Improving the Hospital Performance in Economic Crisis. EUREGIO III - 3rd Master Class Programme Lisbon, March, 2011

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1 Improving the Hospital Performance in Economic Crisis EUREGIO III - 3rd Master Class Programme Lisbon, March, 2011

2 Improving the Hospital Performance in Economic Crisis EUREGIO III - 3rd Master Class Programme March, 2011 CRITICAL ROLE OF INFORMATION SYSTEMS MANAGEMENT IN A HOSPITAL 23 de Março de 2011 International Medical Informatics Association LUÍS VELEZ LAPÃO Professor of Health Information Management IHMT - Universidade Nova de Lisboa

3 TWO STARTING IDEAS: ARE WE FRIENDS OR BROTHERS? High-resolution mtdna evidence for the late-glacial resettlement of Europe from an Iberian refugium. Pereira L. Amorim A: Genome Research 15: 19-24, 2005 A Portuguese Laboratory has prove that people from Iberia Peninsula was critical to repopulate Europe after the last Ice age, years ago! Page 3 3

4 PORTUGAL IS THE 12º HEALTH SYSTEM (WHO, 2000) Portuguese National Health Service (NHS) has: 103 hospitals 73 primary health care groups (ACES) Viana Castelo Porto Braga Vila Real Bragança By law, all Portuguese citizens may access the NHS Aveiro Viseu Most medical data is held by the NHS-IS The small role of the private sector in both primary and hospital care, The NHS-IS was created (in the 80 s), developed and still maintained by governmental ACSS Academia is pervading: UNL, FMUPorto, UAveiro, etc. Lisboa Setúbal Guarda Coimbra Leiria ehealth? Castelo Branco Santarém Portalegre Évora Competition on the increased mode: Only recently PortugalTelecom Health, Alert, Glintt and other players had joined Siemens (which did the first Page implementation 4 of HL7 in 2004) Beja Faro

5 Challenges for European Health Delivery Systems Ageing population, Chronic Diseases Rising costs of healthcare Growing expectations of citizens Improving Patient safety Addressing mobility of patients Page 5

6 IS Hospital Information Systems DEVELOPMENT A MISSION IMPOSSIBLE? Page 6 6

7 THERE ARE SEVERAL CONSTRAINTS... We are approaching the new era with 21st century technologies, 20th century governance processes, and 19th century governance structures. The combination of short-sightedness, irresponsibility, gullibility, human greed, and fear of change is impeding homeostatic evolution of a knowledge society. The co-existence of several uncontrolled trends presents serious societal tensions. Page 7 (Harold Linstone, 1997)

8 AFTER A SERIES OF UNSUCCESSES... In 1969, Donald Lindberg, M.D. (medical informatics pioneer and now U.S. National Library of Medicine Director) said: Computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information Source: Lindberg DAB, Computer Failures and Successes, Southern Medical Bulletin, Page 8

9 UNSUCCESSESS STILL GOES 40 YEARS AFTER Serious clinical computing problems in the worst of places: an Intensive Care Unit EPR was desired by the medical staff to save time and improve care. The MIS department was put in charge of software and hardware selection and configuration. air filtration, maintenance & contaminant circulation from the power supply fans & other ergonomic and medical issues were not considered. The system was also repeatedly crashing & the informaticist was finally consulted: crashes caused by x- ray machine? memory module from a machine and found it was an 8 bit, not a 9 bit, module & therefore did not support parity checking. Administration did not believe ergonomics & technical concerns. In fact, a vendor software design deficiency was found to be causing the crashes. Meanwhile, the system proved more costly to support than MIS had predicted, requiring extensive development & customization. Silverstein(2009) Page He challenges hardware and software developers to build products that better support human needs and that are usable at any bandwidth. Ben Schneiderman

10 WE STILL KNOW LITTLE ABOUT INFORMATION SYSTEMS IMPACT IN HEALTHCARE Crossing the Quality Chasm: A New Health System for the 21st Century Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard it tries. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes. Source: Institute of Medicine (Nat l Acad Sci, USA) Page 10 10

11 BUT, ARE INFORMATION SYSTEMS REALLY DIFFERENT IN HEALTHCARE? Bernard Wess says not really The message to software architects study carefully the years of human-machine interface research and development by NASA and pay much more attention to the But, S. Silverstein says Yes Clinical IT projects are incredibly complex social endeavors in unforgiving environments that happen to involve computers, as opposed to IT projects that happen to involve doctors... requirements for the user interfaces in mission-critical and critical care software Page design... Many IS simply don t reflect the healthcare professional s hectic work environment... Not a calm and solitary environment

12 Costs for Society THE INSTITUTE OF MEDICINE (USA) SHOWN THAT THERE IS A LOT WHERE TO IMPROVE HEALTHCARE QUALITY ~90,000 Deads Eventos Adversos Verdadeiros Eventos Adversos Source: Institute of Medicine, To Err is Human, Page 12 Aceitável Precocious Diagnosis Therapy Rehabilitation

13 WHY DOES IT HAPPENS THIS WAY? What is really the Problem with Healthcare? Page 13 13

14 WHY DOES IT HAPPENS THIS WAY? What is really the Problem with Healthcare? Healing is an art, Medicine a Science and Healthcare is a Business Anounimous. Page 14 14

15 A TYPICAL FLUX OF PEOPLE AND INFORMATION IN HEALTHCARE SHOWS THAT WE NEED TO COPE WITH COMPLEXITY, SERIOUSLY Self-Care Population (média) residentes 76 nascimentos visitantes 66 mortes NHS Direct Chamadas Emmergencies Ambulance Chamadas Healthcare Kits Home care 22 Residential care Não planeados OOH 629 na hora Cirurgias por médicos planeadas A&E Hospital Services Visitas Cuidados Farmacêuticas Primários 255 atrasos nas consultas de medicina familiar 746 MAU Blocos Urgência electivo Cuidados Pós-cirúrgicos 0 altas antecipadas 50 electivas canceladas 529 Page 15 Source: Adaptaded from Boyle & Pratt (2004)

16 SELF-ORGANIZATION WILL ALLOW TO UNDERSTAND THE COMPLEX PATTERNS THAT WILL HELP DECISSION MAKING C O M P L E X I T Y Understanding Patterns Contextualized Information that allows Decision Making and Action Page 16

17 SELF-ORGANIZATION WILL ALLOW TO UNDERSTAND THE COMPLEX PATTERNS THAT WILL HELP DECISSION MAKING Page 17 C O M P L E Understanding Patterns From Contextualized Information that allows Decision Making and Action X I Complexity Theory perspective T Y we can only manage a complex system introducing simple rules and allowing for a distributed self-organization

18 DEALING WITH COMPLEXITY IN HEALTHCARE IMPLIES TECHNOLOGY BUT MORE IMPORTANTLY A COLLABORATIVE ENVIRONMENT Complexity Absorption Motivated Teams Highly Qualified Personel Risk Taking/innovative Culture A Rich Social Network Focus on Quality Information Systems Architecture Hard Rules Technology Page 18 (Lapao, 2008) Complexity Reduction

19 STRATEGY HAS BEEN BADLY USED BUT IT IS CRITICAL Strategy is deciding where and how to use the available resources! A Crew that stands the storm = People Highly Qualified Page 19 19

20 HEALTHCARE STRATEGY AND INVESTMENTS SHOULD MEET THE NEW PARADIGM Self-Healthcare and Telemedicine Local Healthcare Centres IS Regional Hospitals Central Hospitals Acute Hospitals Page 20 Source: Adaptaded from Smith R. The future of health care systems. BMJ 1997

21 WE NEED TO IMPROVE ehealth POTENTIAL TO TRANSFORM HEALTHCARE Quality Cost THE CHALLENGE OF BRINGING THE CITYZEN AS AN ACTIVE PART OF THE SYSTEM OPTIMIZATION: DO MORE WITH LESS RESOURCES Science: The opportunity of learning with others Leadership and Training are critical Page 21 Partnership between Industry, Operators and the Citizen

22 BUT WHAT IS REALLY HAPPENING IN HOSPITAL IS? SURVEY ON HIS IN PORTUGAL(2006) MANAGEMENT INFORMATION SYSTEMS Procureme nt EHR/ERP Citizens INTEGRATED HEALTH SERVICES NETWORK Web 2.0 CRM Page 22

23 EUROPEAN HOSPITALS DO NOT HAVE ENOUGH PEOPLE AND SKILLS... There is a Structural Problem with the IS Teams in the Hospitals Metric: The IT Personel/Total Personel Ratio 1/50 1/55 1/66 1/88 1/100 USA Rikshospitalet (No) St. Llatzar (Spain) Marburg Hospital (D) 1/133 1/200 1/400 HSM Portugal H.Famalicão Page 23 Source: Smaltz (2002) & Luís Lapão (2005)

24 THERE ARE ONLY AN AVERAGE 4-5 IS TECHNICIANS PER HOSPITAL Part of these Technicians are Located Centrally and not in the Hospitals IS Personel Evolution Evolução do número pessoas pessoas no SSI (por tipo de contrato) % 13% 2 12% % Outros Avença Contrato Efectivos Page 24 24

25 43% OF IS MANAGERS HAVE BEEN IN THE POSITION ONLY FOR LESS THEN 3 YEARS How long have you beeing in this position? How long have you being in this position? 35% 30% 25% 20% 15% 10% 5% 0% No responce < 1 Year 17% 43% 1-3 Years 27% 30% 27% 3-5 Years > 5 Years Page 25 25

26 50% OF THE HOSPITALS SAY THEY HAVE NO ORGANIZATIONAL PROCESSES REGISTERED Does the Hospital have Organizational Processes Registered? Processo 10 23% 23% 50% 5 13% 10% 13% 13% Não Responderam Page Sim,induzido pela implementação dos S.I. Sim,induzido pelo Programa de Qualidade Sim induzido por... Não, não estão definidos Outro Não Responde / Não Sabe

27 43% OF THE MANAGEMENT REPORTS ARE ONLY AVAILABLE IN PAPER (NOT IN THE EHR) Describe the Management Information System? SIG % 37% Page Não Responderam ão, fazem-se apenas relatórios de área em papel 7% 3% 7% Sim, existe um sistema protótipo (em teste) o, mas os relatórios de área estão disponíveis n... Sim, toda informação está integrada num SIG

28 IN 58% OF THE IS DEPARTMENT ONLY DEALS WITH HARDWARE AND MAINTENANCE, SHOWING LACK OF MATURITY TO ADDRESS EHR Characterize the IS Department Main Functions? Page 28 28

29 WHY IS THE PHYSICIANS PARTICIPATION THE FIRST SUCCESS FACTOR FOR IS IMPLEMENTATION? Or Why have we forgotten this fact so far? Quais são os factores críticos para o sucesso da implementação de SI? What are the Critical Factors for Implementing IS in Healthcare? Envolvimento dos m... 26,2% 22 Formação aos utiliz... 16,7% 15,5% 13,1% 11,9% Planeamento adeq... Liderança da Admin... Liderança do Directo... Gestão profissional... Page % 3,6% 3,6% 2,4% 1,2% O sistema de quali... Formação "on job" Outro Imposição da soluçã...

30 PROBABLY DUE TO LACK OF REGULATION, THERE IS STILL A FRAGMENTED SEARCH FOR CLINICAL APPLICATIONS Nursing, Pharmacy, PACS, Medical, Logistics and Manchester Systems What new Functionalities are most needed in your Hospital? Que novas funcionalidades estão planeadas para o ano em curso (2006) e no ano ,3% 5 7,4% 7,4% 7,4% ,7%3,7%3,7%3,7% 3,7% SAPE Farmácia hospitalar PACS SAM SICDE Logísitica Imagiologia Módulo urgência - triagem Laboratório Prescrição electrónica 1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1,9%1, Armazéns avançados Gestão de filas de espera /... Active Directory Rede Telemática Saúde Internamentos Consultas Exames especiais SIGLIC Data Ware Housing Módulo Clinico Gestão Hospitalar Data Center Terminal Server Gestão Inform. Serv. Social Gestão correspondência Gestão transportes doentes Sistema controlo de Inf Workflow - Anato Sis Page 30 30

31 ONLY 33% USE PROJECT MANAGEMENT METHODOLOGIES Utilização de Metodologias de Gestão de Projectos ARE YOU USING PROJECTS MANAGEMENT METHODOLOGIES? % No response Não Responderam 40% 33% 27% No Yes Do Not Know Não Sim Não Responde / Não Sabe Page 31

32 VICIOUS CIRCLE THAT EXPLAINS THE DELAY IN DEVELOPING HOSPITAL INFORMATION SYSTEMS Lack of Competition Lack of Skills in health care Information systems Strategic Instability Frequent (almost yearly) changes in Hospital Boards Lack of Regulation Page 32

33 Page 33 THERE IS A GAP BETWEEN CLINICIANS AND MANAGERS: - There are clearly differences between clinicians and managers sociograms/relationships Clinicians sociograms Managers Sociograms Hospital Sociogram

34 DOES WE REALLY KNOW WHERE WE WANT TO GO? Page 34

35 HOSPITAL INFORMATION MANAGEMENT HAS BEEN ADDRESSED AS A TECHNOLOGY PROBLEM Leading to many unsuccessful projects and waste Page 35

36 Leading to many unsuccessful projects and waste Because an Information System is not a Refrigerator Adapted from René Magritte

37 ehealth IS MAINLY AN ORGANIZATIONAL PROBLEM # de Consultas Pediatria e Cardiologia Fetal MANY MEETING AND DEBASTES ARE NEEDED TO DEFINE (EACH) ehealth GOVERNANCE MODEL N=3.500 Page 37 Saúde XXI: 1 Million invested in Telemedicine (APDC, 2004)

38 THERE ARE ORGANIZATIONAL ISSUES BEYOND TECHNOLOGY... INTEGRATION REQUIREMENTS Technical Programming Web Services abstractions.net Bridging different -Syntactic XML Formats formats - Operating Systems CORBA - Network protocols etc. => Easy programming of J2EE Web distributed technology systems EJB Semantics Data Functional Interfaces Meaning of commonly used data Meaningful cooperation of functions ( ) Meaning of contexts In different applications ICD LOINC UMLS Page 38

39 EHR related activities around the World Canada Infoway set up to design and procure National EHR - $1.2 billion of government backing USA - ONCHIT promoting NHIN and RHIO s. Government has invested $140 million to date. EHR Maturity High Medium Low Considering EHR Data N/A or No EHR Presence Page 39 Mexico: No EHR but aim for HL7 Integration Chile: PACS in Santiago University Hospital Q England: Connecting for Health- 6 billion until Netherlands: 88% of GPs have an EHR France: EHR Mandatory by Denmark : National EHR for January Brazil: National Health Card Project. Argentina: 1 st adoption of a digital radiography solution Sweden: Developing a National EHR Germany: E- Health card by January South Africa: No EHR but infrastructure being developed. Malaysia: Lifetime Health Record (LRH) by 2010 China: Plans to develop a national EHR Accenture, 2007 New Zealand: National EHR system in place. Hong Kong: Territory wide Patient Master Index Singapore: EMR system tender expected Q Australia: HealthConnect is developing a National Information Network.

40 WHAT can HIS do for these factors? HIS Health Information Systems Considering the Factors determining a health status of an individual - Quality/Efficacy of Healthcare services - Prevention policy (e.g. vaccination, screening) - Lifestyle: what we eat, drink, breath, - Physical and social environment Health delivery system Exogenous determinants - Genetic blueprint /profile at birth - Acquired genetic changes Endogenous determinants

41 THE ADOPTION OF NEW PRACTICES TAKES TIME Prescriptions 80% Disch. Letters 81 % Lab. reports 95 % Page 41

42 INTEROPERABILITY... STILL A CHALLENGE TO BE ACCOMPLISH... Page 42

43 THE PROMISES OF MOLECULAR MEDICINE New Long term R&D focus: Towards full picture of individual s health status Biosensors Biochips Environmental Data Genomic data Phenomic data Page 43 Integrated Health Records

44 THE PROMISES OF PREVENTIVE MEDICINE The Virtual Physiological Human 1. Integrating information relating to disease from the level of molecule, cell, organ, organism, population 2. Modelling and simulating disease related processes and human physiology 3. Predicting risks and developing more effective treatments or prevention programmes Page 44

45 The Virtual Physiological Human Will imply the support of Huge Information Systems and New Business Models New basis for: Personalised (Patientspecific) healthcare solution Early diagnostics & Predictive medicine Page 45

46 AN ehealth NETWORK OF SERVICES IS BEING BUILD UP AND IT WILL CHANGE HEALTHCARE DELIVERY Page 46

47 Personal Health Systems - Prevention & Personalisation citizen empowerment to manage own health status emphasis in preventative lifestyle management of chronic diseases independent living - In the form of Wearable, implantable, portable systems Point-of-care systems (biochips) Smart home environments BUT WHO IS GOING TO MANAGE ALL THIS INFORMATION? Page 47 WHAT ARE THE BUSINESS MODELS?

48 HOSPITAL INFORMATION MANAGEMENT IS INDEED AN ORGANIZATIONAL ISSUE Information is a key Asset for Hospital Services Delivery To avoid as many mistakes as possible: Evidence Based Medicine & Managem. objective subjective Assesment Planning Society operational Diagnostic Action Therapeutic Action Medical Community Input Process Care Action Output Page 48

49 INFORMATION SYSTEMS DEVELOPMENT REPRESENT AN OPPORTUNITY TO IMPROVE HEALTH SERVICES PROCESSES Health Professionals Processes & Information Systems Page 49

50 ACTION RESEARCH ALLOWS THE DEVELOPMENT OF SPECIFIC SOLUTIONS IN HEALTHCARE SERVICES DIAGNOSIS SPECIFYING LEARNING ACTION PLANNING EVALUATING ACTION TAKING Action-Research methodologies to address the interaction with health professionals and to study their behavior dependence (influential factors) and Social structures; Page 50

51 BECAUSE WE NEED TIME AND HUMAN RESOURCES Page 51

52 IT TOOK US ALMOST 50 YEARS TO REDUCE IMR Portugal TM infantil TM perinatal TM neonatal TM neonatal precoce TM neonatal tardia TM pós-neonatal Page INFANT MORTALITY RATE Source: A. Biscaia Ano Infant Mortality rate 2003 UK 5,3 Ireland 5,1 Portugal 4,1 Sweden 2, ,9

53 THE PRIMARY CARE REFORM SHOULD BE ADDRESSED LIKE THE INTRODUCTION OF AN INNOVATIVE PRODUCT INITIATION PLANNING IMPLEMENTING MATURITY Quality PACES APMCG Livro Azul CS 1ªG Alma -Ata CS 2ªG CS MSCP USF Alfa - RRE ACES ACES 2.0 Tempo Page 53 SNS Serviço Médico à Periferia CS 3ªG SLS New Public Management

54 AS HEALTH CENTERS DO A LOT OF DIFERENT THINGS... ENTIDADES COM INTERESSES CULTURA NACIONAL ENTIDADES COM INTERESSES IPSS OUTROS NÍVEIS DE CUIDADOS DE SAÚDE CULTURA LOCAL VIGILÂNCIA DAS ÁGUAS SAÚDE OCUPACIONAL VIGILÂNCIA HIGIO- SANITÁRIA VIGILÂNCIA EPIDEMIO- LOGICA VACINAÇÃO SAÚDE ESCOLAR CULTURA INSTITUCIONAL H O S P I T A l UTENTE REFERENCIAÇÃO INTERVENÇÃO NA COMUNIDADE CONSULTA GERAL PNEUMOL. FISIOT SAÚDE PÚBLICA CUIDADOS DE SAÚDE PESSOAIS SERVIÇO SOCIAL AT. TOXICODEP PSICOL CUIDADOS CONTINUADOS AT ADOLESC MED DENT PLANEAMENTO FAMILIAR SALA DE TRATAMENTOS AC + SAP OUTRAS TECN SAÚDE SAÚDE MATERNA SAÚDE INFANTIL UTENTE FORMAÇÃO EXTERNA PROFISSIONAIS CHEFIAS INTERMÉDIAS INVESTIGAÇÃO RESULTADOS DA ACTIVIDADE DIRECÇÃO C. SAÚDE PROGRAMAÇÃO DA ACTIVIDADE ESCOLAS ESTAB. DE LAZER Page ARS MINISTÉRIO SAÚDE ESTAB.DE RESTAURAÇÃO

55 BUT INDEED THEY ARE VERY COMPLEX ENTITIES Hospital x Outros Centros de Saúde ARSLVT x x x x x x x x Administrativos/Gestores Saúde O Pública Médicos Enfermeiros Direcção O x O O O Serviços Disponibilizados O Centro de Saúde O O O O Psicólogos Dietistas O O O Assistente Social Escolas O C. Municipal Associação Seg. Social O Projectos esperados Page 55 Feed-back População com acesso (são ligações especiais)

56 THE NEW MODEL FOR PRIMARY CARE ACES EMPHASASIES COLABORATIVE WORK AND MANAGEMENT ARS, BOARD UCSP USF CS UCC ACES USF USF USF USP URAP CS UCSP UCC UCSP Governação Clinical Governance Clínica UCC Unidade de Apoio à Gestão Conselho Comunidade Director Executivo Conselho Executivo UCSP UCSP CS UCC USF Page 56 UCSP CS USF Gabinete do Cidadão Liderança Leadership Conselho Técnico Director Clínico ECLCCI USF Management Gestão

57 AND BUSINESS PROCESS MANAGEMENT Structure for work collaboration and communication Structure for co-learning and innovation Strategic capability of organizations Page 57

58 WITH PROCESS MINING ONE COULD Health information systems typically support logging capabilities that register what has been executed in the organization. These produced logs contain data about cases that have been executed in the organization, the times at which the tasks were executed, the persons or systems that performed these tasks, etc. The EVENT LOGS are the starting point for process mining. Page 58

59 DEFINE WORKING PROCESSES - Process Mining application in healthcare services Improvement Page 59 Modeling

60 A Process Mining Example from Hospital Emergency Lapão (2009) Page 60

61 FROM PROCESS MINING TO MANAGEMENT Process Model Organizational Model Start Register order Prepare shipment Social Network (Re)send bill Ship goods Contact customer Receive payment Archive order End Event Log Page 61 Mining Techniques Performance Analysis Auditing/Security Mined Models

62 O BUILD AN EHR TO SUPPORT QUALITY IT IS EQUIRED THE UNDERSTANDING OF MANY PROCESSES Agendamento Admissão Prescrição Imagiologia, Laboratório, Exames sala DIAGNOSIS CICLO Value Chain ADMINISTRATIVE CYCLE CLINICAL CYCLE Resultados Cirurgia, Enfermagem,... Documentação TREATMENT CYCLE Facturação Alta UCI, U. internamento ERP/HIS Tradicional MONITORING CYCLE Financial Data Asymmetry Diversity of Clinical cases Page 62

63 WHERE IS THE VALUE OF INFORMATION SYSTEMS? We Estimate a Potential of 1 Million and Euros/year per Hospital But how many reach actually this reduction?? Process Automation Less personal Less errors Faster Services Process Optimization More consultations More Surguries (Less waiting list) Less errors Transformation More Services More quality Better respose Page 63

64 WE NEED LEADERSHIP/GOVERNANCE AND TO HAVE PROPER INFORMATION MANAGEMENT SKILLS Two Examples HOSPITAL DA LUZ Lisbon A real CIO in the Board of Management IS Department joints together Both Information Systems and Organizational Focus on developing hospital Processes with users/clinicians/ nurses RIKSHOSPITALET Oslo IS Department Personnel 12 5X 58 2X Page 64

65 A STORY FROM HISTORY TECHNOLOGY IS NOTHING WITHOUT PEOPLE David S. Landes, The Wealth and Poverty of Nations The Chinese never learned to make modern guns. Worse yet, having known and used cannon as early as the thirteenth century, they had let knowledge and skill slip away. Their city walls and gates had emplacements for cannon, but no cannon. Who needed them? No enemy of China had them. No European nation would have been deterred from armament by enemy weakness; when it come to death, Europeans maximized. European technology was also incremental: each gain led to further gain. So it was that in 1621, when the Portuguese in Macao offered four cannons to the emperor by way of gaining favor, they had to send four cannoneers along with them. Page 65

66 IN ORDER TO TRANSFORM HEALTHCARE WE NEED HIGHLY QUALIFIED PEOPLE ALONGSIDE STRATEGY Page 66 66

67 BUT THERE IS HOPE Page 67

68 Obrigado! Page 68

69 INSTITUTO DE HIGIENE E MEDICINA TROPICAL Rua da Junqueira Lisboa, Portugal tel:+(351) Page 69

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