Patient-Oriented Electronic Medical Records for the Critical Care

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1 Patient-Oriented Electronic Medical Records for the Critical Care Adil Ahmed MBBS Research associate Department of Pulmonary and critical care Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.) June MFMER slide-1

2 Objectives Outline of challenges and opportunities in designing informatics supports to enhance safe and effective life support interventions Review exciting local initiatives including AWARE (Ambient Warning and Response Evaluation) Provide some details about recent CMS award

3 Innovation Motivation

4 One in five Americans dies in ICU Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004;32(3):

5 Cost of ICU ICU Hospital budget 20% * - Halpern NA, Bettes L, Greenstein R. Federal and nationwide intensive care units and healthcare costs: Crit Care Med 1994;22(12): ** - Barnato et al. Prioritizing the organization and management of intensive care services in the United States: the PrOMIS Conference. Crit Care Med Apr;35(4):

6 Problem #3: Errors in ICU Care Delivery Preventable medical errors cost $17-29 billion dollars annually and account for an estimated 44,000 to 98,000 deaths every year in US hospitals [1] One study reported that an average of 178 processes of care were delivered to the ICU patient per day of stay with 1.7 of those associated with some error [2] The same study identified 554 errors and over 200 serious errors in a single ICU over a 4 month period Another report demonstrated an average of serious errors/1000 patient days and 36.2 preventable adverse events/1000 patient days in a university hospital ICU [3] [1] Kohn L, Corrigan, JM, Donaldson, MS (ed.): To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; [2] Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov R, Cotev S: A look into the nature and causes of human errors in the intensive care unit. Critical care medicine 1995, 23(2): [3] Rothschild JM, Landrigan CP, Cronin JW, et al: The critical care safety study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005; 33:

7 Problem #4: Data volume in ICU (and before) Microbiology, labs, medications, chest X-ray, Nurses flowsheet, Clinical notes (history and impression/plan) Vitals excluded Herasevich V, Litell J, Pickering B. Electronic medical records and mhealth anytime, anywhere. Biomed Instrum Technol Fall;Suppl:45-8. doi: / s2.45. PubMed PMID: MFMER slide-7

8 Technology Driven PUSH of Information Advances In Science Complicating the Practice of Medicine Advances in medicine (technology driven PUSH unconnected medical information) Medical practice (Need for clinically actionable Data /knowledge) PUSH Noise Huge amount of Data Detailed disease profiling Uncertain Choices

9 EMR in ICU

10 ICU is a Complex System! Laboratory Data Physiologic Monitor Nursing Staff Pharmacist Respiratory Therapy Consult services Physiologic Supports Patient Examination Family Radiology Other investigations

11 Value of this data?

12 Modern hospital electronic environment 2011 MFMER slide-12

13 Bad for patients Failure to recognize (resulting in incorrect diagnosis) Failure to rescue (resulting in late interventions) Waste (resulting in increased costs) Communication breakdown and process failure

14 Who else affected?

15 Where we are

16 Display: 9-inch electroluminescent Resolution: 512x256 matrix, 2 colors Weight: 25 pounds 16-bit processor: 12.5 MHz RAM: 5MB 24x 16x 160x 200x Display: 9.7-inch LED IPS LCD Resolution: m Weight: 1.44 pounds 64-bit, dual core: 1 GHz RAM: 1Gb 2011 MFMER slide-16

17 MFMER slide-17

18 Different settings different information needs

19 Overall satisfaction with EMR Of roughly 1,000 providers who received the survey in early May, about 53 percent responded. More than 200 providers also left detailed comments

20 Need for Improved EMR

21 Solution

22 Clinical information system Type the footnote/source in this space

23 Processing of clinical data ft. view Tools and methods for data entry Control, managing and storing of the data Databases Warehouses Data marts Standardization and transferring of the data HL7 DICOM ICD SNOMED CT CPT etc Clinical use of information Courtesy Dr Herasevich 2011 MFMER slide-23

24 Solution? Ambient Intelligence! 2011 MFMER slide-24

25 Information Flow in the ICU ICU team Organ Status Organ Status Relevant History Relevant History Diagnosis Relevant Exam Relevant Exam Relevant Therapies Relevant Therapies Treatment Relevant Invx Relevant Invx Data Information Packets Clinical Decision

26 How clinician works

27 Data flow: Primary Care Past medical history Complains and present status Plan of care. Orders Data flow: Critical Care Past medical history Complains and present status Plan of care. Orders

28 Recognition of the context Who? Where? When? From Time magazine - Aug. 10, 2009 PHOTO-ILLUSTRATION FOR TIME BY ARTHUR HOCHSTEIN. HEAD: BRENDAN HOFFMAN/EPA. BODY: BRAD WILSON/GETTY MFMER slide-28

29 Art Dr. Pickering AWARE

30 Acute Warning And Response Evaluation (AWARE) philosophy 1. Identify and present only relevant information 2. Bundled into discrete packages to facilitate decision making 3. Automated collection and display in real-time

31 Data Utilization for Decision Making in the ICU Physician Survey Results Pickering BW, Gajic O, Ahmed A, Herasevich V, Keegan MT. Data Utilization for Medical Decision Making at the Time of Patient Admission to ICU*. Crit Care Med

32 Doe John Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane Doe Jane

33 A) Organ Identifier and status C) Current Organ Physiological Status D) Status of relevant investigation B) Historical Contextual Data E) Provider Actions/support 2010 MFMER slide-33

34 Process of care tools Claim patient Indicator who is provider Easy page Task list Shared list of tasks Not part of official clinical note Rounding tool Addressed important questions Help generate clinical note Tool for meaningful EMR use

35 Testing

36 Evaluation and technology assessment Clinicians Technology Patients Is it fast? Is it accurate? Is it user friendly? Developers Purchasers Is it safe? Is it help me? Does it work? Will they use it? What is cost/benefit? Is it reliable? Adopted from: Friedman and Wyatt, MFMER slide-36

37 Multidisciplinary team Built Reduced cognitive load (happy clinicians) Reduced errors (happy patients) Reduced time (happy administrators) Standard Interface Novel Interface

38 AWARE peer-reviewed publications Ahmed A, Chandra S, Pickering et al. The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. Critical Care Medicine 2011;39(7): Pickering B, Herasevich V, Ahmed A, et al. Novel Representation of Clinical Information in the ICU - Developing User Interfaces which Reduce Information Overload. Applied Clinical Informatics 2010;1(2): MFMER slide-38

39

40 Pre-Rounding Resident Time Spent Gathering Data Per Patient Time (minutes) Pre-AWARE Post-AWARE n Mean Std Error Lower 95% Upper 95% Pre-AWARE Post-AWARE

41 Preliminary survey 1 and 3 EMR (n=129) mean±sd AWARE (n=106) mean±sd 1 The provides the precise information I need. 3.89± ± P 2 The information content in meets my needs 3.77± ± The provides me with sufficient information 3.8± ± I get the information I need in time using 3.3± ±0.81 < The provides up to date information 3.7± ±0.79 < I am satisfied with the accuracy of the 3.8± ± I think the information is presented in a useful format 2.7± ±0.93 <0.001 with 8 The information presented by the is clear 3.2± ±0.62 < makes task of data gathering difficult 3.39± ±0.83 < Data gathering with was mentally demanding 3.17± ±0.86 <0.001

42 AWARE in Cloud

43

44 Cloud AWARE

45 Outcomes of Interest Better care: Adherence to and appropriateness of processes of care, provider satisfaction Better health: Rate of ICU acquired complications, discharge home, hospital mortality, ICU and hospital readmission Lower cost: resource utilization, severity adjusted length of ICU and hospital stay and cost

46 U.S Health Care Cost Source: National Health Expenditures, % 30 % 20 % Source: National Health Expenditures, Health Policy and the Affordable Care Act Ezekiel Emanuel, MD 2011 MFMER slide-46

47 AWARE Outcome scheme Implementation Pre Implementation Validation period Cloud based automatic Reporting Patient outcomes Resource utilization Process outcomes Cost Jun 2012 Jan 2013 June 2013 Jan 2014 Jun 2014 Jan 2015 Jun MFMER slide-47

48 Goals Better Care >90% adherence to best ICU practices o DVT prophylaxis o Stress ulcer prophylaxis o Lung protective mechanical ventilation o Daily assessment of continuous sedation o Daily assessment of ventilator weaning o Daily assessment of need for intravascular devices and urinary catheter o Daily assessment of physical therapy goals Better Health - 50% reduction of preventable ICU complications o Ventilator associated events o Catheter related blood stream infection o Urinary tract infection o Pulmonary embolism - 5% increase in discharge home vs other health care facility Lower Cost - cumulative $$ decrease up to 20% with 3-year savings of $81 Million o Length of ICU stay o Length of hospital stay o Resource utilization (ventilator days, days of antibiotic use, transfusions, central line usage) Key Drivers AWARE Technology Ergonomic displays and cognitively effective information design decrease cognitive load/fatigue Patient-centered information management brings everyone on the same page, facilitates communication and prevents omissions Streamlined (lean) processes decrease the chance for error and improve efficiency Timely bedside decision support with safe defaults and smart alerts mitigates knowledge deficits Timely feedback reinforces good behaviors ProCCESs AWARE Iterative implementation of AWARE technology in four hospitals over 3 years Educate physicians, nurses and respiratory therapists in bedside use of AWARE technology (250 year 1, 1200 over 3 years) Serve 5,500 Critically Ill Patients in year 1; 30,000 over 3 years Secondary Drivers Milestones Develop & Deploy Technologies AWARE prototype refinement (design/usability, speed, reliability, extended functionality) Development and Deployment of Cloud AWARE (Confidentiality, Data Standards, Data Acquisition) Knowledge Transfer (Training & Workflow Implementation) Prioritization of best practices for ProCCESs AWARE Workflow Analysis and Optimization Educational /Training of Local Champions and Implementation Specialists Full Implementation of ProCCESs AWARE Outcomes Assessment Development and Implementation of real-time Reports of Care Processes Data Acquisition of Health and Cost Outcomes (CMS data access) Outcome analysis (Care, Health, Cost)

49 AWARE 2.0

50 A future generation of EHR A future generation of EHR need to exploit the advantages offered by the digitalization of the ICU environment. Key functionalities will include: 1. an in which they are operating; 2. reduce information overload by configuring the user interface to preferentially display subsets of to bedside providers at the point of care; ; 4. provide systems surveillance of health care delivery and on performance with reference to established standards of care; 5. be seamlessly and workflow in a manner which exploits our understanding of distributed cognitive function and choice architecture to optimize patient-centered outcomes; 2011 MFMER slide-50

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52 AWARE study PIs Brian Pickering, MD Ognjen Gajic, MD Vitaly Herasevich, MD, PhD

53 Acknowledges Kashyap, Rahul, M.B.B.S.; Kojicic, Marija, M.D.; Herasevich, Vitaly, M.D., Ph.D.; Li, Guangxi, M.D.; Thakur, Sweta J., M.B.B.S.; Vedre, Jayanth, M.B.B.S.; Johnson, Ann R. [RO CCS]; Parker, Stacy J.; Rasinski, Renee T.; Schmidt, Rachel L. [RO CCS]; Vonch, Linda J.; Wickert, Linda M. Cartin-Ceba, Rodrigo, M.D.; Dong, Yue, M.D.; Herasevich, Vitaly, M.D., Ph.D.; Kashyap, Rahul, M.B.B.S.; Krpata, Tami S.; Li, Man; Wilson, Gregory A., RRT; Li, Guangxi, M.D.; Kojicic, Marija, M.D.; Trillo Alvarez, Cesar A., M.D.; Bice, Thomas J., M.D.; Pickering, Brian W., M.B.B.Ch.; Vedre, Jayanth, M.B.B.S.; Thakur, Lokendra, M.B.B.S.; Thakur, Sweta J., M.B.B.S.; Lee, Kun-Moo, M.D.; Reriani, Martin K., M.B.B.Ch.; Fernandez Gomez, Javier, M.D.; Hanson, Andrew C.; Afessa, Bekele, M.D. Aksamit, Timothy R., M.D.; Asay, Garth F., M.D.; Atkinson, John, M.D.; Bannon, Michael P., M.D.; Barsness, Gregory W., M.D.; Bell, Malcolm R., M.D.; Berge, Keith H., M.D.; Best, Patricia J M, M.D.; Brown, Daniel R., M.D., Ph.D. [RO CCS]; Caples, Sean M., D.O.; Chandrasekaran, Krishnaswamy, M.D.; Clements, Ian P., M.D.; Colby, Christopher E., M.D.; Comfere, Thomas B., M.D.; Cullinane, Daniel C., M.D.; Daly, Richard C., M.D.; Daniels, Craig E., M.D.; Dearani, Joseph A., M.D.; Derleth, Douglas P., M.D.; Diedrich, Daniel A., M.D.; Dunn, William F., M.D.; Farmer, Joseph C., M.D.; Findlay, James Y., M.B.Ch.B.; Fulgham, Jimmy R., M.D.; Gajic, Ognjen, M.D.; Gali, Bhargavi, M.D.; Gay, Peter C., M.D.; Gersh, Bernard J., M.B.Ch.B., D.Phil.; Gracey, Douglas R., M.D.; Hahn, Peter Y., M.D.; Heller, Stephanie F., M.D.; Hubmayr, Rolf D., M.D.; Jaffe, Allan S., M.D.; Johnson, Robert V., M.D. [RO NP]; Keegan, Mark T., M.D.; Kor, Daryl J., M.D.; Lapeyre, Andre C. III, M.D.; Manno, Edward M., M.D.; McGregor, Christopher G A, M.D.; Mullany, Charles J., M.B.,M.S.; Murphy, Joseph G., M.D.; Narr, Bradly J., M.D.; Oh, Jae K., M.D.; Orszulak, Thomas A., M.D.; Ouellette, Yves, M.D., Ph.D.; Park, John G., M.D.; Peters, Steve G., M.D.; Prasad, Abhiram, M.D.; Puga, F. J. (Francisco), M.D.; Rabatin, Jeffrey T., M.D.; Rabinstein, Alejandro A., M.D.; Ramar, Kannan, M.B.B.S., M.D.; Reeder, Guy S., M.D.; Rickman, Otis B., D.O.; Rihal, Charanjit S., M.D.; Ritter, Matthew J., M.D.; Roy, Tuhin K., M.D., Ph.D.; Sawyer, Mark D., M.D.; Scanlon, Paul D., M.D. [RO PUL]; Schears, Gregory J., M.D.; Schiller, Henry J., M.D.; Scott, John P., M.D. [RO PUL]; Seferian, Edward G., M.D.; Sinak, Lawrence J., M.D.; Subla, Mir R.; Sundt, Thoralf M. III, M.D.; Swanson, Karen L., D.O. [RO PUL]; Tilbury, R. Thomas, M.D.; Vlahakis, Nicholas E., M.D.; Whalen, Francis X. Jr., M.D.; Wijdicks, Eelco F., M.D., Ph.D.; Wright, Alan J., M.D.; Wylam, Mark E., M.D.; Zietlow, Scott P., M.D.; Jenkins, Donald, M.D.; Vrchota, Jan M., C.N.S., R.N.; Warfield, Karen T., C.N.S., R.N..; Fulgham, Jimmy R., M.D.; Gajic, Ognjen, M.D.; Gali, Bhargavi, M.D.; Gay, Peter C., M.D.; Gersh, Bernard J., M.B.Ch.B., D.Phil.; Gracey, Douglas R., M.D.; Hahn, Peter Y., M.D.; Heller, Stephanie F., M.D.; Hubmayr, Rolf D., M.D.; Jaffe, Allan S., M.D.; Johnson, Robert V., M.D. [RO NP]; Keegan, Mark T., M.D.; Kor, Daryl J., M.D.; Lapeyre, Andre C. III, M.D.; Manno, Edward M., M.D.; McGregor, Christopher G A, M.D.; Mullany, Charles J., M.B.,M.S.; Murphy, Joseph G., M.D.; Narr, Bradly J., M.D.; Kashyap, Rahul, M.B.B.S.; Kojicic, Marija, M.D.; Herasevich, Vitaly, M.D., Ph.D.; Li, Guangxi, M.D.; Thakur, Sweta J., M.B.B.S.; Vedre, Jayanth, M.B.B.S.; Johnson, Ann R. [RO CCS]; Parker, Stacy J.; Rasinski, Renee T.; Schmidt, Rachel L. [RO CCS]; Vonch, Linda J.; Wickert, Linda M. Cartin-Ceba, Rodrigo, M.D.; Dong, Yue, M.D.; Herasevich, Vitaly, M.D., Ph.D.; Kashyap, Rahul, M.B.B.S.; Krpata, Tami S.; Li, Man; Wilson, Gregory A., RRT; Li, Guangxi, M.D.; Kojicic, Marija, M.D.; Trillo Alvarez, Cesar A., M.D.; Bice, Thomas J., M.D.; Pickering, Brian W., M.B.B.Ch.; Vedre, Jayanth, M.B.B.S.; Thakur, Lokendra, M.B.B.S.; Thakur, Sweta J., M.B.B.S.; Lee, Kun-Moo, M.D.; Reriani, Martin K., M.B.B.Ch.; Fernandez Gomez, Javier, M.D.; Hanson, Andrew C.; Afessa, Bekele, M.D. Aksamit, Timothy R., M.D.; Asay, Garth F., M.D.; Atkinson, John, M.D.; Bannon, Michael P., M.D.; Barsness, Gregory W., M.D.; Bell, Malcolm R., M.D.; Berge, Keith H., M.D.; Best, Patricia J M, M.D.; Brown, Daniel R., M.D., Caples, Sean M., D.O.; Chandrasekaran, Krishnaswamy, M.D.; Clements, Ian P., M.D.; Colby, Christopher E., M.D.; Comfere, Thomas B., M.D.; Cullinane, Daniel C., M.D.; Daly, Richard C., M.D.; Daniels, Craig E., M.D.; Dearani, Joseph A., M.D.; Derleth, Douglas P., M.D.; Diedrich, Daniel A., M.D.; Dunn, William F., M.D.; Farmer, Joseph C., M.D.; Findlay, James Y., M.B.Ch.B Oh, Jae K., M.D.; Orszulak, Thomas A., M.D.; Ouellette, Yves, M.D., Ph.D.; Park, John G., M.D.; Peters, Steve G., M.D.; Prasad, Abhiram, M.D.; Puga, F. J. (Francisco), M.D.; Rabatin, Jeffrey T., M.D.; Rabinstein, Alejandro A., M.D.; Ramar, Kannan, M.B.B.S., M.D.; Reeder, Guy S., M.D.; Rickman, Otis B., D.O.; Rihal, Charanjit S., M.D.; Ritter, Matthew J., M.D.; Roy, Tuhin K., M.D., Ph.D.; Sawyer, Mark D., M.D.; Scanlon, Paul D., M.D. [RO PUL]; Schears, Gregory J., M.D.; Schiller, Henry J., M.D.; Scott, John P., M.D. [RO PUL]; Seferian, Edward G., M.D.; Sinak, Lawrence J., M.D.; Subla, Mir R.; Sundt, Thoralf M. III, M.D.; Swanson, Karen L., D.O. [RO PUL]; Tilbury, R. Thomas, M.D.; Vlahakis, Nicholas E., M.D.; Whalen, Francis X. Jr., M.D.; Wijdicks, Eelco F., M.D., Ph.D.; Wright, Alan J., M.D.; Wylam, Mark E., M.D.; Zietlow, Scott P., M.D.; Jenkins, Donald, M.D.; Vrchota, Jan M., C.N.S., R.N.; Warfield, Karen T., C.N.S., R.N. Kashyap, Rahul, M.B.B.S.; Kojicic, Marija, M.D.; Herasevich, Vitaly, M.D., Ph.D.; Li, Guangxi, M.D.; Thakur, Sweta J., M.B.B.S.; Vedre, Jayanth, M.B.B.S.; Johnson, Ann R. [RO CCS]; Parker, Stacy J.; Rasinski, Renee T.; Schmidt, Rachel L. [RO CCS]; Vonch, Linda J.; Wickert, Linda M. Cartin-Ceba, Rodrigo, M.D.;. Reeder, Guy S., M.D.; Rickman, Otis B., D.O.; Rihal, Charanjit S., M.D.; Ritter, Matthew J., M.D.; Roy, Tuhin K., M.D., Ph.D.; Sawyer, Mark D., M.D.; Scanlon, Paul D., M.D. [RO PUL]; Schears, Gregory J., M.D.; Schiller, Henry J., M.D.; Scott, John P., M.D. [RO PUL]; Seferian, Edward G., M.D.; Sinak, Lawrence J., M.D.; Subla, Mir R.; Sundt, Thoralf M. III, M.D.; Swanson, Karen L., D.O. [RO PUL]; Tilbury, R. Thomas, M.D.; Vlahakis, Nicholas E., M.D.; Whalen, Francis X. Jr., M.D.; Wijdicks, Eelco F., M.D., Ph.D.; Wright, Alan J., M.D.; Wylam, Mark E., M.D.; Zietlow, Scott P., M.D.; Jenkins, Donald, M.D.; Vrchota, Jan M., C.N.S., R.N.; Warfield, Karen T., C.N.S., R.N. Dong, Yue, M.D.; Herasevich, Vitaly, M.D., Ph.D.; Kashyap, Rahul, M.B.B.S.; Krpata, Tami S.; Li, Man; Wilson, Gregory A., RRT; Li, Guangxi, M.D.; Kojicic, Marija, M.D.; Trillo Alvarez, Cesar A., M.D.; Bice, Thomas J., M.D.; Pickering, Brian W., M.B.B.Ch.; Vedre, Jayanth, M.B.B.S.; Thakur, Lokendra, M.B.B.S.; Thakur, Sweta J., M.B.B.S.; Lee, Kun-Moo, M.D.; Reriani, Martin K., M.B.B.Ch.; Fernandez Gomez, Javier, M.D.; Hanson, Andrew C.; Afessa, Bekele, M.D. Aksamit, Timothy R., M.D.; Asay, Garth F., M.D.; Atkinson, John, M.D.; Bannon, Michael P., M.D.; Barsness, Gregory W., M.D.; Bell, Malcolm R., M.D.; Berge, Keith H., M.D.; Best, Patricia J M, M.D.; Brown, Daniel R., M.D., Ph.D. [RO CCS]; Caples, Sean M., D.O.; Chandrasekaran, Krishnaswamy, M.D.; Clements, Ian P., M.D.; Colby, Christopher E., M.D.; Comfere, Thomas B., M.D.; Cullinane, Daniel C., M.D.; Daly, Richard C., M.D.; Daniels, Craig E., M.D.; Dearani, Joseph A., M.D.; Derleth, Douglas P., M.D.; Diedrich, Daniel A., M.D.; Dunn, William F., M.D.; Farmer, Joseph C., M.D.; Findlay, James Y., M.B.Ch.B.; Fulgham, Jimmy R., M.D.; Gajic, Ognjen, M.D.; Gali, Bhargavi, M.D.; Gay, Peter C., M.D.; Gersh, Bernard J., M.B.Ch.B., D.Phil.; Gracey, Douglas R., M.D.; Hahn, Peter Y., M.D.; Heller, Stephanie F., M.D.; Hubmayr, Rolf D., M.D.; Jaffe, Allan S., M.D.; Johnson, Robert V., M.D. [RO NP]; Keegan, Mark T., M.D.; Kor, Daryl J., M.D.; Lapeyre, Andre C. III, M.D.; Manno, Edward M., M.D.; McGregor, Christopher G A, M.D.; Mullany, Charles J., M.B.,M.S.; Murphy, Joseph G., M.D.; Narr, Bradly J., M.D.; Oh, Jae K., M.D.; Orszulak, Thomas A., M.D.; Ouellette, Yves, M.D., Ph.D.; Park, John G., M.D.; Peters, Steve G., M.D.; Prasad, Abhiram, M.D.; Puga, F. J. (Francisco), M.D.; Rabatin, Jeffrey T., M.D.; Rabinstein, Alejandro A., M.D.; Ramar, Kannan, M.B.B.S

54

55 2011 MFMER slide-55

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