By L. Faesul. Roanoke College.
Afordability is a central element nised and common defnition of what represents added for reimbursement cheap kamagra soft 100 mg free shipping erectile dysfunction drugs covered by medicare, and thus an additional challenge of value (Henshall et al best purchase kamagra soft erectile dysfunction 40s. Inevitably competing from the perspective of healthcare systems is very much policy goals have to be balanced: maximising health be- linked to the expression ‘clinical utility’ as well as ‚personal nefts for the population as a whole and ensuring that in- utility‘ and when diagnostics and treatments go hand-in- novation is fnancially rewarded discount 100 mg kamagra soft with visa erectile dysfunction medicines, while at the same time hand purchase 100mg kamagra soft impotence quotes the sun also rises, there is a need to consider how the existence and containing costs. That is, if we can efectively and correctly categori- spective of healthcare systems. The possibility of providing se patients, will other therapeutic or preventive measures diagnostics and care that are tailored to the characteristics be taken and will that improve the health of the afected of the individual has been one of the main goals of he- patients? There is the promise of better tem, its organisation and its workforce to assume and en- outcomes; each patient will be given only what he or she sure the adequate implementation of this technology and needs, avoiding the at times trial-and-error based ‘classi- paradigm. There is also the prospect of a interoperability of existing clinical record databases for this reduction in costs related to this trial-and-error paradigm, new purpose (see Challenge 2); the ability of health profes- together with a reduction in resources required to address sionals to build the capacity required for them to assume risks such as adverse events and incomplete benefts that their new role (see Challenge 1); and appropriate systems might arise from not applying the best available option. Initially, there will be a need for invest- ethical practices, there is a need for a trustworthy and trans- ment in quality assurance, organisational aspects and ca- parent interaction between healthcare systems and clients, pacity building. For this purpose, the should provide services with sufcient guarantees of safe- analysis of the target population and its characteristics, the ty and quality and, in principle, on the basis of supporting development of adapted materials and improved health the paradigm of the general assembly of United Nations literacy are crucial. While there are no one-size-fts-all solu- on Universal Health Coverage that includes a system for tions, good practice can be shared (see also Challenge 1). European Best New models for pricing and reimbursement have to be Practice Guidelines for Quality Assurance, Provision and discussed. Where patients provide their personal health Use of Genome-based Information and Technologies: data and Member States invest in infrastructure, the pri- 2012 Declaration of Rome. Reimbursement has to ensure campaigns, support patient groups and recognise the fair rewards for the research investment and risks taken by patient’s right to seek information. This should be done the producer, but also afordability for the entire health by initiating and supporting constructive and informati- system as well as equity for each patient. At the same time, health systems have need sound economic and medical evidence to support to shift focus from acute disease treatment to preventive their decision-making process. Funding organisations health management in parallel with treatment of disea- should collaborate with healthcare providers to identify se. Develop prospective surveillance systems for is crucial to promote inter-, trans- and multi-disciplinarity personal health data that facilitate accurate and in healthcare providers (e. Encourage a citizen-driven framework for the adoption of electronic health records. In this case, major challenges can be identifed: accuracy of data, interoperability of databases, which includes the ca- As has been pointed out earlier, the interaction between pacity to trace individuals while securing anonymity, and health system and client is one of the major points to ana- appropriate storage capacities. Another limiting factor is lyse, especially considering that the owners of the data are the capacity to analyse and integrate big data (see Challen- the patients. There are initiatives paving the way by establishing tronic data storage and data-sharing; this is relevant when supercomputing centres in order to solve this problem of there is a need to combine clinical data with other data storage, integration and analysis (Merelli, 2014). Promote engagement and close collaboration platforms, coordination at the semantic level and, fnally, between patients, stakeholders and healthcare education mechanisms and awareness raising. Therefore a collaborative partnership between he- eHealth services (Commission Recommendation of 2 July althcare professionals and patients should be sought. Pati- 2008 on cross-border interoperability of electronic health ents should be helped to become active managers of their record systems notifed under document number C(2008) own health, and healthcare professionals should learn how 3282). Better solution is the primary vehicle for delivery of [cross-bor- collaboration between primary care, secondary care and der] care, for example a second opinion delivered by vi- hospital care and the coordination of health and social care deo conferencing with simultaneous capture and transfer services should be encouraged (Godman et al. The legal and regulatory issues include also adminis- status – and is sustainable for health systems. These layers will now be populated with In the case of reimbursement, the main problem centres standards, specifcations, case studies, workfows, subsets on budget constraints and single technologies analyses; in of terminologies, interoperability agreements, guidelines many cases the prices of reference limit the improvement developed by specialised organisations, fora, consortia of methods to defne prices and gain reimbursement. This is in logies analysis and pricing, and budget impact analysis of principle positive because of its promise to reduce uncer- these single technologies (Leopold et al. Develop an optimised overall healthcare fnancing and determination of added value and the difculties in strategy. For example, a shared risk-and-beneft mechanism could be There is also a lack of knowledge among professionals and elaborated. Additionally a ‘full cost of the patient’ view should citizens about the signifcance and consequences of these be established and adopted. The most innovative approaches with capacities could ensure faster patient access to innovative their strong intellectual property protection are especially technologies and cost-efective translation, which could re- complicating for shared decision-making processes. Therefore, public–private healthcare systems (Goldman, 2012; Said & Zerhouni, 2014). Thus, managed entry-agree- number of patients involved, for example in the case of rare ments, coverage with evidence schemes and new ways of diseases and stratifcation. Gaps of evidence and uncertainty innovative public procurement processes are good candi- management: When uncertainties regarding outcomes are dates for addressing most of the issues that are currently still in the pipeline and added value from existing eviden- under debate. Mechanisms exist that can be valuable in the case of new evidence generation while ensuring access to a. Practice Guidelines for Quality Assurance, Provision and Use of Genome-based Information and Techno- logies’). The implementation of the concept of public Key Enablers for Challenge 5 health genomics, being the responsible and efective Europe: e. Ministries of health, regulatory au- logies for the beneft of population health, requires thorities’ (e. In this concept, genome-based 37 information is highly holistic and includes not only all the adoption of technologies with proven value in ‚omics‘ data but also environmental, socioeconomic hospitals. Decision-makers in hospitals are thereby of the projects in health sector that are already in pla- informed of the likely value of a health technology for ce can be viewed at http://www. It is a clear example of well-presented in- labelling and the defning of functional and other cri- formation for patients and professionals and provides teria. EuroRec is organised as a permanent network of a comprehensive health information service to help national centres and provides services to industry (de- put individuals in control of their healthcare. The web- velopers and vendors), healthcare providers (buyers), site helps people make choices about health, from de- policy makers and patients. There are also hundreds of thousands of and Certifcation of Electronic Health Record systems entries in more than 50 directories. The forum has published vari- archiving and distribution of personally identifiable ous papers that address value-based pricing and ad- genetic and phenotypic data resulting from biome- aptive licensing (http://www. To this end, stakeholders representing all pies, for example by the validation of biomarkers. But too relevant perspectives were included, such as research po- many current approaches result in failure at some point licy and funding, healthcare provision, and citizens’/pati- along the development pipeline or do not demonstrate ents’ needs and interests. For these reasons, additional participation, a very broad spectrum of recommendations funding for clinical implementation and ‘real-world’ as- and potential felds of action has been identifed. Research projects that are carri- it has been a signifcant challenge to pinpoint reasonable ed out in close collaboration with, for example, regulatory concrete actions. This will confront rese- ges as well as the 35 recommendations several enablers archers with hitherto unfamiliar communication and co- have to join forces on either European or national level. Several recommendations relate to more than one of the As a result, the challenge for research funders and decisi- defned fve challenges or cut across more than one of the on-makers will be to fund research beyond the classical three broad areas of activity which have been identifed funding schemes. In these cases, the recommendations communication and training modules, more outreach have been ascribed to the challenge or activity area to activities, and more non-research cross-sectoral projects which they mainly relate, in the interest of producing a to complement ‘classical’ basic and translational research clearer picture. Funding also needs to provide incentives to in- linked package of measures will provide sufcient impact clude specialists from a wide range of areas such as: on the wellbeing of citizens, the sustainability of health- care systems and the competitiveness of relevant indus- • Big data and information and communication techno- tries in Europe and beyond. Some of these recom- mendations are also related to other challenges, therefore they are shown again within the circle. Furthermore, there are manifold interrelations between the fve challenges; these have not been indicated in order to keep the clearness of the fgure. Research to investigate diferent trial designs and their Such an investigation would inform the regulatory pro- results; whether they have been successful in addressing cess and the drug development process. Research on tools for more personalised healthcare and Paving the way for providers to implement standardised, rehabilitation. Already existing software applications and tools have to be integrated into a security framework. The challenge is to bring together multiple applications and multiple data standards to allow a datafow in a meaningful and secure way. Reclassifcation of diseases at the molecular level for Development of new and more efective diagnostic and optimisation of therapeutic strategies. Modelling of health and diseases by interdisciplinary The aim is the representation of health and disease research projects, for example via systems medicine and based on the simultaneous consideration of clinical, in silico modelling/simulation approaches. Support clinical validation of pharmacogenomics appro- The fndings will accelerate the translation from basic aches that integrate age and gender considerations into research biomarker development to their efcient genetically divergent populations. Research on phenotype–genotype correlations on exis- Optimal use of national resources for established co- ting data and specifcally established cohorts. Correlation studies of phenotypic evolution of diseases Evidence on the impact of the environment on the in subgroups or individuals within longitudinal cohorts, evolution of diseases. Support for decision makers and for example in terms of poly-pathologies, socio-econo- providers to set up public health measures for disease mic inequalities and access to care. Develop inexpensive and rapid test systems to produce A better understanding of disease mechanisms related a short development cycle for diagnosis and therapy, to genetic variants and the design of biopharmaceutical e. Earlier diagnostic markers would support the assessment of prognosis, monitoring and identifcation of the most efective treat- ment for a given group of patients. Optimise individual drug therapies and poly-pharmacy More specifc and efective drug therapies particularly especially in the case of multi-morbidity.
Translating information about genetic risk of disease into focused prevention kamagra soft 100 mg with visa erectile dysfunction caused by steroids, such as gene therapy purchase kamagra soft 100mg online impotence aids, that extinguishes disease risk at the molecular level buy kamagra soft 100mg free shipping trazodone causes erectile dysfunction, remains a daunting scientiﬁc and technical challenge purchase kamagra soft with visa erectile dysfunction korea. However, one hundred years will not have to pass before genetic information reshapes healthcare. This signature is then 16 Digital Medicine compared to computer libraries of known strains of the virus that are susceptible or resistant to various drugs in the therapeutic cocktail. By tailoring the elements and dosages in the cocktail to the genetic signature of the virus, far more rapid and efﬁcient clearing of the virus has been achieved. Giving the drug to patients whose cells do not display this receptor means wasting $20,000 on a drug with no clinical effect. Many new drugs will be approved in the next few years conditional upon a genetic test to determine if the therapy is likely to be effective. These uses represent only the beginning of a new era of personal- ized, genetically customized medicine (Figure 2. Within a decade, the genetic signature of a pathogen such as a virus or a cancer cell may form the basis for fabrication of customized therapies, such as vaccines, speciﬁcally targeted at that pathogen. Clinical laboratories will use genetic information to identify targets on the cell surface or in the nucleus of the pathogen that can be blocked by antibodies or by agents that retard or prevent dangerous genes from expressing in the ﬁrst place. Progress in gene therapy has been ham- pered, however, by the vigor of the immune response to new genetic material introduced into the body, as well as by an inability to target new genetic information to the right places in the genome. Control over expression of disease-causing pathogens or genes may be a more achievable goal than inserting the “correct” genetic information. This curative role will be the result of molecular infor- mation technologies—microarrays and computerized cell sorting, principally—focused on acquiring genetic information about the patient and the pathogen. Pathologists will also ﬁnd themselves competing in genetic diagnosis with the radiologists as they develop molecular imaging technology. Impact on Health Systems The ability to use genetic information to guide and craft therapy will become a key differentiator of hospitals and health centers within the next decade, much as open-heart surgery was during the 1970s. Personalized medicine based on genetic testing represents the leading edge of a huge new service opportunity for our nation’s health system, as well as a powerful tool set for making drug therapy safer and more effective. Previously, the output of these analyses was paper notes with line drawings, x-ray ﬁlm, and pathology slides. Today, the analyses are in digital form, and the results can be stored, retrieved, and sent electronically. Diagnostic results will ﬂow seamlessly through the so-called “electronic medical record” into structured and timely recommendations to the care team. Clarke once said that at some level of sophistica- tion, technology is indistinguishable from magic. Flow Cytometry Flow cytometry enables a laboratory technician to count and sort individual cells ﬂowing through a highly pressurized thread of water up to a rate of up to 70,000 cells per second, plucking single cells of interest (each less than one-twentieth of the width of a human hair) out of the stream with magnetic pulses and dropping them into wells in a laboratory tray. This remarkable speciﬁcity is made possible by computerized interpretation of the diffraction patterns of a laser beam passing through the thread and bouncing off individual cells. The scat- tered light reaches electronic plates positioned around the stream, which record the pattern of light as digital information. Using a computer-controlled magnetic pulse, the operator can pluck speciﬁc cells from the stream for further analysis. Flow cy- tometry is powerful enough to detect, for example, fetal cells in a 20 Digital Medicine sample of the mother’s blood and extract them without the need for invasive and sometimes dangerous amniocentesis. It can also count and categorize cancer cells by their shape or the constellation of receptors on their surface. If this becomes possible, ﬂow cytometry will be the tool hospitals use to ﬁnd stem cells in the blood. These cells will be cultured and redirected to therapeutic levels for treating diseases like Parkinson’s, diabetes, or spinal cord injury. Because they are cultured from an individual’s own cells, the recipient will not require a lifetime of immune suppressants to enable them to do their work. In all cases, the signals are detected by digital arrays and converted to digital information structured and stored by computers. These technologies, revolutionary when they were developed, made noninvasive evaluation of tissues and internal organs possi- ble, tilting diagnosis decisively away from exploratory surgery (and tilting power and clinical inﬂuence toward radiology). These images can reveal the extent of damage to the heart or brain from a heart attack or stroke and help determine if a tumor has been destroyed by radiation or chemotherapy. In addition, the capability of diag- nosing the type of lesion has increased by 40 percent. With molec- ular imaging, these technologies will actually be able to identify real-time cellular changes or gene expression patterns that preﬁgure disease. In the 30 years since they were invented, there has been a logarithmic growth in the computing power of a microchip. This growth in computing power was predicted by Gordon Moore, one of the founders of Intel, in 1967. In one of the most extraordinary (self-fulﬁlling) predictions in the history of technology, Moore said that the power of a microchip would double every 18 months with cost remaining constant (Figure 2. More powerful computing engines mean more rapid acquisition of images and more options for manipulating and reconstructing these images. Today, these modalities stand on the brink of eliminating the need for invasive procedures, such as colonoscopy and coronary angiography, and are capable of produc- ing remarkable three-dimensional images of functioning internal organs. Changes in Radiology Two key changes in radiology—teleradiology and machine inter- pretation of radiological images—have been made possible by the successful standardization of formats for digital radiological im- ages. With the advent of broad- band Internet connections, radiological images can not only be transmitted instantaneously inside hospitals or clinics, but they can also be sent virtually anywhere in the world where someone is avail- able to interpret them. Teleradiology has created service opportunities for isolated rural hospitals and practitioners who cannot afford full-time sub- specialized radiology coverage. Advances in image recognition software will enable radiology equipment to interpret as well as create radiological images. Recent studies have established that machine-read mammograms detect more lesions and stage them more accurately than do human radi- ologists. Human judgment will be focused on the “tough calls,” the machine-identiﬁed exceptions that require overreading. Remote Monitoring In Philadelphia recently, a newly formed technology ﬁrm, Car- dioNet, created the ﬁrst regional wireless network to monitor ambu- latory cardiac patients. This device is contained in a wireless sending unit the size of a personal digital assistant, which transmits the signals to a base station where human operators are assisted by continuous computer monitoring of their heart rhythms. If the patient appears to be experiencing cardiac distress, a voice channel will enable the operator to communicate directly with the patient, verify his or her condition orally, and direct him or her to take action. The system automatically alerts the patient’s physician to the problem and can even trigger an ambulance call to bring the patient to the hospital if required. Taking this process to the next step, Medtronic, the technology leader in cardiac pacemakers, has developed an implantable device that monitors, stores, and transmits information about the patient’s cardiac rhythm directly to the patient’s physician. These devices can be programmed (and reprogrammed remotely) to vary pacing depending on the patient’s unique needs and can also administer an electric shock to restart the patient’s heart if it moves into atrial ﬁbrillation. Progress in miniature sensing technologies is creating a new gen- eration of devices that can be worn or embedded in people’s homes to monitor their health noninvasively and automatically alert fam- ily or caregivers if problems arise. The “smart shirt,” for example, enables monitoring of multiple vital signs (heart rhythms and res- piration) and transmittal of aberrant results to family or the care team. These same technologies, when embedded in the home envi- ronment, will enable one to determine if an elderly person has fallen, is having trouble breathing, has taken prescribed medications, or is eating. In November 1999, clinicians in New York City made history by successfully performing a colecystectomy on a patient in Stras- bourg, France. These same technologies will enable students to learn via “virtual” surgical procedures us- ing interactive software that reﬂects to them real world images of internal organs. Telepresence technologies are producing live, three- dimensional images of internal organs, which enable physicians and their students to “tour” the body of a patient virtually. Voice response technolo- gies are likely to play an important, augmenting role in connecting patients and people at risk to the health system. During the Inter- net frenzy, many observers dismissed the voice channel of telephone communication, assuming that most of it would be displaced by digital data. The software algorithm at the heart of Eliza is so sophisticated that it can recognize and respond to millions of responses to the question, “Is this Jeff Gold- smith? Eliza is so warm and accepting that patients or family members will reliably return its calls if they are not at home to receive the initial call. However, no one would quarrel with the assertion that no technology since the invention of the telephone has created such a sensation as the Internet. The Internet enabled instantaneous and asynchronous commu- nication between any parties connected at ﬁrst to an existing tele- phone network and later using cable, ground-based wireless, and satellite modalities, allowing the Internet to be accessed in auto- mobiles, airplanes, or literally anywhere in the world where one can receive a wireless signal. With increased bandwidth has come 28 Digital Medicine the ability to transmit virtually any form of digital information, including sound and both still and streaming video ﬁles. People who use the Internet are on a mission; they actively use the Internet to seek knowledge and connection to others. Society seemed to awaken in the mid-1990s to discover that it had grown a whole new nervous system. The connections spawned by the Internet have resulted in the spontaneous formation of what futurist Howard Rheingold dubbed “virtual communities” revolv- ing around common interests and issues. Six million people use the Internet to seek health information every day, just in the United States,37 and according to the Pew Trust Internet American Life Project, 62 per- cent of adults connected to the Internet sought health information through it. Internet applications have empowered consumers to deﬁne their own medical reality and to reframe and broaden their relationships to physicians. The Internet and Health Plans As discussed in Chapter 6, the Internet has also brought a host of powerful new applications to health plans to communicate with their vast and diffuse networks of subscribers, corporate customers, and the health system itself. These applications form the core of an emerging “consumer directed” model of health insurance. The Internet and Healthcare Delivery Internet applications have less direct saliency to hospitals and other healthcare delivery institutions, where improving clinical and ﬁ- nancial operations is the most immediate management challenge. However, Internet technologies will be used to make hospitals and the information they contain more accessible to patients and fam- ilies.
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A central nervous system is purchase 100mg kamagra soft amex injections for erectile dysfunction, among other things discount kamagra soft online amex erectile dysfunction treatment operation, a powerful tool for making and implementing decisions on behalf of the whole organism (not its individual limbs or organs) generic 100mg kamagra soft with mastercard erectile dysfunction joliet. To take advantage of having a central nervous system buy kamagra soft 100mg low cost impotence smoking, however, it is important to have a spine. Hospital boards must be more willing than in the past to function as the spine of their organizations. Separating strong from weak claims on institutional resources and being less tolerant of excuses for institutional practices that expose patients to unaccept- able risks are two important things boards can do to safeguard their community’s trust. The balancing of hospital capital-spending priorities has been one of the traditional roles of the hospital board. Constructing buildings is one of the exciting things hospital boards have tra- ditionally done. There is something reassuringly concrete about a new building, and you can name it after someone. Boards must reexamine their spending priorities and decide how important it is to have a humane, responsive clinical care system. Some of those routines need disrupting, as they do not support safe and effective patient care. Hospital boards must be prepared to be a little less patient and tolerant of excuses that serve to delay the wiring of their institutions. Electronic clinical and ﬁnancial systems will bring greater discipline and focus to patient care decisions. Boards and managers need to hasten an era of greater accountability for decisions that affect patients’ lives. Venture ﬁrms, bankers, pension fund and mutual fund managers, and individual investors seemed to be playing on 78 rpm while the customer was listening on 33 rpm. The tragedy of e-health was that these radically different expectation sets were never harmonized. One wonders whether those who invest in and inﬂuence capital markets learned the right lessons from the e-health debacle. Most e-health ﬁrms were funded by venture capital ﬁrms whose managers and investors expected 30 percent per year compounded annual returns on their capital and a public market for their in- vestments to materialize within three years. Given the superheated stock market in the late 1990s, it was actually possible to ﬁeld a new company and take it public within 18 months (with “revenues,” but often no earnings). This was a marvelous, if unreal, economic en- vironment for venture capitalists, who were enabled in their search for a quick exit by breathless and starry-eyed investors. Federal regulatory approvals impose seven- to ten-year lead times on new discoveries in biotechnology and conventional pharmaceutical research. For medical devices, approval times are shorter, although 182 Digital Medicine not dramatically so. Closer to our subject, complex software devel- opment in healthcare often takes ﬁve years or more from the gleam in the software architect’s eye to a ﬁnished, debugged, and installed product. To develop the software and supporting infrastructure for the important applications discussed in this book will require tens of billions of dollars in investment. The challenge for investors is simply that this ﬁeld is unfolding at what seems like a glacial pace, given the metabolism of large, complex health enterprises and markets. In our technologically obsessed society, it is almost inevitable that we overestimate the short-run impact and market signiﬁcance of new technologies when they are introduced (in a wave of hype). There follows a similarly inevitable disillusionment when one realizes that the technologies are not “ﬁnished” and need reﬁnement to be truly useful. If the disillusionment is pervasive enough, a technology becomes unloved and unﬁnance- able. The key to becoming indispensable is for vendors and their engineering and marketing staffs to develop strong feedback loops with their customers and users and rewrite and rescope their products until they solve a real problem or meet a real need. Having the patience to recognize the ultimate value of a technology and to tolerate the ﬁddling is necessary to make it truly useful. Successful investors will understand 184 Digital Medicine that this process requires patience and conﬁdence in the managers and scientists they support. Healthcare applications require “warm” money—returns in the high teens and time frames of seven to ten years and the patience to retest assumptions about what actually works in the ﬁeld. On the other hand, technology changes lives in ways one cannot anticipate or control. Technology has a funny way of morphing into an end in itself unless it is wielded and controlled by a strong, purposeful hand. Americans (and people in other countries as well) have paid the price for this lag in absurd paperwork burdens, exces- sive administrative costs, delayed or unresponsive decision making, burned-out caregivers and managers, a consumer-unresponsive and unfriendly healthcare experience, and an unacceptably high risk of adverse events. Emerging information technologies can change all these things with the right combination of patience, ﬁnancing, and intolerance of excuses and poor performance. The key to achieving a more intelligent, responsive, and safer health system is to raise collective expectations of how the health Making an Effective Digital Transformation 185 system performs. All of us, in our roles as consumers, practitioners, managers, trustees, capital funders, and policymakers, can inﬂuence the pace of transformation. Thoughtful application of these powerful new tools can create a better healthcare experience and improved health. See Computed tomography Computerized interpretation, 24 Cunningham, Rob, 159 Computer(s), 2–3; clinical laboratories Customers. See General Electric outsourcing, 30; savings, 129 Gelernter, David, 40 Health Care Financing Administration. See Picture archiving and commu- Moore, Gordon, 22 nication system Moore’s Law, 22, 171 Palm. Record-keeping systems, 75 versus United Kingdom, 73–74; Referrals, 168 wealth of, 67; younger versus older, Registration, in physician ofﬁces, 76 71 Regulatory barriers, 86–87 196 Index Remote computing: applications, 75; Spielberg, Alissa, 70 transparency of, 62 Spinal cord: infection, 100; stem cells and, Remote medicine, 24–28 21 Remote monitoring, 25–26 Standardization, 161–65; consideration of, Remote servers, 8 164–65; funding, 163–64 Research studies, 36 Start-up companies, 58 Results reporting, 181 Stem cells, 21 Reuters Business Insight, 15 Stevens, Rosemary, 47, 85 Rheingold, Howard, 29; on virtual Stock market, 182 communities, 103 Stowers Institute of Medical Research, 15 Ridley, Matt, 14 Stroke damage, 22 Risk minimizing, 127–30 Subscriber enrollment, 120 Rivalries, 55 Subscription services, 113; health payment, Robotics, 27 165–69 Rufﬁn, Marshall de Graffenried, Jr. He has taught health policy and manage- ment at the University of Chicago Graduate School of Business, the Wharton School at the University of Pennsylvania, and other lead- ing universities. Goldsmith received his doctorate in sociology from the University of Chicago in 1973. He worked for the governor of Illinois as a policy analyst and the dean of the Pritzker School of Medicine at the University of Chicago, where he was responsible for planning and government affairs for the Medical Center. Goldsmith is a member of the board of directors of the Cerner Corporation, a healthcare informatics ﬁrm, and Essent Healthcare, an investor-owned hospital management company, and he is a member of the board of advisors of the Burrill Life Sciences Capital Fund, which invests in biotechnology innovation. He is also an advisor to Cain Brothers, an investment banking ﬁrm that works exclusively in healthcare. Goldsmith’s principal activity is forecasting technological and economic trends in the health system. He has consulted widely for ﬁrms spanning the health system spectrum, including hospital systems, health plans, medical device and product ﬁrms, pharma- ceutical companies, and multispecialty physician groups. Some counties hold household hazardous waste collection days, where prescription and over-the-counter drugs are accepted at a central location for proper disposal. Mix drugs with an undesirable substance, such as cat litter or used coffee grounds. Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag. Conceal or remove any personal information, including Rx number, on the empty containers by covering it with permanent marker or duct tape, or by scratching it off. The sealed container with the drug mixture, and the empty drug containers, can now be placed in the trash. 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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Mitchell, Editors Committee on the Prevention and Control of Viral Hepatitis Infections Board on Population Health and Public Health Practice Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Any opinions, fndings, conclusions, or recommen- dations expressed in this publication are those of the author(s) and do not necessarily refect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Hepatitis and liver cancer : a national strategy for prevention and control of hepatitis B and C / Heather M. Mitchell, editors ; Committee on the Prevention and Control of Viral Hepatitis Infections, Board on Population Health and Public Health Practice. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www.