DIGITAL HEALTH: AN EMERGING TREND IN TECHNOLOGY AND ITS LEGAL IMPLICATIONS

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1 General Editor: Domenic A. Crolla, Gowling Lafleur Henderson LLP, Ottawa VOLUME 5, NUMBER 1 Cited as ( ) 5 Electronic Healthcare Law Review AUGUST 2015 DIGITAL HEALTH: AN EMERGING TREND IN TECHNOLOGY AND ITS LEGAL IMPLICATIONS Geoffrey D. Mowatt and Nikolas S. Purcell Dimock Stratton LLP As the digital age continues to evolve, the technologies behind a relatively new concept, digital health, are quickly percolating into the lives of all Canadians. What is digital health? This is a broad term used to describe technology-driven innovation in the healthcare field, which represents a melding of the fields of information technology and healthcare. Digital health encompasses technologies as readily accessible to today s savvy, In This Issue DIGITAL HEALTH: AN EMERGING TREND IN TECHNOLOGY AND ITS LEGAL IMPLICATIONS Geoffrey D. Mowatt and Nikolas S. Purcell... 1 CRITICAL CONSIDERATIONS FOR ESTABLISHING AND PARTICIPATING IN AN econsult SERVICE: LESSONS LEARNED FROM THE CHAMPLAIN BASE TEAM Dr. Erin Keely and Dr. Clare Liddy... 5 connected consumers as itriage (provided by itriage LLC) and WebMD (provided by WebMD LLC) two mobile device apps that provide answers to medical questions related to symptoms, medications, diseases, and medical locations to even more specialized technologies, such as MED-eDigital a digitally encoded paper combined with an epen used to improve medication monitoring and compliance for the elderly in long-term care facilities, provided by Medical Pharmacies Group Inc. Another example of a digital health technology is the Connected Wellness service of the Torontobased firm NexJ Systems Inc., which was recently featured in the Globe and Mail. Connected Wellness is a software solution aimed at furthering patient education and participation in the management of chronic disease. One feature of the cloud-based service is that the patient s healthcare records are available to the patient. As well, the service improves efficiency by fostering communication between

2 Electronic Healthcare Law Review Electronic Healthcare Law Review is published quarterly by LexisNexis Canada Inc., 123 Commerce Valley Drive East, Markham, Ontario L3T 7W8 Design and Compilation LexisNexis Canada Inc., Unless otherwise stated, copyright in individual articles rests with the contributors. All rights reserved. No part of this publication may be reproduced or stored in any material form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright holder except in accordance with the provisions of the Copyright Act. ISBN: X ISBN: (Print & PDF) ISBN: (PDF) Subscription rates: $200 per year (print or PDF) $295 per year (print & PDF) Please address all editorial inquiries to: Boris Roginsky LexisNexis Canada Inc. Tel. (905) ; Toll-Free Tel Fax (905) Toll-Free Fax Internet GENERAL EDITOR EDITORIAL BOARD Domenic A. Crolla, Gowling Lafleur Henderson LLP, Ottawa ADVISORY BOARD MEMBERS Dr. Patrick Ceresia, Canadian Medical Protective Association, Ottawa Jennifer Chandler, University of Ottawa, Faculty of Law Giuseppina D Agostino, Osgoode Hall Law School, Toronto Paul DeMuro, Broad and Cassel, Fort Lauderdale, FL Chantal Léonard, Canadian Nurses Protective Society, Ottawa Anne MacDonald, Ottawa Hospital Maureen Murphy, Gowling Lafleur Henderson LLP, Ottawa Jean Nelson, Canadian Medical Association, Ottawa Robert Sheahan, Gowling Lafleur Henderson LLP, Ottawa Note: This newsletter solicits manuscripts for consideration by the General Editor, who reserves the right to reject any manuscript or to publish it in revised form. The articles included in Electronic Healthcare Law Review reflect the views of the individual authors. This newsletter is not intended to provide legal or other professional advice and readers should not act on the information contained in this report without seeking specific independent advice on the particular matters with which they are concerned. healthcare provider and patient by using messaging services and by allowing patients to submit pre-examination information to their healthcare provider. The functionality of digital health products is remarkable. For example, Helius, by Proteus Digital Health, is a capsule-sized ingestible sensor designed to improve treatment outcomes by monitoring drug therapy compliance and the patient s vital information. Helius is designed to provide clinicians, families, and also patients, with real-time information about medication taking, rest, and activity to optimize patient care. Emerging products go beyond the traditional scope of healthcare technology, which until this point, has served as a repository for storing and accessing information regarding patients, pharmaceuticals, therapeutics, and diagnostics. New innovations extend to gathering and interpreting patient information to assist healthcare providers with care management. These technologies have a direct effect on treatment outcomes. As with any novel technology, digital health products in the patient information management segment are sure to attract legal attention, with the advanced nature of the technology and the sensitive nature of the information involved. Emerging digital health products frequently involve the collection of sensitive, personal information and data. With this, any federal or provincial privacy laws applicable to public and private entities may be engaged. For instance, with Helius, the data generated includes patientspecific medication compliance and treatment 2

3 response information. Included in this data is sensitive and private information about the patient s medical and healthcare history. On the other end of the spectrum, services such as DebMed s Group Monitoring System a technology used to electronically monitor, track, and report compliance rates for hand hygiene events within healthcare facilities to ensure compliance with hand hygiene guidelines appears to have been designed to avoid the need for any personal information from patients or employees and, as such, does not raise any concerns related to the privacy of patient health information. There are two main pieces of federal legislation governing privacy in Canada namely, the Privacy Act 1 and the Personal Information Protection and Electronic Documents Act [PIPEDA]. 2 The Privacy Act regulates how federal departments and agencies handle personal information. Under the Privacy Act, personal information is explicitly defined in s. 3; however, it does not apply to personal information collected in a healthcare setting. This is because the Privacy Act s purpose is expressly limited to personal information held by a government institution, which is defined therein so as to exclude hospitals and other healthcare facilities. In Canada, healthcare falls within provincial jurisdiction (per s. 92(7) of the Constitution Act, 1867 (UK), 30 & 31 Vict. c 3, s 91, reprinted in R.S.C App II, No. 5) and is therefore not regulated by the federal government. PIPEDA is another piece of federal legislation that relates to privacy and governs how private sector organizations collect, use, and disclose personal information in the course of commercial 3 business. Both personal information and personal health information are specifically defined in s. 3 such that PIPEDA applies to personal healthcare information that has already been disclosed in a commercial setting (see Wyndowe v. Rousseau). 3 PIPEDA does not apply to public bodies, and, in any event, this legislation does not apply at the provincial level if there is corresponding provincial legislation that does apply. The relevant privacy legislation in Ontario is the Personal Health Information Protection Act, 2004 [PHIPA]. 4 Under PHIPA, information capable of identifying an individual and that relates to their physical or mental health is deemed personal health information and is subject to its expansive privacy protection provisions. Generally, PHIPA applies to healthcare practitioners (i.e., physicians, dentists, pharmacists) and institutions (i.e., hospitals, long-term care facilities, and pharmacies) and pertains to the collection, control, and custody of personal health information. PHIPA contains detailed provisions related to the consent and disclosure of personal health information and, where necessary, provides a review procedure for the Privacy Commissioner. PHIPA also outlines various criminal offences in cases of major breaches. Those implementing digital health technology in both the public and private domains must adopt an informed and cautious approach to ensure the protection of personal health information and compliance with the applicable privacy laws. From a regulatory standpoint, depending on the nature of the digital health technology, the Food and Drugs Act 5 or the Medical Devices

4 Regulations 6 may apply to govern market approval and post-marketing compliance. The definition of medical device under the Food and Drugs Act [FDA] and Medical Devices Regulations is broadly defined to encompass any device that is manufactured, sold, or represented for use in diagnosing, treating, mitigating, or preventing a disease, disorder, or abnormal physical state. For market approval, depending on how a digital health product is designated under the Medical Devices Regulations, it may be necessary for a manufacturer to satisfy Health Canada s rigorous safety and efficacy screening as a condition to receiving a licence to market. In the postmarketing phase, given the large commercial aspect to digital health products, it is important that manufacturers be aware of the advertising provisions under the FDA and Medical Devices Regulations. For instance, the FDA prohibits any person from advertising a health device as a treatment, prevention, or cure for a wide host of conditions outlined in Schedule A of the Act. The same prohibition is commonly discussed with respect to pharmaceuticals, where the selfinterest in promotion may cloud the dangers inherent in many medications. But for many digital health products, however, the dangers are less apparent, such as devices that address medication compliance or collect vital information. Educating the public through advertising is important in promoting these useful devices and will ultimately serve to promote the public good through improved patient care outcomes. There will be technology that is more active in disease management and whose adverse effects 4 will be less benign, such as technologies that encroach on diagnostics. It will be interesting to see how the law develops in these areas. As new innovative products play an advanced role in diagnostics and patient care management, provincial laws pertaining to the regulation of health professionals will need to be vigilantly applied and adapted. For example, Ontario s Medicine Act, restricts the communication of the diagnosis of a disease or disorder to members registered thereunder. From a practical perspective, this means that while some digital health solutions related to receiving diagnoses for patients electronically may be beneficial to health professionals, the functionality of such solutions would need to be appropriately restricted in scope and, as a result, may have limited value to the average consumer. Intellectual property laws have and will continue to play a central role in digital health well into the future. As novel digital health products continue to emerge, these laws will likely develop as quickly as the technology at issue. For example, patent protection will provide innovators with a limited statutory monopoly as a return on their investment, while trademark law will protect the valuable goodwill garnered by the most technologically successful and wellmarketed innovations. Digital health continues to bring a deluge of exciting and innovative products and services that are revolutionizing the healthcare field before our eyes. Digital health also promises to raise new and interesting legal issues that could have a similar effect on the Canadian legal landscape.

5 Dimock Stratton LLP [Editor s Note: Geoffrey Mowatt is a partner at the firm of Dimock Stratton LLP. His practice includes all areas of intellectual property law, with a focus on patent and trademark litigation including pharmaceutical litigation under the Patented Medicines (Notice of Compliance) Regulations. Geoff is also a registered patent agent and trademark agent. You can reach him at <gmowatt@dimock.com>. Nikolas Purcell is a lawyer at the firm of Dimock Stratton LLP. His practice includes all areas of intellectual property litigation, with a focus on patents concerning pharmaceutical, chemical, and mechanical subject matter. Nik is also a licensed pharmacist. You can reach him at <npurcell@dimock.com>.] R.S.C. 1985, c. P-21. S.C. 2000, c. 5. [2008] F.C.J. No. 151, 2008 FCA 39, paras S.O. 2004, c. 3, Schedule A. R.S.C. 1985, c. F-27. SOR/ S.O. 1991, c. 30. CRITICAL CONSIDERATIONS FOR ESTABLISHING AND PARTICIPATING IN AN econsult SERVICE: LESSONS LEARNED FROM THE CHAMPLAIN BASE TEAM Dr. Erin Keely and Dr. Clare Liddy Access to specialist physicians remains a major 1, 2, 3 barrier to effective healthcare in Canada. Excessive wait times, inequitable access depending on geographic location, and poor communication between providers can often lead to patient anxiety, delays in diagnosis, duplication of services, dissatisfaction among providers, and ultimately poor patient care. 4 We need to consider new models of care, where specialists work collaboratively to best serve their referring physicians, address their community s needs, and make best use of limited resources. 5, 6 Innovative approaches such as population-based, central reorganization of specialist care integrated with emerging technologies can greatly improve access to specialist 7, 8, 9, 10 care. Virtual consultations offer one approach to improving access. In a virtual consultation, the specialist provider and patient do not meet faceto-face. Rather, the specialist communicates electronically with the patient s primary care provider (PCP), who receives specialist advice to provide care to his/her patient. Virtual consultations can be facilitated through several media, including telephones, , and electronic real-time or asynchronous platforms. Telephone consultations are difficult to coordinate, as they require PCPs and specialists to be available simultaneously, and communication does not meet current privacy requirements for sharing personal health information. 11 In order to reduce wait times for access to specialist advice, we developed the Champlain BASE (Building Access to Specialists through econsultation) econsult Service, an asynchronous platform facilitating communication 5

6 between PCPs and specialists. This secure webbased service allows PCPs to submit a patientspecific clinical question to a specialist. PCPs can attach relevant electronic files (e.g., lab results, images, information generated from EMRs) that would help the specialist with diagnosis and recommendation. The econsult is assigned to the appropriate specialist, who receives a notification via . The specialist has three response choices: provide recommendations and avoid the need for a face-to-face consultation request additional information recommend a formal referral, in which case any recommended diagnostic tests or courses for treatment could be initiated before the appointment Iterative communication between the specialist and PCP may occur for clarification or obtaining additional information. 12 The service automatically creates a permanent record of the econsult, which can be downloaded into the patient s health record. Specialists are currently paid by special funds provided by the Champlain Local Health Integration Network (LHIN) and project funding at a prorated hourly rate based on the self-reported time they required to complete the econsult. As of May 31, 2015, a total of 704 PCs (585 family physicians and 119 nurse practitioners) have registered to the service a number that represents over half of all PCPs in the Champlain Local health Integration Network (LHIN) and over 7,300 consults have been processed. Participating PCPs can access advice from 67 different specialty groups, the largest menu on offer from any such system worldwide. The service has proven effective at reducing wait times and increasing access to specialist care. Over 40 per cent of cases managed through econsult have resulted in avoidance of an unnecessary face-to-face referral, representing nearly 3,000 patients who no longer require a specialist visit. Among primary healthcare providers, 38 per cent indicated that they were able to confirm a course of action that they had originally had in mind for the patient, and 58 per cent got good advice for a new or additional course of action. The econsult service has been described in greater detail elsewhere. 13,14 Throughout the implementation and evaluation of the econsult service, we have learned a great deal regarding the factors that support and inhibit the development of technology-based healthcare innovations. The purpose of this article is to outline six key considerations, based on our experience. Impact of Redesigning the Referral-Consultation Process Family physicians and specialists no longer work side by side in a hospital setting, reducing their opportunities to interact informally and build relationships. The traditional referralconsultation process is unstructured, which often makes it a source of frustration for PCPs and specialists alike. Poor communication flow, lack of collegiality, missing information, and misaligned expectations contribute to this frustration. Furthermore, an explosion of new knowledge has resulted in subspecialists with limited 6

7 scopes of practice, making it difficult to know which practitioner provides which service. The econsult service allows asynchronous exchanges between providers, where the specialist provides advice without any direct encounter with the patient. Of course, not all patient questions can be answered electronically. In many cases, a face-to-face consultation is required in order to collect a thorough patient history, perform a test or physical examination, or interface with patients in a manner impossible by less direct means. Likewise, econsult cannot replace the immediacy of direct telephone or face-toface contact in urgent situations. However, by allowing specialists to support PCPs in treating those patients who can be managed in a primary care environment, the econsult service frees up valuable resources that can allow patients with urgent or complex conditions to be seen more quickly. In the traditional referral-consultation process, PCPs usually select a specific individual for the patient to see. However, this strategy is often less efficient than one using a central intake system, wherein patients are directed to the first available specialist in the appropriate specialty group unless they request a particular individual. When instituting an econsult service, it is important to respect the usual referral pathways and communities of practice in order to engage PCPs and specialists. Some providers feel very strongly about choosing an individual specialist from a pool of specialists who may be providing econsults. However, in our experience, most PCPs feel that having timely access to specialist advice is more important than the opportunity to select a specific specialist. Choosing and Building the Technology Platform When developing a healthcare innovation, the technology one chooses is paramount to the innovation s success or failure. A number of factors are essential to success, including population need, accessibility, and incorporation into workflow. Population need For an innovation to be truly effective, the first question to be asked must be: what is the need that I am trying to address? The need should drive the selection of technology, not the other way around. Many technology initiatives are driven by ehealth experts rather than clinical champions. The econsult service was created by two clinicians a family physician and an endocrinologist as a result of the desire to reduce wait times and improve PCPs access to specialists. We were not tied to a particular vendor and were free to explore all available options until the most promising strategy presented itself. Accessibility In order for a technological innovation to be scalable and sustainable, it must be able to adapt to a number of different environments and circumstances. Building a system that is not sustainable is a waste of valuable resources and time. Innovators may be tempted to develop a service as an extension of a specific EMR program or vendor, since harnessing an existing platform can reduce the upfront time and costs 7

8 associated with development. However, greater flexibility will support wider adoption, allowing the service to reach a broader segment of the population. Incorporation into workflow Physicians will adopt only the kind of technology that improves quality of care without unduly disrupting the workflow. Successful technologies must be straightforward and easy to learn, and external support should be offered if possible to help ease the service into physicians workflow. For example, PCPs who sign up for the econsult service receive an orientation session with an experienced trainer completed by telephone. Training takes only 30 minutes, and technical support is available by telephone or seven days a week. In addition to simplicity, successful technologies must also be flexible in order to incorporate the practice s administrative structure into the service s workflow. This may require the capability of a delegate function. PCPs may experience frustration or anxiety throughout the adoption process, and resistance to new technologies among healthcare providers is well documented. 15,16 A growing body of literature has begun to explore the causes of this resistance, noting the importance of identifying perceived barriers and assessing their relative importance to physicians. 17 Understanding Changing Privacy Requirements Protecting patient privacy must be a priority for all healthcare providers and facilities. During the development of the econsult service, 8 privacy rules changed, and our technology solution needed to adapt to meet new requirements. A proper privacy and threat analysis must be conducted prior to launching any new platform where patient health information is located. In the traditional referral-consultation model, the patient knows that a referral has been made as they are given an appointment for the specialist. In a virtual system, the patient may be unaware that their PCP has allowed another provider to have access to their data. In our econsult service, PCPs are required to confirm that the patient agrees to the transfer of information in order to complete the econsult. The Canadian Medical Protective Association (CMPA) statement provided to Ontario MD states that patient consent is implied in the econsult process, as the interaction remains within the circle of care. Given the importance of protecting patient privacy, in our view, it is prudent to obtain and document patients express consent prior to transferring any personal information. Defining Duty of Care and Provision of Service Providers using the econsult service must understand their professional and legal obligations when answering econsults. By participating in an econsult, providers undertake a duty of care in the same way as they do when providing advice in a hallway consultation or over the telephone. As such, specialists are required to provide a reasonable opinion with the information provided to them. Specialists are given three options when answering econsults: (1) provide advice to the PCP to guide the patient s

9 treatment, (2) request more information, or (3) recommend a face-to-face referral. The advantage of econsult is that it provides a full transcript of the encounter, which is stored in a secure server and can be retrieved by the PCP or specialist at any time. An econsult does not constitute transfer of care to the specialist, and the PCP remains the person responsible for all decisions made pertaining to the patient s care. This has implications for recordkeeping. In our system, the responding specialist is not required to open a chart for the patient, as the responsibility lies with the PCP. However, a record of the interaction is accessible to the specialist as needed. In a traditional consultation, there may be confusion regarding which provider is responsible for organizing tests, adjusting medications, or providing support in the setting of change in condition or adverse effects of treatments. This confusion should not exist in a virtual consultation. Although essentially all Canadian physicians have liability protection through the CMPA, the provincial regulatory bodies also have a vested interest in the provision of econsults. In our discussions with other provinces and territories, we have encountered concern over regulations affecting our ability to provide econsults across provincial boundaries. Greater clarity is needed on the regulatory and licensing requirements associated with interprovincial econsults. Selecting Specialists Who Provide the Service In order for any healthcare service to be successful, the healthcare providers involved in its 9 implementation must be supportive of its objectives and invested in it as an improvement in how they provide care. Not all specialists are necessarily interested in or well suited to providing econsultation. As such, not all specialists should be required or invited to participate in an econsult service. However, limiting participation in an econsult service to a subset of specialists runs the risk of placing excluded specialists at a financial disadvantage. Furthermore, such restrictions might raise contention among practitioners regarding the criteria for inclusion. As econsult services become more widespread, more attention will need to be paid to selection and credentialing of participating specialists. Understanding Patients Perspectives and Expectations Patients are growing increasingly impatient with long wait times and inefficient health services. Technological advancements have led patients to expect immediate answers, resulting in frustration with poor access to expert advice. Patient acceptance is vital to the success of any healthcare innovation, and patients perspectives on new and innovative services must be thoroughly established. We conducted a survey of individuals who had waited to see an endocrinologist. In their responses, 46 per cent of patients identified econsultation as being an acceptable option to avoid face-to-face visits. 18 Patients who saw econsultation as a viable alternative to traditional referrals cited reduced travel time and quicker responses as advantages, while patients who did not see econsultation as beneficial stated they would feel more confident talking to a specialist in person. As econsult

10 services continue to develop, more work must be done to help innovators better patients acceptance and expectations of such services in order to create services that deliver high levels of patient satisfaction. Summary It is very exciting that new strategies and technologies are being developed to reduce wait times for Canadians. Although there remains much work to be done and many questions to be answered, econsult services have huge potential to improve access to specialist advice in a costeffective, efficient manner. We have learned a great deal on our journey of establishing the Champlain BASE service and hope that our experiences will help others interested in establishing similar innovations in their own communities. No doubt as experience and spread of these solutions grows, new issues will be identified that will need to be addressed. Erin Keely and Clare Liddy [Editor s Note: Dr. Erin Keely works in the Division of Endocrinology and Metabolism at The Ottawa Hospital and is a Professor in the Department of Medicine at the University of Ottawa. You can reach her at <ekeely@toh.on.ca>. Dr. Clare Liddy works at the CT Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, and is an Associate Professor in the Department of Family Medicine at the University of Ottawa. You can reach her at <cliddy@bruyere.org>.] B. Barua and F. Fathers, Waiting Your Turn: Wait Times for Health Care in Canada (Vancouver: Fraser Institute; 2013), < uploadedfiles/fraser-ca/content/research-news/ research/publications/waiting-your-turn-2014.pdf>. G. Carrière and C. Sanmartin, Waiting Time for Medical Specialist Consultations in Canada, 2007, Statistics Canada, Health Reports 21, no. 2 (June 2010). L. Jaakkimainen et al., Waiting to See the Specialist: Patient and Provider Characteristics of Wait Times from Primary to Specialty Care, BMC Family Practice 2014; 15(1):16. Supra notes 1 and 3. Ontario Medical Association, ehealth Policy Paper (Toronto, September 2013), < ehealthpolicy pdf>. Ontario Medical Association, OMA Principles and Recommendations: Models and Processes of Delivery for Specialty Care (Toronto, 2011), < ModelsandProcessesofDeliveryforSpecialtyCare.pdf>. J. Stoves et al., Electronic Consultation as an Alternative to Hospital Referral for Patients with Chronic Kidney Disease: A Novel Application for Networked Electronic Health Records to Improve the Accessibility and Efficiency of Healthcare, Qual. Saf. Health Care 19, no. 5 (Oct. 2010): e54. J. E. Kim-Hwang et al., Evaluating Electronic Referrals for Specialty care at a Public Hospital, J. Gen. Intern. Med. 25, no. 10 (October 2010): K. Horner, E. Wagner, and J. Tufano, Electronic Consultations between Primary and Specialty Care Clinicians: Early Insights, The Commonwealth Fund 23 (October 2011): Y. Kim et al., Not Perfect, but Better: Primary Care Providers Experiences with Electronic Referrals in a Safety Net Health System, J. Gen. Intern. Med. 24, no. 5 (May 2009): L. J. Caffery and A. C. Smith, A Literature Review of -Based Telemedicine, Stud. Health Technol. Inform.161 (2010): E. Keely, C. Liddy, and A. Afkham, Utilization, Benefits, and Impact of an e-consultation Service across Diverse Specialties and Primary Care Providers, Telemed. J. E. Health 19, no. 10 (2013): Ibid. C. Liddy et al., Building Access to Specialist Care through e-consultation, Open Med. 7, no. 1 (2013): e1 e8. 10

11 15 16 A. Bhattacherjee and N. Hikmet, Physicians Resistance toward Healthcare Information Technology: A Theoretical Model and Empirical Test, European Journal of Information Systems16, no. 6 (2007): , < _Physicians%27_resistance_toward_ healthcare_information_technology_a_theoretical_ model_and_empirical_test>. A. Bhattacherjee and N. Hikmet, Enabelers and Inhibitors of Healthcare Information Technology Adoption: Toward a Dual-Factor Model, AMCIS 2008 Proceedings. Paper 135, < viewcontent.cgi?article=1114&context=amcis2008>. Supra note 15. E. Keely, L. Traczyk, and C. Liddy, Patient Perspectives on Wait Times and the Referral-Consultation Process While Attending a Tertiary Diabetes and Endocrinology Centre: Is Econsultation an Acceptable Option?, Can. J. Diabetes 39, no. 4 (2015): ELECTRONIC VERSION AVAILABLE A PDF version of your print subscription is available for an additional charge. A PDF file of each issue will be ed directly to you four times per year, for internal distribution only. 11

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