Professional Documents
Culture Documents
.*tr.
F;J;"i;i
FIrnEy lruuistring
w1379
PROJEGT HUGO AT LHSC: LEADING URGENT CHANGE IN
HEALTHCARE
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Veaion:2gB4lAO
l,
Susaa
lohsoa tmk
a deep
bred
as she entercd
&c
@iqg
lot
of
the l,ondon Hcalth Scieace Cffio (LHSC]. StF bad just lsrrtrftod her children into a new school ycar.
Johnson smiled as she rocalled the excitemcnt and tuticipnticr on dreir faces at their fiestr stryt bsck to
school. I{er smile lessend
her thougtts hrnd to the monumenal obange laadership task
lay
th
ahead.
Todry would hiag a public announcanent by the senior mranagcmd tqm &at'het''Pr,oject
fre direcCIr of Pharriaoy Scrviccs at IJISC. Over tbc past yar, sbo hed bean planning for
thp launch and implcmentation of Projec't IIUGO, an acrqnym for Healttnse Un&rgoing Optinization
HUCO would bc one of the nrost Gomplx, ercpemive aod cballenging projccs wer undcrtakel by thc
Jo'hrson was
registratioa to pdient dischalge. Whcn fully implemcgbd, the physicians, nur!6 md otha healthcar
provid'ls rvould be using a fiilly eleefronic pstimt reoord (EPR) in place of tlie current pryer-based
eystEm d all Inndon horyihls and thp nine smallor regirmal bepials that paftered with LHSC.
ffig
in6e Hluray, slr had nm ino a plXnician whom *re had though wauld have
suppor&r of HUGO. Yet, surpisingly, lhc Sysician had scated, "Susart" I believe that ws will have
electronic order entry very soo& hrt you know, I will never entet my own ordrs, My secretry will do
Jtst fte prcvious wk,
been a
Johnson knewtlrat divrrtirg thls process to clerical strfrwould dilqtr the geins in safgty. She also recalled
a conversation witrr &e den of the medical school who hld stded unequivocdly thd by introducing
elcctrsnic otdcr Grfiry, lndical sfudob uould not lann bow to p'r.cscribe ordqs and proprly care for
Fagq 2
9HIGO3E
patiens. *Thit
is
'coo&book' medioiae,'the
pfu
ar
individuals.
Although hml&carc spending abaoftcd nsre thn US$I.? biltioo pff ycat in the Unitsd Strbs aild morc
thm C&S175 blllion in Cansda' prcnatrre rnortatiry in Nqth Anerica remained higher tan in mny
other &vcloped munties. Msst medical recsds were still stored on papor, whhh preeluded lte
coordination of care or routin measurencfi .of qrntity, ad oflea ted to crttical, ofteo fant, nedical
erron. Recsrt media reporb had highligbfcd the tragic corucqunoes of,mdical erron:
,
.
.
.
.
.
*Da6s of 3 Babies in
Indiana Spodight Mcdication Mix-ups"
Sasran Glabe, SWembq 23, 2006
lQuaids Sue Blood-thinncr Manufrctrer',
Lw Angeles ?ilnel, Dec S,?AO7
'Heparia ovsdoses Hit Babis in To<as Hospital'
vau street Jaur.nal,July 9, 200g
"3 PhihdelphiaInfaGDicAftrMix-upatHospitalPhnmqy''- Phtlefuhia lryuir*,Jurw l9.ql0
*Iwo Die in Hospicl Dialpis Mu.-Up"
March 19, A004
*Hospibl Enor,
Wonnaa
Did'*rBC, -Natiorutlpast,
Wedaesday, April 4,?ffi1
In addition to these alffsdng media reports, the asadomlo litratue abo painbd a bleak picure. Tbe
Instinrte of Medieine published findings of widesproEd uediaal errors in ib rpo4 To En k Htrllprtt''fte
rWort sugge$ed that ss marry as 98,(n0 Ameeiens died erery yqt as a rcsrtt of mcdicd crnor. A
subsequcut Cansdian snre/ ectocd ttrcse fi'yrirug rcporting Ut"t-Z.S pr
'ctrt of peierrts
-colsidercd
"d-itd to
hmpital had exPeritnscd sn adve,rse evat Of those patients, 37 per cpnt rryr
to haw
otpedenced preventable evnts, and2.l percot had dicd as oresult oftheh adversc evrits. Acroos key
{ees in the medkdsa prooess, ditrrerdt}"es of enors oosrrred with difraent ficqrrncics. Enors were
classifitd into odering erron, tranccription erors, dispelrsing rrers, and administation mon (see
Extribft 1).
LHSC, one of Canada's largest aoute-care teaching hoqpitals, cared for the moat critically itl pationts and
the most medically cor4plex casoe in the region. In 2010, 150,000 patients visited the-emergcucy
doparhcnts,700,000 patienb visited oubstint derprhr*rnb aad 40,900 patients wele adniilsd. [HSC
t
&rs&rda
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G.
hbtHtp',
To
En tstlwran: Buitdima
ffir lffi.ella
Sya#n.
N&d AenyFncs,
!'.tdlludorl D.c..
Rer &ab et 4., 'TiF &lnsd&l't ,d/vee tunb thfi4 frp tm:dern of,{da/se Erads azror4l r$gfid
Can&n ltccfrp/ Asffin Jaurnd. m4" wt. lVA, ttc'. l l, g. I 6ltl ffi9.
@nadg.,' Tlp
tu&,rils ilr
Pegc 3
9Blt0038
was the lqest mPloyer in London, wi& rnorc tran 2,200 dostors and medical studonb, alnost 3J00
rursq 500 olinical str(such as pliararcists, ntfitionist and pnvsioucrrylsel ard
4p,roxim*oly 7,000
It
ilotpitrl, Vi6rt"
Ilospttal md Ctil&n's llospitaf Byron Fanily Mdical Ccrt md VictoriaFmrily lrtodfu Ceuge, aod
was home to the FowlsKenncdy SportMedieine Cfnic, Canadian Surycsl fecUrotogies aqd Advamcd
Robotics (CSTAR), Lowssn tlealtt Ress&h Institr*. Childrcn's Health Foun&tion iad Lonfon lleatrh
Seienca Foundatiur-
St Joeepb'r l{lth C,are London (st Jospht) r+rs a m4ior pciem catr, eaceiry and rtsca13h cEbe. It
ryU{ 8L JosePh:s HolPilalr Parkwood Hospital, Mount Hope Centre for Lofu-rerm &re, Regionsl
Mental Health Carc Londod ad RegionalMental Heslth Car-eSt Thomc. Annually, morc than 50O,OOO
PdiEilB vbitodthc cr@Lart clinics et SG Josephrs, fi,fl)0 surgerics ..rar petfotneO aod 41,000 111g*
cslE csss nr{minictspd. St Joeeph's uore e8a 5,000 ;aff ne;bers imtrUea almost l,SO0
ihysiciinq
residcrtr aqd medical studocilE aad 1,100 nursing,srd allicd health profcssionals.
sms
Johcrson knew that. statr diftred md csutd be categorircd into physicienq muss and alliod
healtl
professionals. Becauso physicians were in@ndcnt md not reguhr drployo of thc bospial,
h$pital
adnin5qcion rves permittcd only lirrired dircct influence over physiciansi wor*flow. phlrsicians rrere
more likely lirn nums or allied hedth professionals CI switc,h iroipiats seveml times in'their Gj1.ce6.
Thgr_ofiel compared tho pcrftrrrance oftheir hoepitat wittr the perforrrurce of ofter hospitals in g116rio
-nna
and Canada. Many pbysicias rsisted chmge in &eir mfins
resntsd purcly adniniemtive trsks.
rndenA$e
atlied^h{tr proessionals tms the most diverse group-ofhospitai rtifi, i"cfudiqg sweral smaller
Soups of professionals, .such as phannacists, physiortrerapists, egcupsionl nrrryirq dieficios, 1ab
technisianq radio teclmioians and mmsage thr.rpfu" tesi pnofesionrls rrcre Aivin Ui fbeir afifiy
rc
Providc sfe sd sffoctivc care frr pdeffi in m effisieni msnnei. T.hey wcre elso concerd with
communic*ioos wi& bo& physicb and patieira. For all throe groups, tlrc abilry to rccpss pdient
remrds from uywhcre in thc hcpitat aod bcfore sseing a pdient woutU signinearrly irrprovc *eir
Sility to provide higbauatity, e&ctivecare in aoefficient mannr.
gmup of
$u9A1t
JoHilsot{
Susan Johnson hsd ta*ur orrfte role as dirEctor of Pbarmacy at LHSC six mordlrs eadier. She
had been
as a clinical phamacist and had gained rclatcd experience in muttiple artas over alnost ZO
I-"ttd
bd
y"ro
sttc038
Pegn 4
In 200t, Jo&ns& hsd esfiSlisM lhc new trledic*ion Srfety Oep6@nt d St J6c?tr's ltrcaltb C.r! aad
bccn i6 ooordinalor frr 19 )8ls. In tbis mlc' sh had furylac d wveral mcdicci'm safrty
th
Prcviously, slrc hrd reecivcd hcr bacMor of ssisrcc dcgrae in pharmacy from ths Univcrsity of
xrd hcr
dogrc in hcalth strdcs $-Gedcr*rip) fom Athahsca Univenig.
ne's
Tmolo
HUGO uas LHSC's seoond smptto imptrcnrcnf raelec*ronis pcient rcoord (EPR) systcin. Fmm 2003
to ?I)05, a maumatal etrlrt trad becn undcrbkcn to irnplaffirt ooryrmitd ptrovidcr ore s$y
(CFOE) ad cllnical doqrucrmtion" Inforrnation er,hnology sffi, not clinicst gtafi, had &ivea this
Frojecl Sevsmlconsutaab S,omfrs UrdtdStEFs bdbeeq{pars,h$od in*btltcorgetz*mbbuild
&ilod b tDcd
dlincs"
tlc systEm- In ttc spriry of 2@5, t$c FNCiect was ovrr{ndgrt and
Clinicims had coqsidersd fu sysEm eumbcrsmre ud rruupprtive of patient mte. Hspe, they werc
frustnfd by tre eystm bofore it had wen been larnclrs4 and drcy had clarly itrdicelGd tbey would
re.yerusc ir ?lE projec-t nas put on idcfinie tnld ad bd nmaired dornad umil2009; horrcter, ttc
organidional mclnory of the frilod dqnpt b isboduae EPR hod stayod alivo in the minds ofthc nnry
shffudto bad rcmained at tba hospitat
bf
tco
rder Johnson'r ladership, a naw trm was forn4 fr. Clinical Infmaics Team. This
was staftd with olinicians, includiilg nuscq phnrnmlsh and nufritimisfs, and v*as taskd with lhe
dcsig& imptemerilation, educdion urd Saining of the clinical systcrns. Thb tem a#d u advocales for
thc clinigat stafflnd fq the r:sc of tcobnologl to cnhanc qrnlity of oare and petient saftSy. Thy ako
played kcy roles a; ffi$latorc bctwecn thc infurm*iqn e$enobgr staff and clinical stafr, t$o grorye
o*enused very di&rent lffuage.
In 2009,
&*
In 2010, witl6s Clinical Infsnnstics Term oo 6s Sound dd trc Tocmto horyitals rcpctiag swcescftl
CPTOE implerrenatioqs, the Lonilos hospitsls e:cpcrieircod rcneupd intgrst in a scod uy
implmcfing CPOE. A rcport was rplcread that oorrpcod Cangdian hospitals' dopd@ of ncw
tocbmhgr. I,ondoq typically s nstimal lsdor, uns sbrtirg to ftll behfud mrrci smslla Canadiao
hospitats. In addltion, mporB wem emerghg from wory rnqior organization regerdfutg tb trernsdotts
gaim in pdiqrt saftry bing reatized as a r$rtr of the irnplonrntatim of aa ohcursric psticctt r6d.
bcpials for
rpordc. Ercpoce-d to follow suit was Ceade Hsalth lnfoway, a Sdcrally fundd
gowrnmont orpnizstcn creed to foeilcr ud accelerstc adoption and implemcrrrion of ekctronic
hsd& rccffds.
Utrdcr President Obarm, &e U.S. adninistruion had &rvestsd billiqrs of dolhrs in U.S.
clec,tronlc pdint
PRN'E
HU@
Senior leadership st tbs hocpihl bd sskd fohnson to deermire u&at it would uke O larmch a full
had caarpleed an ercEnsiye rmlysis of the
SC. In resporoc,
elecbonic petient record project d
phCIrsical
re
r)rrcs
atd tto ptoposed roll-ors plaa. Tls
rquircd,
tho
ad
trdsd
human
clrangp sftrt
estimatod ccst of HUGO was mor &an $25 million. Part of this cost uns tbc tochology thd wag new,
33tte$0
Prg! 5
soenis*ara aad arposiva tha soo'pe of hjoct HUGO was mrsivg considsriag tto nmbcr of
hspiials ed shtr involvod. The anont of d& rbd wqrld be poeesod loctrodcslly insd of
rnarudly was dso shggsingly higb Information on approrirnealy ssvon millior pdieot vbib was
alrGody ol4 dcwisfurrdimsd{dbaddod quic*ln &ctorryidlyiscaaingbea![ca,eneedr.
ph includd an rgglwsive tlme sahdule tut would sc &c prciest rollou occtr over o 24moue paiod bqinring in fubr ml2. At lcast 100 additioosl staffMrbcrs rrurH nced b bc bircq
ard the curcnt clinicim wstflow EouH d !o dange dranfcatly.
Johnsoa's
lYorkflons in hospiul healthcnrc system were highly wnplex, rwulting in inefficimcics ad rom for
error. A process andyds, frm a Stsiclm orfuing a msdicstion io 6e administration of6c drt4 to thc
prticnt sluwcd &e involverrcnt of at lea$ five pcoplo and 24 kcy stps (rco Exhibit 4). HUGO would
shortrn this pocess aonriderebly (see E:cttibit 5). Handruitien ordas thd uEG oftea illcgible addd to
cdcrs
dsk of seriour crus (sce E &ibit 6l HUGO would climin# th ncsd b tuiphcr poorly
and w.ordd po&rce easily redlblc ad hanedbls rmdicuion ordens {se Exhibit 7).
*rikr
fu
tb
LI{SC" St" Jos'ph's and tbe regiooal hpihts ahsady had in phoe the fouoddioml aonponmb of
horrryver, to aohiw *rc promise of a fully fimctiotrrd and i@nted EPR, firther dwehpnent uas
ncossary. All of thc pmgrams would rcquire sipificant process rcdesigtr drd chtngps in clinicigtrs'
b*aviorn md ein&iry; Sysnm, scrstlncs ud proccsc would ncd to be aligned ad imuiomatly
designod to achievc the dssird ot$cqrc&
EPft
rym.
ft
patietr's olcctnonic
lwrd"
savinp, a rrduction in nedical eros ad inprsvcd hcalttt' A p{ient's blood tSDe' pressibed dru$r
mcdiaal cmditioss and odrcr tspects of srcdisrl hictdry cotrH bc moounied frr much rnae Af*ty. At
thc very lcast, an EFR could raw tlrre attbs doctor's ome. At most, guick access to reeor& could savc
Rbfisd
rffit
A{lelr8.
tucod qnhnt
5, Fp,
&l
17'
Trans|om
,W,
Cnr?
ffefi
8ett.fr*
Prg.8
0a1{o03t
lives ia
Dsspitu
fu
fu
tb
ledcrship Eiln bad dccidod thrt tbe potcotid ggins io quality of pdicdt
c;harge
rccnily apprcvedProjcstHuc0.
A SOSII CHAilCE
While ,IohnsEn knew tftat gEtiing HUCO offtbe grorrtd was a ms'nrnnantrl dntloge sle also lnctil that
rEsrdB srqff bG *ell wordr thc eftre Sfts hsdspent rnuch of the last for yeers rccearching
HUCO wagn't
causes of msdi$tion ensE ad advocating for chargx to ths sys&m. Sls lcn{r
efficiac,y or saving monoy; it was about savirg live She tlnught about thc modia bcsdlhes thet ulut
burnod into her mamory f6wrr. Shs hDelrl thirt dl of tlmcs tagdies could have beeo pwatd !y
fu
systcms
fu
fuit
fu
likeHUCO.
Yt Johm *as dso mnly arwu oftts mrry &aors &d could tuve a sdow nqilivo impart ou tho
adoptio of fiis pmjcct $hs "lso tnew thst ltlc od& of $rwss were st in her ftvour, with t4 to 50 por
fiwt clinicians" Shc rcmcmborcd Eading
ccart of CPOE p,roject tlryicatly &iline kuse of ruitu
sbort Ctus Sinai Horylat in Celiforni& ln 2W2" tts orgrniztisn had bm forad to sanp a $il
million s),stem when pbysiqisnc bad *wslked orf of tte hopital and rcfirseil to work lmtil the c)rstfit
was rcmovcd-{ Many rcasms had booa noted for wbf EPR systams hd fiild (sec Extrtbit 9).
Tbinking bqck o hcr prior convecsdims with physicians, Johnson knevy tht ttp clinicirns Se had
lno*Ed with on a daily basis hsd fuir or'n peisoml ncasffi for Fsisting HUGO. Atd it was ad just
ptr;rsiciae tb.qJotrcmhad bad &omwlilc wo'rkingon&e HUCO propos,el. Nutos *sr6 slso vocal in
their oppositim. Tby hd carcd for pdc6 f.u many years using pen and pryer (ofun weu just a per
torvcl), r*ic'h tley fclt bd wo*sd jnet fire. Thesc nurses chirncd tr* mistrlses did lot htppen to lhNrl
beerse thoy had pcrfeced tbe nanual pmcesscs. Johnson was rsmindd of r repsfit from a hospinl tbet
noted ir tbe firsf sk mootLs a$er the irnplenrentatftn of barcodd msdioation afuioiete$oo' a total of
746 medicatim errolB had b@6n evoidsd- Most of ttese ffion r,rould bave gonc unrmticed by nursing
suJf, Bvcn Johrgon's orm pharnacy strff md othcr allicd health providen bad lcse,rmtims sborf
HUGO. Moot sdbelievcd+ltet tlp ph5rsicimr r*ould find a cfiy to defloct order entry rusponsibility
phannacir$ or nrnse ard thus rqs,ttd the W@d inspse in ftoir workload.
blamed for poor infegtion pordr,ol practicc. Wait timcs in the anergcnry deparErcffi ntrt much longer
than in any orthsr hospial in Canada; patiorrs werc waiting r4 to trree days br a bed a$cr a phpician's
bsing ou8ottttod to
decigionO gdmil 6Nrlr Ia addition, tbo informatioo tecblogy (IT) scrrricc
Uritcd Statsf and many of &c r(prtlschnical $atredLHSC nepdd to re$ on hd bcst laid ofr, SoIf
&rorrghouttb qgmidian ws cxhnstod, morals at an all timc lory and siek timo qru at rccord lsvels.
tb
lwt
'
tun aN tupq, by Ud
Coruroily,
l$rp1r}n&l-frgl"
2M
,Nch
21.
z06t
Ntl.
gBtlCtXtE
Prgr7
{JA||D
SrFR
Johm wu well arruc of lho mgnindc of ttc oreeizdisrat clwrgc challagc fu sbo ftod- She
knc*' 6s ec implenron ion of an EFR ws lils a hrriostrG wltipping fuoqgh m oqeniuioa
Evcrything thsl staffonse brp wotrld changp.
'Thchappy
orcitmt brthc rcw soblyear thdny childra ftcl could rctbe more diftrtntfronthc
not so joyous
rnticiprim of HUC0
for hoepitrl
ctsff,
Jahnson
fbsttgtl
E$tbttt
EFFEST OF HEALTH NFORTATPII TECI{ilOLOCVAT KEY gTAGE9IiI THE Prc|CESS OF
TEDIGATIoTI USE
dil
ngorandke*nm
T.rrteiptio!
6hgodAerm4Il*ofd
:rgdanr rnrSn&acrltn
unfr
mtcfut'or
ir.dbtliln
rdmlnmnAon
rsd
sedour mrdkrtiolieimrs
\AtHfi
Jn l
tcc*te-NlO,
d.8Z
W. t@F|mt.
AdrNtrsldbn,'
tug&lnd
Page
gBttc038
Exhlbtt2
SUNTARYOF HOAFfTALS IIIVOLYED Iil PRE'ECT HUGO
Acnto-crrc
Irondon
Ilcdtl
Sdenccc
Ccntre
t98
bmH4rnd
(offcri4
rtccrrch
hotpfrrl
Pnsvidpd carc
et&io
Vimia Hospial,
Meior prdent
IlcltthCrrc
crrqtcrctiry
rnd roorrch
ge&tric servicrs
r27E
ccotre
maoamrd svRtam
uomruBtty
35
varicty of rcrviceq
inolufug rdical, day Eulgery aod thcrapy u morc than 20,(F0 padants
hcatfrcarc
provider
snually
(bmmrmity
healtlmse
LIv![-Ir
{T
DisrictHospital
p'mvidcr
WDH:
furidi:s
34
Commnity
SlvtGII:
healthcare
54
FiCHS:
provider
l6
Community
healttrcaF
t9
nrrvider
Comnmity
health cue
tffi
pwider
Comrudty
healthse
$DH)
cddimert
qrB
of E9'0oo residstts
5t
ll3
Srviry;ffiot
providcr
Gornmunity
hatthcnrc
host of ser.vices,
mider
rrehabiliratiur
wGIr provides a
tB{{c038
PagF {0-
Erhlblt 3
OROAI{trATIOM1 Y|g|gil STATETEHT8
Londqr
Thle
\rndon
ffil$rryttodG rd
rfunh:oryrnerilon
Srarr3ft
8t Jo.cphl [b.Ah
Garsfs Vblon
From the shortest visit to the longest sry, we eam ccmple& confidence in tho cale we provide, and make
alastingdiffernos infu otmtto live frrllv.
SoryDa: Sl.
Jogptrbfroalfr Cr,n,
l-o,1dq, Wrl{vvtw-ryhclrrdononca/rrischrrvdebmadrrs
hge
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11
ExhlHi{
GUFRETY
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WORI(FLIOYS
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Serd Sopy tn Fr
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S*tgb*a
ttf.lisa{tDr:
Skti*xaa
trerg$ltsrrsrrs
Pre- CFOE
OoecReconcili*tbrti -- 24 Key
l-ranractitffls
Itrn.'al Bi$rnc
Abb;Rfl=ragdrpclrrnse,'tlARcmaM
qty
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fuanlelffioa
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filb[5
PrcFOSED HUCOWORKFLOIfl
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- qr$y'rt&rd pltdtbr
Dc.&flffi,
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cboilronb ncdlrd
ffinisdlrqr. B@d
9BfiS3E
Prse 13
E$iHt6
SATPLE HATIilRITTE}I TED|CATIOI{ ORDER
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SATPLE HUGO NED|CATION OruER
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for arry pcienq anywhere,
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evids!e cffir sae, higlrCqllity oara Physioim rGceives
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ldodietionsrycardirecrlym
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as a poccss
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acountrbi$ty
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80eGs;
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their
8. Tcchnologr
rerrided bv tbe
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misrahbelid6ar
hosp,itals can do it on
or&
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at thc clbow.
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hEvp soeific rhvsicisn tplp line.
IT staff will suppon fu sY$m Un aftr he
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