Home Healthcare Nurse:
Feature: CE Connection
Best Practices for Heart Failure: A Focused Review
Suter, Paula M. BSN, MA, CCP; Gorski, Lisa A. MS, HHCNS-BC, CRNI, FAAN; Hennessey, Beth BSN, MSN; Suter, W. Newton PhD
Paula M. Suter, BSN, MA, CCP, is the Director of Integrated Chronic Care Management, Sutter Care at Home, Fairfield, California.
Lisa A. Gorski, MS, HHCNS-BC, CRNI, FAAN, is a Clinical Nurse Specialist at Wheaton Franciscan Home Health & Hospice, Milwaukee, Wisconsin.
Beth Hennessey, BSN, MSN, is the Executive Director at Integrated Chronic Care Management, Sutter Care at Home, Fairfield, California.
W. Newton Suter, PhD, is a Professor in Educational Foundations in the Department of Educational Leadership, University of Arkansas at Little Rock, Little Rock, Arkansas.
The authors and planners have disclosed that they have no financial relationships related to this article.
Address for correspondence: Paula M. Suter, BSN, MA, CCP, Integrated Chronic Care Management, Sutter Care at Home, 4830 Business Center Dr., Suite 140, Fairfield, CA (email@example.com).
For 42 additional continuing nursing education articles on cardiovascular topics, go to nursingcenter.com/ce.
Heart failure (HF) is a progressive condition and is associated with high patient mortality rates and frequent hospitalizations. This article provides an overview of clinical, self-management support, and care transitions best practices for HF care in the home care sector. Clinicians armed with competencies in HF management are positioned to meet the 3-part aim of healthcare reform: improved health, better care, and lower cost.
The Need for Heart Failure Best Practices
Heart failure (HF), as defined by the Heart Failure Society of America (HFSA, 2010, p. 48), is a “syndrome” resulting from heart muscle dysfunction or loss and characterized by pulmonary/systemic venous congestion, inadequate peripheral oxygen delivery, and/or ventricular dilation/hypertrophy, leading to neurohormonal and circulatory abnormalities.
HF is associated with high mortality and frequent hospitalizations. Although it is considered a progressive condition, current treatments can stabilize and even reverse the disease process (HFSA, 2010). Many sectors of healthcare, including acute care, long-term care, and home care, are striving to implement best practices for these patients to minimize rehospitalizations and improve patient quality of life. This article provides an overview of clinical, self-management support, and care transition best practices for HF care in home care.
Best Practices in the Clinical Management of Heart Failure
Many hospitalizations for HF exacerbation are preventable when attention is paid to early signs and symptoms, contributing factors, and improving patient self-care management (Moser & Mann, 2002). Common contributing factors to rehospitalizations (Hunt et al., 2009) include
* Nonadherence to medical regimen, sodium restriction, and fluid restriction (if ordered);
* Untreated high blood pressure (BP);
* Atrial fibrillation/other dysrhythmias;
* Addition of negative inotropic medications;
* Pulmonary embolism;
* Nonsteroidal anti-inflammatory drug (NSAID) use;
* Excessive alcohol use/drug use;
* Endocrine abnormalities; and
To provide safe and effective care for patients with HF, the home care nurse must recognize potential causes of HF exacerbation, understand them, and apply evidence-based practice guidelines aimed at reducing risk of exacerbation, carefully assess and monitor the patient, and provide effective patient and family education and self-management support. The scope of nursing includes the nurse's role in systematically enhancing quality and effectiveness of nursing practice (American Nurse Association, 2004). According to Rosenberg (2011, p. 18) “nurses should be actively engaged in monitoring the quality of care to minimize gaps in its delivery.” Furthermore, this author speaks about the importance of nurses determining root causes of gaps in care delivery and working with the healthcare team to bridge them. For example, home care agencies are increasingly working with local acute care hospitals to study readmissions, identifying opportunities for improvement, and developing strategies to improve care outcomes. To monitor care quality, the home care nurse should be familiar with improvement models and processes, such as the Plan, Do, Study, Act model, as well as best practice guidelines, to compare current care delivery with best practice recommendations to identify gaps (Langley et al., 1996).
The evidence-based practice guidelines from the American College of Cardiology/American Heart Association (Jessup et al., 2009) and the HFSA (2010) list general areas to address in HF management and include:
* assessment and follow-up;
* medication management;
* immunizations: pneumococcal, annual influenza vaccines;
* Smoking cessation;
* Limiting alcohol intake
* ≤ 2 standard drinks/day in men and ≤ 1 in women or
* Alcohol induced cardiomyopathy—abstinence; and
* Physical activity: regular exercise to avoid general deconditioning, optimize weight, BP and diabetes control, reduce cardiovascular risk.
The following sections focus on assessment, medication management, and diet for patients who have HF with reduced left ventricular ejection fraction (< 40%), sometimes simply referred to as systolic HF.
Assessment and Follow-Up
The home care nurse performs a comprehensive assessment including a physical assessment on admission and reassesses the patient with each home visit. Important assessment parameters for patients with HF are listed in Box 1. Findings are compared to previous assessments recognizing that (a) changes are often subtle and may fluctuate, (b) patients usually have a consistent pattern of signs and symptoms associated with increasing fluid retention—these should be documented to individualize the plan of care, and (c) changes in condition require reporting and intervention.
Patient education is an important nursing intervention for both patients and caregivers. When symptoms can be identified quickly, timely action is possible. In a study examining HF patients' symptoms and actions taken before hospitalization, researchers found that patients delayed contacting healthcare providers for worsening HF symptoms for several days (Friedman & Quinn, 2008). Common symptoms included increasing dyspnea with exertion, fatigue, orthopnea, weakness, edema, and cough. Those patients who had a history of HF reported more fatigue than those newly diagnosed.
The use of telemonitoring for patients with HF should be considered as an adjunct for assessment and monitoring of these patients. Telemonitoring has been found to decrease hospital admissions, improve patient satisfaction, and reduce the cost of care (Darkins et al., 2008).
Medication management is a complex area of intervention for patients with HF. Home care nurses should possess a good understanding of recommended medications, mechanisms of action, indications, side effects, and adverse reactions. Attention to medication reconciliation and medication adherence is essential. Although an overview of key medication classes is presented, the nurse is referred to the HFSA (2010) and AHA (Jessup et al., 2009) for detailed information, recommendations, and lists of specific medications.
For patients who have HF with a reduced ejection fraction (< 40%), two classes of medications have become the “cornerstone of therapy to delay or halt” disease progression and dysfunction and improve mortality: angiotensin converting enzyme (ACE) inhibitors and β-blockers (HFSA, 2010, p. 486). ACE inhibitors inhibit the renin–angiotensin–aldosterone (RAA) system, which is activated in the presence of reduced cardiac output, resulting in the undesirable effects of vasoconstriction and fluid retention. ACE inhibitor use may be limited due to side effects, such as cough and angioedema. In such situations, the alternative to ACE inhibitors is the angiotensin receptor blocker (ARB) class. Although both ACE inhibitors and ARBs inhibit the RAA system, their mechanisms differ. However, adverse reactions such as hyperkalemia and renal insufficiency can result from both ACE inhibitors and ARBs. In these situations, a combination of hydralazine and an oral nitrate is recommended as an alternative.
Beta blockers, the other cornerstone of HF medications, inhibit the sympathetic nervous system (SNS), also activated in the presence of reduced cardiac output, resulting in increased circulating catecholamines that cause vasoconstriction and increased heart rate, which can trigger arrhythmias. Although activation of the SNS initially improves cardiac function, long-term activation of both SNS and RAA causes chronic vasoconstriction, fluid and electrolyte abnormalities, and can result in left ventricular remodeling. Beta blocker use is recommended in most patients with HF with reduced ejection fraction and is started at low doses and increased gradually. Side effects to monitor include fluid retention, fatigue, symptomatic hypotension, and bradycardia.
Diuretics are used to reduce sodium and water retention. Loop diuretics (e.g., furosemide) are preferred over thiazide diuretics. The addition of chlorothiazides or metolazone may be considered in patients with fluid retention despite high-dose loop diuretics. Digoxin in low doses (0.125 mg) may be added to improve symptoms while receiving standard ACE inhibitor/β- blockers, and is also used to treat atrial fibrillation. Patients with atrial fibrillation may be treated with anticoagulants or antiplatelet agents.
Digoxin is no longer used routinely in HF but may be prescribed for symptomatic patients with late-stage HF on maximal medication therapy. Clinicians should be aware of the symptoms of digoxin toxicity and situations that may potentiate toxicity. Toxicity typically occurs when digoxin levels are greater than 2.5 ng/mL. If the patient is hypokalemic, however, toxicity can occur at any therapeutic concentration. Hypokalemia sensitizes the myocardium to digoxin and may reduce the positive inotropic effects of this medication. Other signs and symptoms of digoxin toxicity include nausea, vomiting, anorexia, and appearance of yellow-green halos in the visual field, as well as the development of cardiac arrhythmias.
Certain medications should be avoided in most patients, as they can exacerbate HF (Jessup et al., 2009). These include antiarrhythmia medications, calcium channel blockers, and NSAIDs. Calcium channel blockers have a myocardial depressant effect. Antiarrhythmic medications can have a proarrhythmic effect in patients with HF. The use of amiodarone may be considered for recurrent symptomatic arrhythmias in patients with implantable cardioverter defibrillators (HFSA, 2010). It is important to recognize that amiodarone interacts with a number of medications, and adjustment in other drug doses may be required. Because NSAIDs are available over the counter and are widely used, patient education about risks of use is critical. NSAIDs cause sodium retention and peripheral vasoconstriction and can increase the toxicity of diuretics and ACE inhibitors (Jessup et al., 2009).
Although there are no specific time frames for monitoring laboratory studies, serum electrolytes and renal function should be routinely monitored (Jessup et al., 2009). Key facts to remember include:
* Hypokalemia is a common adverse effect of diuretic treatment;
* Hyperkalemia may complicate therapy with ACE inhibitors, ARBs, and aldosterone antagonists;
* Declining renal function may require medication adjustment; and
* Hyponatremia and anemia may be signs of disease progression.
Brain natriuretic peptide (BNP) levels are also periodically monitored and reflect clinical severity of HF. BNP levels tend to decrease during aggressive treatment; however, there is a lack of evidence supporting serial BNP measurements to target therapy or titrate drugs (Jessup et al., 2009). BNP levels of between 300 and 900 pg/mL may indicate a spectrum from mild-to-severe HF but due to the variability of levels from a multitude of influences, such as the presence of renal insufficiency and obesity, there are no recommendations for measuring BNP in the outpatient setting at this time. Clinicians need to be aware of the fact that some physicians may use levels as a basis to modulate therapy.
Low-Sodium Diet and Fluid Restriction
Attention to the patient's diet is an important area of focus for the home care nurse. In fact, dietary teaching is important for all patients with HF. Teaching must address not only reducing salt but a review of the patient's diet and hidden sources of sodium. The HFSA (2010) recommends dietary sodium restriction of 2 to 3 g/day with further restrictions of less than 2 g/day in moderate-to-severe HF. Fluid restriction is not a general recommendation, but fluids should be restricted to less than 2 L/day in patients who have significant hyponatremia (<130 mEq/L). Fluid restriction may also be considered when patients have difficulty controlling fluid retention despite high diuretic doses and sodium restriction (HFSA, 2010). The HFSA has excellent resources for dietary instruction.
Best Practices in the Provision of Self-Management Support for Patients With HF
Patient self-management is critical to the realization of positive health outcomes and the minimization of chronic condition sequelae. Self-management support provided by healthcare professionals extends beyond patient education. The Institute of Medicine (IOM) defines self-management support as the “systematic provision of education and supportive interventions to increase patients' skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem solving support” (Adams & Corrigan, 2003, p. 52).
Based on the IOM definition, patients must possess competencies to be successful, including having the knowledge, skill, and confidence to manage one's own condition. Research demonstrates that when patients are engaged and empowered, the acquisition of these competencies can be facilitated through a collaborative process, which is more effective than the provision of education alone (Bodenheimer et al., 2002).
The situation-specific theory of HF self-care (Riegal & Dickson, 2008) provides a theoretical framework for understanding and evaluating these patient competencies. Four key propositions described by this model include (a) symptom recognition; (b) self-care that is better in patients with more knowledge, skill, and experience; (c) confidence moderates the relationship between self-care and outcomes; and (d) confidence mediates this relationship.
Facilitating the improvement of patient self-management requires the provider to have an in-depth knowledge of the level of patient competency in these areas as well as knowledge of patient expectations, priorities, and barriers. The Patient Activation Measure (PAM) is a tool that assesses these three competencies and is used to segment patient populations into levels of activation, thereby facilitating a tailored approach to coaching and education. The PAM tool, as well as the Stanford Self-Efficacy with Disease Management tool, is a reliable and validated tool that can provide valuable information needed to better incorporate effective interventions in their care delivery (Hibbard et al., 2004; Lorig, Ritter, et al., 2001). Patients with low activation scores or those reporting low self-confidence with condition management would need approaches designed to build self-confidence prior to the initiation of action planning, whereas those already confident and activated may be ready to develop a comprehensive action plan. One recommendation for scale use would be to evaluate these domains near the beginning of a care episode, with repeated measurements at mid episode and end of episode to evaluate patient progress toward improved confidence and skill acquisition.
Common Barriers to Effective Self-Management
If the patient is to be successful with self-management, the provider must work to identify barriers that hinder success so that problem solving can be facilitated. Common barriers found in patients with a chronic condition are subsequently listed.
Depression is prevalent in the home care population (Bruce et al., 2011). Home care, along with nursing homes, has the highest patient rates of depression among all other healthcare sectors. Depression is an independent predictor of poor adherence to the medical plan of care, and is often underdiagnosed and undertreated (Ell et al., 2005). The presence of depressed mood and diminished interest in pleasurable activities are the first two questions of the Personal Health Question-9 (PHQ-9), a validated depression-screening tool. These two questions, referred to as the PHQ-2, are incorporated within the Outcome and Assessment Information Set (OASIS-C) at the start of care assessment. A PHQ-2 score of 3 or greater is an indication for further assessment (Li et al., 2007). The full PHQ-9 tool provides a symptom severity score, which permits evaluation of effectiveness of treatment regimens over time, such as antidepressant medication effect or counseling and stress reduction interventions. Administering this tool at 2- to 4-week intervals is a reminder that administration of antidepressant medication does not necessarily equal symptom relief, as flat scores or progressively higher scores suggest the need for treatment adjustment. These authors proposed utilization of a best practice protocol for depression screening and symptom monitoring as provided in Box 2.
Low Health Literacy
Quality of care can be jeopardized by patients' functional health illiteracy. One groundbreaking study (Williams et al., 1995) revealed dramatic statistics regarding the consequences of poor health literacy in the United States. Poor health literacy was found to be independently associated with significantly poorer health outcomes, with low literacy being most prevalent in vulnerable populations such as older adults. Follow-up research (e.g., Agness et al., 2008) found “nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease” and confirmed that the “elderly patient is at especially high risk for having low health literacy” (p. 378). According to the Institute for Healthcare Advancement (2012), 36% of American adults have below basic or basic health literacy skills, and about half cannot read above a 5th-grade level. Unfortunately, most patient education materials are written at a 9th- to 12th-grade reading level, or higher. Experts recommend that printed patient education materials be written at no higher than a 6th-grade reading level, or lower if possible.
In a study by Peterson et al. (2011), HF patients with low health literacy had significantly higher all-cause mortality. Efforts should be made to raise staff awareness of the red flags for poor health literacy, such as the inability to name personal medications or a history of nonadherence to the plan of care. Methods should be adopted to identify patients with low literacy via the use of validated screening tools. The “Newest Vital Sign” available through Pfizer and the “Rapid Estimate of Adult Literacy in Medicine” available through the U.S. Department of Health and Human Services are two examples of health literacy assessments.
Aging will affect cognitive capabilities in many adults beginning as early as age 45 (Singh-Manoux et al., 2012), including the processing of information at a slower pace and a reduction of working memory. Instruction aimed at increasing health literacy outcomes requires individualized, personalized attention. The “Magic Number Seven” (plus or minus 2), the oft-cited limits of our capacity for processing information (Miller, 1956), may be reduced to 2 or 3 when educating the elderly patient.
Resources abound to assist clinicians with self-management support for individuals with low health literacy. These include the Health Literacy Universal Precautions Toolkit (available from the U.S. Department of Health and Human Services) and the American Medical Association Health Literacy Kit (available from the American Medical Association). The utilization of adult education principles should guide patient education practice, for example, ensuring that instruction is practical, relevant, and experiential (a full lifespan of such they can relate to). Using teach-back principles (patients are asked to instruct the clinician about the prior clinician-presented information) has been found to enhance retention of presented information in HF patients (Howie-Esquivel et al., 2011) and reduce HR hospital readmission rates by 30% when combined with a transitional care focus (“Readmission Rates,” 2010).
Scenario-based learning (asking realistic situational questions, such as “What would you do if….”) may also enhance patient retention.
Mild Cognitive Impairment
Cognitive impairments are associated with poor health outcomes in patients with chronic conditions (McLennan et al., 2006). Evidence suggests a large number of patients with HF may have unrecognized cognitive impairments (Cameron et al., 2010), a strong predictor of poor self-care management. Cameron et al. (2010) suggest mild cognitive impairments (MCIs) affect the patient's ability to recognize important symptom changes and hinder the ability to make appropriate decisions, increasing the risk of hospital admission or premature death. Screening tools such as the Mini-Mental State Examination (Folstein et al., 1975) or the Mini-Cog (Borson et al., 2000) can be readily administered and readily used in the clinical setting by the field clinician (Borson et al., 2000). The identification of potential impairment warrants further evaluation so that interventions can be planned and provided appropriately. Appropriate interventions for use with patients who have MCI include frequent repetition and the use of environmental cues. Targeting self-management support to the patient's family or caregiver may net better patient outcomes.
The aforementioned assessment tools are proposed based on our literature review, which identified the most common barriers home health patients with chronic conditions are likely to experience. The authors acknowledge the additional time required for incorporating new assessments. It is envisioned that future revisions of the OASIS data collection tool will refocus needed attention to these identified barriers. It may be appropriate to add these assessments to a visit subsequent to the start of care, such as a full depression screening assessment, as the patient may have developed more trust in the provider relationship by that time and the clinician will have more time to devote attention to these areas.
Provider Interaction Style
One important but sometimes overlooked contributor to the acquisition of self-care competence is the relationship between the provider and the patient. This relationship has been found to be directly linked to health outcomes such as adherence to treatment plans and patient satisfaction (Rollnick et al., 2008). The manner in which the provider speaks and relates to patients can substantially influence the patient's motivation to change their behavior or not change their behavior.
Patients have an enormous wealth of unacknowledged practical knowledge and experience about their life, which, when tapped into, can have a profound effect on treatment planning. Approaching the patient with the “curious style” of motivational interviewing and avoiding categorization and judgment of prior nonadherent behavior is the key to being open and receptive to understanding the patient's own personal goals and aspirations (Rollnick et al., 2010). Validating that behavior change can be of significant cost to patients, along with sincere expressed empathy, can move a patient from a state of inaction to action. Empathy is what often facilitates the building of trust between patient and provider. Trust building is essential if patients are to divulge sensitive information to their provider, such as a fear of prescribed medications or inability to understand presented information.
Low Self-Confidence/Self-Efficacy With Condition Management
Bandura (1986) describes self-efficacy as a person's belief in their capabilities to produce designated levels of performance that exercise influence over events affecting one's life. Patients possessing strong self-efficacy with condition management see challenges as tasks to be mastered and are more interested in these tasks overall. Bandura posits that self-efficacy can be increased, mainly through experiencing successes in the domain of interest. Clinicians can facilitate confidence building by structuring opportunities for the patient to experience success, which will improve self-efficacy with condition management (Lorig, Sobel et al., 2001). This is accomplished through the process of collaborative goal setting. When goal setting is structured so that there is a high likelihood of patient success, and that success is experienced time and time again via subsequent goal setting, patient confidence begins to build. This patient experience of a “cascade of successes” should be the endeavor of every clinician who provides self-management support.
Best Practices in Care Transitions
Comprehensive quality care for the individual with HF includes not only best practices in clinical care and self-management support but also best practices related to transitions of care. Central to identifying best practices in care transitions is recognizing that the focus of many transition initiatives is on the transition from hospital to home, and the subsequent 30 days postdischarge. The definition of transitions offered by Coleman and Boult (2003, p. 556) broadens the search for best practices to include the multitude of transitions an individual will encounter over the course of their HF trajectory: “the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.”
The cost to the U.S. healthcare system of ineffective transitions is substantial, and providers, payers, and policymakers recognize the need for immediate solutions to address the rapid growth in healthcare spending. The Medicare Payment Advisory Commission (MedPAC) statement to Congress indicated that 18% of Medicare hospital admissions resulted in readmissions within 30 days of hospital discharge, and preventable readmissions cost Medicare as much as $12 billion annually (U.S. Congress, 2009). This same report indicated that the most costly preventable readmissions for Medicare beneficiaries include individuals with HF, chronic obstructive pulmonary disease (COPD), pneumonia, and acute myocardial infarction (AMI). Based on these findings, hospitals face penalties for high readmission rates, making effective and efficient care transitions a key driver for healthcare providers across the continuum.
There are numerous variations of care transition models. Models have been designed, deployed, and replicated to address the current target of decreasing avoidable readmissions within 30 days, as well as to impact readmissions long term and prepare for future reform initiatives such as bundled payments and population management. Four specific models have been chosen to identify best practices to decrease both 30-day and long-term readmissions. They are (a) the Coleman Care Transitions Interventions, (b) the Naylor Transitional Care Model, (c) the Hospital to Home Campaign (H2H), and (d) the Community-Based Transitions Model.
Two widely adopted models for effective care transitions include The Care Transitions Intervention (Coleman et al., 2006) developed by Dr. Eric Coleman and Transitional Care Model (Naylor, 2004) developed by Dr. Mary Naylor. Although these models use different providers as the “health coach,” they both posit that transitions interventions should provide the patient and/or caregiver with the tools needed to take an active role in their care. Both models address common transition problem areas including medication lists that do not match, lack of knowledge around signs and symptoms of condition exacerbation, and timely follow-up care. These models support the use of a personal health record (PHR) to engage the patient in active roles in care management (Coleman et al., 2006; Naylor, 2004).
There are other transitions initiatives that build and expand upon Naylor's and Coleman's models such as the H2H developed by the American College of Cardiology and the Institute for Healthcare Improvement. H2H (2011) further defines interventions around medications, signs and symptoms, and early follow-up by including the “AND” extension: patient understanding of their medication regimen AND do they have access to these medications, patient securing an early follow-up appointment AND their ability to get to the appointment, and finally the patient's comprehension of signs and symptoms to report AND whom they should contact if the symptoms occur.
Another is the Community-Based Transitions Model (CBTM), which is designed as an integrated care delivery approach with its base in home care and the community (Hennessey & Suter, 2011). This model includes clinicians who have the requisite competencies for supporting the patient with both the immediate transition from hospital to home and the ongoing self-management needed beyond the 30-day postdischarge. CBTM emphasizes best practices in motivational interviewing, personal goal setting, and building confidence in the patient's ability to change behavior and problem solve. CBTM expands on models developed by Naylor (2004) and Coleman and colleagues (2006), and the H2H campaign by targeting interventions that address patient's adherence and perseverance to their medication regimen, the patient's appropriate access to follow-up care beyond the initial medical doctor office visit, and the patient's ability to successfully self-manage their condition across providers, settings, and their health and illness trajectory. Central to the work in this model is a patient-centered approach, where the initial intervention includes determining patient-specific concerns about their transition from the hospital to home. Patient-centered care is further reinforced in medication reconciliation with the identification of patient-specific barriers to medication adherence. Principles of adult learning and health literacy are incorporated into signs and symptom management so that patient-specific needs and barriers are addressed. Patients are encouraged to use their PHR to log their self-monitoring, and share this with their physician at the first and subsequent follow-up appointments.
Common to each of the four models are best practices that can drive effective and efficient transitions of care for HF patients, including a patient-centered focus of care, medication reconciliation and management, patient-activated learning for signs and symptoms management, timely physician follow-up posthospital discharge, and exchange of meaningful data, including the patient's PHR.
The call for healthcare reform requires both payment and care delivery reform. The identification and deployment of best practices for clinical care, self-management, and care transitions for individuals and populations with HF is a clear starting point for achieving better health, better care, and lower cost of care. This call can be answered by providers that build a foundation of care that is person-centered, evidence-based, and coordinated across time, providers, and settings. Arming home care clinicians with the requisite competencies associated with these best practices will position agencies as a sector of value in the healthcare environment of the future.
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