major challenges specific to pediatric care first young patients are vulnerable because of their young age as you can imagine child patients have insufficient self-knowledge communication skills and maturity to manage their self-care so they heavily rely on their parents and others in addition to their physical symptoms they also struggle psycho psycho socially and emotionally second their parents suffer from caregiving burden on top of regular parenting responsibilities and healthcare providers also experience communication challenges because of the difficulties of understanding the child's emotions and expressions so they tend to talk to the parents mostly rather than talking directly to the child patients to better understand pediatric patients experience we look at medical and psychological literature we found that while negative experience and impact of illness on patients have been dominantly studied in the field some prior work showed positive aspects of living with current illness for instance when when child patients experience a loss of control patients also improve personal attributes such as resilience and sense of responsibility and they enhanced relationship with their parents and peer patients and gain a sense a greater sense of self however these p these studies these prior studies largely focus on adolescents or young adults who had childhood cancers retrospectively so little is known about the perception of young children with chronic illness as they are living with their illness so in this project we aim to discover the positive experiences of child patients as they adapt to life with their illness and then to provide design for a system that could help enhance these experiences in terms of the project process we conducted a qualitative study at a pediatric hema oncology clinic at the children's hospital the inclusion criteria for patients were english speakers aged 6-12 they're in at least two months after diagnosis so that we can reduce their emotional burden to participate in our inner study we conducted a semi structure interview study with 25 child parent pairs and 10 clinicians we particularly develop and use the child-friendly questionnaires for child patients to identify their thoughts and emotions about managing their illness everyday life with the help of child psychologists all of our child participants went through either chemotherapy or bone marrow transplant procedures which is a medical treatment that replaces your bone marrow with healthy cells because these medical procedures require a very strict and lengthy treatment process patients had negative perception of the impact of their illness on themselves the risk and side effects of treatment and medication made patients have numerous restrictions on their daily activities and also sometimes make them feel different from their healthy peers in our study however we discovered that over the course of their illness and treatment patients had several types of positive experiences because of the limited time i will share three of them now and you can find more of them in our paper i like to share a case of child patient to illustrate patients positive experience with that in mind i wanted to meet evelyn wallace this is the actual photo of evan and her dad that was published in wall street jonah which reported her treatment story she is a six-year-old and she was diagnosed with leukemia two years ago following many rounds of chemotherapy avalon kept relapsing and developed infections and she had a stem cell transplant after her diagnosis evelyn immediately recognized that she lost certain aspects of her life due to the illness she missed her friends and sisters while she was staying in the hospital with the painful tres uh stressful treatment procedures she often focused on her stressful present circumstances and sometimes kept comparing her current reality to her healthy past she was for example very sad about not being able to play soccer or run outside however as evelyn worked through her treatment protocol and adapt to new situation with her illness she started to build expectations about her hopeful future like getting better results on her treatment or increasing her interest in the clinical world rather than only focusing on her stressful present circumstances as you can see in this quote evelyn told her that she would like to be a cancer nurse and she even act like a cancer nurse when she played with her toys wanting to know more and learn more about nursing tests evelyn proactively participated in treatment procedures just like assisting her parents with a caregiving task we call this a change in her perception future oriented thinking we identified two types of this new perception with different time scales one is building expectation in the short term for example better treatment results and the other is developing long-term hopes for the future like desired career or life goals this future oriented thinking was often enabled by the patient's health understanding of their health related information as their parents and clinicians explain more information about treatment test results and upcoming clinic visits to them the child patients were able to understand and anticipate what to expect from their care with less anxiety and uncertainties in turn the future become more predictable getting back to the story of evelyn while she experienced the loss of opportunities over time she felt like she gained valuable knowledge and wisdom not just about the illness and treatment but also about life and develop personal growth from her illness and treatment evelyn believed she got wiser after diagnosis as her perspective on other sick people has changed she now saw that merely treating sick people more nicely and carefully might not necessarily help them feel better but in fact it might make them feel more different from others such wisdom and awareness came from her own experience sparked evelyn's inner growth and development her parents mentioned some other evidence of greater maturity like her using more complicated vocabularies than her peers we found that this change of perception recognizing gay knowledge wisdom life experience and personal growth led to patients like avalon to experi to experience greater confidence and more positive attitudes about their unique situation of living without illness getting back to the avalanche story again after avalanche stem cell transplant the health management protocol required for her were very extensive and complex such as managing more than 20 pills intake daily cleaning ports on her chest washing hands eating certain meals etc this made her depend physically and emotionally on her parents and other adults however over time evelyn recognized her her new routines for her treatment and began to learn self-management skills like maintaining consistent meal time daily medications and regular exercises in addition she became more familiar with treatment process and processes and protocols she developed her own coping mechanism to better handle and prepare others perception of her illness and side effects as you can see in these comments her mom shared evelyn joke about not having hair as a way of explaining to other people guess how fast i can take a shower she said evelyn's really clever reaction to her situation made her mom feel proud the joke and humor evelyn came up with were very fun and optimistic rather than serious since medical topic could be too heavy to discuss with a pair of her healthy peers as we have seen in the case of evelyn the child patients in our study not only learn self-care skills but also develop protective coping mechanisms becoming independent in managing their health further indicated their active participation in their own care to summarize our findings so far despite having negative experience associated with their illness pediatric patients also had positive experiences such as developing hope about their future gaining life experience and knowledge and developing self-management and coping skills though they were different degrees among children of how they perceive positive experience depending on patient individuals personality and situations these findings were identified commonly among our participants in the study looking at commonality across the patient's positive experiences our study indicates that the process of positive adaptation to illness occurred through three mechanisms recognizing understanding and developing when facing a stressor such as changed appearance or limitation on their activity daily activities patients first recognize the impact of the stressor on their lives going through the treatment process patients work to understand their illness and treatment process as they learn and gain more health related information from their parents and clinicians and then they gradually develop skills knowledge new perspective and attitude in response during this process patients had negative and also positive experiences but as shown in our findings positive experience occurred when patients started developing expectations for their short-term and long-term future valuing their gain newly gained knowledge and life experience and feeling independent after developing self-management and coping skills our analysis further indicates that the patient adaptation is an evolving process rather than a linear one as positive experience directly influenced patients perception of a new problems brought by the illness for example a positive attitude developed through personal growth affected their perception and recognition of the impact of a new stressor at a later time in other words patients initially recognized the negative impacts of the illness begin to understand their illness and treatment and develop new views skills and coping strategies that in turn help them better recognize the positivity during later times this is a new important insight because most existing technology designed for patients promote the representative adaptation style by alleviating and reducing their negative experience such as designing a robot toy or games that help children reduce anxiety during their clinic visits or most technology focus on partial or single aspect of patient adaptation by only focusing on understanding illness or developing social skills rather than recognizing the entire process of this evolving cycle based on what we learned we argue for design considerations that support or enhance each phase of the patient's positive adaptation process so that patients can reorient their views and facilitate their positive thinking considering the evolving nature of their positive rotation process we suggest that patients understanding of their illness and treatment trajectories should be supported first to facilitate patients understanding of their health conditions we suggest having patients set goals and plans in collaboration with their parent caregivers setting goals can provide valuable opportunities for child parent pair to discuss the child's current health conditions ongoing progress and expectation about their future together by doing so they can make plans together about health related tasks or social activities based on their short-term and long-term goals for example when a patient cannot play sports after a bone mallet transplant procedures because of the risk of infection they can add an activity like go swimming with david to their short-term goal list and then the parent can assist with determining the visibility or appropriate timing for each goal so for example go swimming after getting the port removed from your chest so in this way the child learn more about the treatment process by setting their goals we also think that it's important for the system to help patients set concrete and more realistically achievable goal by making recommendations for other related activities or tasks they might enjoy or need since we also expect that patients may feel depressed when they have setbacks or their health condition worsens preventing them from making progress toward their goals the proper visualization also needs to be implemented in order to present the patient's progress and achievement even including small and incremental progresses and then to support the next developing phase we argue that positive scenarios and stimulation help them can help them facilitate patients learning proactive coping strategies and skills simulation with scenarios are often used with technology to help children experience various situations and learn different skills by enabling patients to indirectly experience various situations they may face patients can learn about how to manage challenges proactively discuss issues with parents and practice their responses without actually experiencing them in the real situations and being hurt unexpectedly the positive scenarios can also provide tips and guidance on patient's interpretation by nudging them to take more positive approach to such situation for the last recognizing phase we suggest reminding child patients of positive gains to emphasize the silver lining of living with illness in the psychology literature such positive gains are referred to as benefit finding defined as positive effects that result from a traumatic event so drawing on this concept we argue for a system design that leverages positive moments and seek to enhance them for example patients can capture and record their daily positive moments with their family members or clinicians or positive thoughts in the form of text photos videos or drawing these accumulated records can serve as reminders of positive moments when they are going through difficult times later based on the patient's treatment trajectory the system can also provide the right timing for reminding about such positive moments such as at stressful moments like right after bone marrow transplant procedure or during a time period of missing school days by reflecting on previous positive experiences the reminders can serve as a bridge that links the positive memory in the past to patients perspective on current situations and maintains their sense of gratitude even if they are currently experiencing difficulties in the process i like to emphasize the importance of recognizing positive aspects based on previous positive experiences since this is a tipping point of the evolving process of patient adaptation to their new life with illness if they do not recognize the positive gain and moment the other parts cannot be reinforced each design consideration i have presented so far should work together with the others rather than individual design design requirements as they are part of the positive adaptation process that evolves by nature to provide an illustration of how our design implication can be applied in practice we have been developing an interactive genre system which is an ipad based application our interactive genre system can allow patients to create general entries through different methods including writing drawing or uploading photos videos or music to describe their daily experiences providing a goal list recommended scenario simulation reminders of positive movement and prompt we expect this will enhance the positive experiences of the child patient we are very early in the process of develop developing a prototype people hope to have a testable prototype ready by next year we'll be conducting participatory design workshop with the child parent pairs to finalize the specific design features and with a more robust prototype we'll continue to conduct a technology prop study where we can deploy and evaluate our design visibility in this line of research i currently have several ongoing projects with different population with vulnerabilities including college students with mental health issues black patients living in low research communities and elderly with chronic pain i've seen how some of these technology design implications relate to patient adaptation process can be also relevant and applicable to these other populations so i'm very excited to see what lies ahead with such different populations and i'll be continuing this line of research for patient activation and patient part empowerment so now that you know about my two research projects that i have been so focused i hope you can see now why these research has such a value and importance and why i'm so excited about this my research led me to argue that both ed patients and pediatric cancer patients adapt to their care context by seeking adopting the most appropriate and workable method that work for the unique needs and goals to their specific care context based on this insight i like to highlight not only the active role and efforts patients with vulnerability engaged in but also the necessity of enhancing and activating their role throughout the care processes this can allow patients to take more agency and manage their health and illness as well as interacting with caregivers their healthcare providers as well as using their own health systems as we can as we learn about patient adaptation process among ed patients and child cancer patients what does it mean for technology how can we inform health technology design these are the questions that must continue to be answered in my work as well as the work of others i find adaptation is crucial and essential as a way to understand and design what the best practice may be for individuals especially those with vulnerabilities with this in mind here are my three key takeaways first understanding patient adaptation would help designing health information technologies that are adaptable or learnable from patient strategies second learning from patient adaptation we can or we should consider a complement designing a complementary role that enhance the process of patients creation of their strategies and positive experiences rather than merely educating them or providing medical information to the patients lastly adaptation would help prioritize patients own value instead of putting our designers and researchers on value when designing health technology for vulnerable populations in particular whose values are different were not recognized easily so for successful system design and implementation as hci and ux researchers and designers our goal should be not to just provide the best technology which is almost impossible for healthcare but to design the best practice by learning from patient strategy experience and adaptation thank you for your attention and for spending time with me this evening if you want to know more then please reach out to me thanks again yes wow you

2021-03-25 14:42

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