EFFECTS OF TECHNOLOGY HIKE ON HEALTH CARE

EFFECTS OF TECHNOLOGY HIKE ON HEALTH CARE

Presented to Ms. Nighat Sultana Rizvi

By Zubair Ahmed Farhan Ali Students of MHM (Saturday)

May 03, 2008

LETTER OF AUTHORIZATION
May 03, 2008

Dear Reader As students of IOBM, we have been authorized to carry out a small scale study on Effects of Technology Hike on Healthcare, by the faculty of the Institute. The enclosed report contains an overview of technology and its implications in modern day healthcare. Those who are interested in exploring more about the subject are more than welcomed by us and are advised to feel free to contact us at the following numbers on 10 am to 5 pm. Zubair Ahmed: 03332464411

We hope that this report will serve its purpose of being an introductory set of information about the aforesaid subject.

Sincerely

Zubair Ahmed MHM Institute of Business Management Karachi

LETTER OF TRANSMITTAL

May 03, 2008

Ms. Nighat Sultana Rizvi Institute of Business Management Korangi Creek Karachi Dear Madam Rizvi Here I submit the term report on Effects of Technology Hike on Healthcare which you had assigned us for the course which we have attended in spring 2008 under your instructorship. We are submitting this report to you as an essential part of the curriculum for the course. A pharmaceutical industry was visited by our group to explore the views of healthcare professionals working in the industry about the subject of our report. Internet was extensively browsed and group discussions were also carried out within the group to gather and compile the information being presented in this report. Should you require any explanation, we would be glad to provide you the required information.

Sincerely

Zubair Ahmed MHM Institute of Business Management Karachi

LETTER OF ACKNOWLEDGEMENT

May 03, 2008

Dear Reader We would like to convey our inbound gratitude to our instructor for her cooperation extended to us in compiling this report. Furthermore, we would also like to extend our thanks to Dr. Irfan Michael Roy (Q.C. Manager of Roche Pakistan Limited) and Mr. Tahir Nabi Mirza (Head of QC/ QA, Roche Pakistan Limited) for providing us extremely valuable information regarding implication of Technology in Pharmaceutical Industry and providing us the valuable information for the compilation of this report.

Sincerely Zubair Ahmed MHM Institute of Business Management Karachi

TABLE OF CONTENTS
LETTER OF AUTORIZATIONii LETTER OF TRANSMITTAL.iii LETTER OF ACKNOWLEDEMENT..iv EXCUTIVE SUMMARY..v IINRODUCTION TO TECHNOLOGY........8 IINRODUCTION TO HEALTHCARE.9 ELECTRONIC HEALTH RECORD....11 The Criteria for an Electronic Health Record.................................. 11 Electronic Health Record Vision.......................................................11 MODELIING OUTCOMES FROM A SIMPLE TO A COMPLEX VISION OF THE EHR..................................................................................12 Economic Benefit...............................................................................12 Clinical Benefit..................................................................................13 TIMELY ACCESS TO HEALTHCARE.......................................................14 Demand..............................................................................................14 Supply.................................................................................................15 Communication..................................................................................15 TECHNLOGY AND FUTURE OF THE HEALTHCARE INDUSTRY......16 Visit to Roche Pakistan Limited..........................................................16 RISING COST OF TREATMENT.................................................................17 BENEFITS AND DRAWBACKS OF HEALTHCARE TECHNOLOGY....19 BIBLOGRAPHY.............................................................................................20

LISTS OF FIGURES
Figures 1. Packaging of Pharmaceutical Products.......................................................10 2. State of the Art Lab Equipment for Analysis of the Pharmaceutical Products.................................................................................10

LISTS OF TABLE
Table 1. Health Status by Income Level....................................................................19

EXCUTIVE SUMMARY Purpose of Report

The purpose of this report is to provide a comparison of benefits and drawbacks associated with use & increasing implication of technology in health care, especially in hospitals & pharmaceutical industries. The report will focus on evaluating those technology driven factors which play a vital role in either increasing or decreasing the productivity and efficiency of health care providers. The scope of the report will be limited to provision of valuable information regarding dependency of health care services on technology and it will not focus on mentioning historical backgrounds & evolution of technologies presently used in the health care sector. The report is intended to be significant for health care professionals in terms of increasing their knowledge of technology and health care coordination and it will help them to realize that keeping abreast with technology updates and identifying their appropriate use in the provision of better health solutions is of acute importance.

Effect of Technology Hikes in Health Care

In an era in which technology and health care go hand in hand, it is presumed that technological advancements have given health care a whole new direction in terms of increased patient awareness & access to seek health care, ease for medical professionals & pharmaceuticals to provide better health solutions and drift of pharmaceutical industries towards biotech products from conventional medicines. Besides all these blessings of technology there are certain difficulties associated with its increasing implication in health care. Rising costs of treatment, increasing self diagnosis, effect on national economies are some common examples in this context.

INTRODUCTION OF TECHNOLOGY
Technology is a broad concept that deals with a species usage and knowledge of tools and crafts, and how it affects a species ability to control and adapt to its environment. In human society, it is a consequence of science and engineering, although several technological advances predate the two concepts. Technology is a term with origins in the Greek "technologia", "" "techne", "" ("craft") and "logia", "" ("saying").[1] However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. The term can either be applied generally or to specific areas: examples include "construction technology", "medical technology", or "state-of-the-art technology". The human race's use of technology began with the conversion of plentiful natural resources into simple tools. The prehistorically discovery of the ability to control fire increased the available sources of food, and the invention of the wheel helped humans in traveling in and controlling their environment. Recent technological developments, including the printing press and the Internet, have lessened physical barriers to communication and allowed humans to interact on a global scale. However, not all technology has been used for peaceful purposes; the development of weapons of everincreasing destructive power has progressed throughout history, from clubs to nuclear weapons. Technology has affected society and its surroundings in a number of ways. In many societies, technology has helped develop more advanced economies (including today's global economy) and has allowed the rise of a leisure class. However, many technological processes produce unwanted by-products, known as pollution, and deplete natural resources, to the detriment of the Earth and its environment. Various implementations of technology influence the values of a society and new technology raises new ethical questions. Examples include the rise of the notion of efficiency in terms of human productivity, a term originally applied only to machines, and the challenge of traditional norms. Philosophical debates have arisen over the present and future use of technology in society, with disagreements over whether technology improves the human condition or worsens it. Neo-luddism and similar movements criticized the pervasiveness of technology in the modern world, claiming that it alienates people and destroys culture; proponents of ideologies such as transhumanism and techno-progressivism view continued technological progress as beneficial to society and the human condition. The distinction between science, engineering and technology is not always clear. Generally, science is the reasoned investigation or study of nature, aimed at discovering enduring principles among elements of the phenomenal world by employing formal techniques such as the scientific method. However, technologies are not usually direct products of science, because they have to satisfy requirements such as utility, usability and safety; therefore the application of scientific knowledge to concrete purposes requires the contribution of engineering research. Engineering is the goal-oriented process of designing and building tools and systems to exploit natural phenomena for practical human means, using results and techniques from science.
1. Definition of technology. Merriam-Webster <.http://en.wikipedia.org/wiki/Merriam-Webster > (Retrieved on 17 March 2008).

The development of technology broadly involves the use and application of knowledge, such as scientific, engineering, mathematical, linguistic, and historical knowledge, to achieve some practical result. It is usually a consequence of science and engineering although technology as a human activity has preceded the two fields. For example, science might study the flow of electrons in electrical conductors, by utilizing already-existing specialist technology and knowledge. This new-found knowledge may then be used by engineers to create new tools and machines, such as semiconductors, computers, and other forms of advanced technology. In this sense, scientists and engineers may both be considered technologists; the three fields are often considered as one for the purposes of research and reference.[1] In the modern world, superior technologies, resources, geography, and history give rise to robust economies; and in a well-functioning, robust economy, economic excess naturally flows into greater use of technology.

INTRODUCTION OF HEALTHCARE
Healthcare is the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical, nursing, and allied health professions.[2] According to the World Health Organization, health care embraces all the goods and services designed to promote health, including preventive, curative and palliative interventions, whether directed to individuals or to populations.[3] The organized provision of such services may constitute a health care system. This can include a specific governmental organization such as, in the UK, the National Health Service or cooperation across the National Health Service and Social Services as in Shared Care. Before the term "healthcare" became popular, English-speakers referred to medicine or to the health sector and spoke of the treatment and prevention of illness and disease. The healthcare industry is one of the world's largest and fastest-growing industries. Consuming over 10 percent of gross domestic product of most developed nations, health care can form an enormous part of a country's economy. In 2003, health care costs paid to hospitals, physicians, nursing homes, diagnostic laboratories, pharmacies, medical device manufacturers and other components of the health care system, consumed 15.3 percent of the GDP of the United States, the largest of any country in the world. In 2001, for the OECD countries the average was 8.4 percent with the United States (13.9%), Switzerland (10.9%), and Germany (10.7%) being the top three. There are many ways of providing healthcare in the modern world. The most common way is face-to-face delivery, where care provider and patient see each other 'in the flesh'. This is what occurs in general medicine in most countries. However, healthcare is not always face-to-face; with modern telecommunications technology, in absentia health care is becoming more common. This could be when practitioner and patient communicate over the phone, video conferencing, the internet, email, text messages, or any other form of non-face-to-face communication.
1. Intute: Science, Engineering and Technology. Technology War < http://www.intute.ac.uk/sciences > (Retrieved on 15 March 2008). 2. Definition of Health Care. Encyclopedia of Public Health <http://www.answers.com/library/Public+Health+Encyclopedia-cid-37082 > (Retrieved on 15 March 2008). 3. World Heath Organization Report, 2000 Annual Report. Why do health systems matter

A traditional view is that improvements in health result from advancements in medical science. The medical model of health focuses on the eradication of illness through diagnosis and effective treatment. In contrast, the social model of health places emphasis on changes that can be made in society and in people's own lifestyles to make the population healthier. It defines illness from the point of view of the individual's functioning within their society rather than by monitoring for changes in biological or physiological signs.

Packing of Pharmaceutical Products

State of the Art Lab Equipment for Analysis of the Pharmaceutical Products

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ELECTRONIC HEALTH RECORD

In his 2004 State of Union Address, President Bush noted: By computerizing

health records, we can avoid dangerous medical mistake, reduce cost, and improve car. This statement has been applauded by
many who recognize that electronic health records (EHRs) represent a huge opportunity to improve patient care and health system operation. However, efforts to achieve an EHR have represented a long journey from early visions to todays reality of possibility. The EHR is not a simple computer application; it represents a carefully constructed set of systems that are highly integrated and require: A significant investment of time, Money, process change, and Human factor reengineering.

The Criteria for an Electronic Health Record The Computerized Patient Record Institute, now the part of Health Information and Management System Society (HIMSS), identified three key criteria for an EHR. The electronic health record must: Integrate data from multiple sources Capture data at the point of care Support caregiver decision making

Electronic Health Record Vision EHRs may not yet be as widely implemented as the Institute of Medicine (IOM) would have desired, but the IOM vision remains firm. The IOM vision for EHR remained committed to the use of IT for number of purposes including: To document all episodes of healthcare whenever take place. To provide immediate access to data. To process data in verity of ways to support better decision making for patient care and clinical and health service research. To increase the efficiency of Healthcare organizations and decrease the cost of service. To ensure the confidentiality of data To improve the quality of care and promote the wellness of the population.

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MODELING OUTCOMES FROM A SIMPLE TO A COMPLEX VISION OF THE EHR

Result Reporting, Document Imaging, Data Repository Aggregation of Data Data Messaging, Clinical Workstation, Work Flow Changes Access to Data User interface Support, Automatic Data Capture, Controlled Vocabulary, and Structured Data Entry. Documentation of Care Links Knowledge Sources, Rules Engine, Integration with Care Process. Decision Support Consumer Health Information, Vertical Private Network, Competitive Positioning. Data Outreach Multidisciplinary Care Pathways, Enterprise Systems Continuum of Care Research Epidemiology/Public Health Longitudinal Data Patient/ provider satisfaction Improved quality of life Enhanced productivity Better economic conditions Cost of care improvements. Quality of care improvement Improved patient outcomes Improved service quality Improved cost of care Improved service efficiency Operational Availability of data

cost saving

Operational cost impact

IMPACT OF EHR ON HEALTH

Economic Benefit: Cost Saving or Cost Avoidance.

Not having to expand the file area to house more paper chart. Avoiding staff recruitment costs because the EHR has improved staff
retention. Avoid the cost of a specialty care referral when primary care physician use rules-based decision support.

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 Avoid the cost of repeat diagnostic studies when results are

unavailable.

Not having to hire additional telephonic receptionists as patient volume

increases.

Avoiding more expensive medications through presentation of costeffective alternatives. Revenue Increase and Contributions to Profit.

File Room takes considerable space by converting it to suite of offices

and examining rooms for a new physician generate additional revenue.

Increasing the of annual physical examinations through an automated

reminder system or booking aftercare at the time of discharge, which is likelier to secure the follow up visit than if the were left to schedule the appointment at a later time. Productivity Improvements

Point-of-care charting improves the productivity by reducing the

amount of dictation, which contributes to cost savings in transcription time.

Reduced time tracking diagnostic study results may improve physician

productivity by freeing the physician to see an additional patient each day, which has the potential to increase revenue. Clinical Benefit: Better Access to Clinical Information.

Information immediately accessible in the emergency department can

ensure the patients chronic conditions and current medication are readily available.

Clinical information that is always available can provide a much more

effective picture of a patients health history. Improved Clinical Decision Making and Disease Management.

Reminder of adverse drug event at the point of care reduces the

number of hypertensive patients taking non recommended medication. More Tailored Patient Education.

Although many providers Keep a supply of a wide variety of

intuitional handouts available to give their patients, the EHR can not only generate the handout as need, but also can incorporate a patients specific medications and other information that may be unique to his or her situation. More Time with Patients.

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 Many of the above benefit converge to impact work flow and hence
contribute to spend more time with patient, improved care, and improved quality of life for both patients and caregivers.

TIMELY ACCESS TO HELTHCARE (Facilitated by Innovative Technologies)

Timely access to healthcare services is a priority for any health care institution. To achieve a healthcare system that is able to respond with the right service, by the right provider, at the right time requires a comprehensive and coordinated approach. Development of a strategy to improve access to services will help to guide efforts in achieving a service delivery system that strives for excellence in quality and patient safety. In February 2003, the Department of Health and Office of Health Promotion (now the Department of Health Promotion and Protection, USA) jointly released a document entitled Your Health Matters: Working Together Toward Better Care. The document highlighted the importance of wait time information and outlined proposed plans for governments to monitor wait times and improve access in rural areas. Broader than the national focus on cancer and cardiac care, sight restoration, joint replacement and diagnostic imaging, Pakistan government has increased activity to improve access to programs and services across the continuum of healthcare including, but not limited to, mental health, primary healthcare (collaborative healthcare practices), pain management, chronic disease prevention and management, renal dialysis and continuing care. Efforts to improve timely access will need to build on current strategies and activities; improve existing programs and services; implement new processes, programs and services, technological solutions and provincial standards; and, strategically invest in infrastructure and human resources. Timely access to service is complex and is influenced by the balance between the demand and supply for that service. Reviewing these influencing factors provides additional information in determining the focus of strategies and activities. Demand Disease prevalence the higher the prevalence of a particular disease or condition the greater the demand will be for the services required to diagnose and treat that condition. Support for the technologies and resources required for epidemiologic and other research will enhance the ability of the system to respond to the 14

specific needs of the population. In addition, strategic investment in health promotion, disease prevention, and disease management strategies will reduce the burden of illness in the population and the demand for accessible, quality services. Physician referral practices - referrals that are not necessary add volume to wait lists and lengthen wait times. Physicians threshold for performing procedures physician individually determines the need for performing a diagnostic test or procedure. A standardized approach to patient assessment will ensure equitable access across the province. Patient preference - physicians for whom there is a greater demand are likely to have longer wait times. Patients are more likely to endure these longer waits to ensure they see their physician of choice. Emergency Cases - greater numbers of emergency cases or a decrease in the threshold of what is considered an emergency case will result in cancellations of elective cases and increase wait times. Wait times - long wait times can act as a deterrent in seeking a particular service and thereby prevent the wait time from lengthening.

Supply Human Resources health human resources are needed to operate and manage facilities, equipment and technology, as well as to provide direct delivery services. Within the context of global competition, recruiting and retaining the appropriate human resources to support the system is an ongoing challenge. Creating the right mix of health human resources is critical in creating an efficient system from the first point of contact to discharge, follow-up, and continuing care. Facilities, Equipment and new Technologies within the everchanging world of architecture, engineering and technology, it is an ongoing challenge to provide the most up-to-date facilities, equipment and technology that will provide the highest quality services that contribute to improved health status of the population. Strategically investing in facilities, equipment, and new technology is critical to stay up-to-date with current trends and to improve timely access to quality services that focus on patient care, safety, and outcomes. Organization in the complex world of healthcare, a coordinated system of processes, procedures, and practices 15

will facilitate timely access across the system. Creating a seamless transition between and among programs and services will contribute greatly to the quality and safety of service delivery. Communication Communication is critical to supporting timely access to services, including communication with and among health care professionals, with patients, and with the public.

TECHNOLOGY AND THE FUTURE OF HEALTH CARE INDUSTRIES

The pharmaceutical industry is highly complex. The technologies leading to drug discovery and development are at the limits of human knowledge. The huge size of the companies and the complexities of their processes and technologies presents many organisational and management challenges. The development and management of the distribution system is highly costly. However while excellence in managing all these aspects of the industry is a necessary condition for the survival of the global pharmaceutical companies, the uncertainty of the discovery process and the potentially huge returns from the discovery of a single drug means that like drilling for oil or randomly choosing the black beans from a jar of overwhelmingly white ones, success in the industry depends on a high measure of luck. Much of the thinking about business strategy in the industry is how best to cope with this uncertainty. This has not always been the case. Colonel Ely Lilly gained his initial competitive advantage, in manufacturing, by producing true to label products in competition with the various snake oils and other dubious concoctions of the era. The highly skewed nature of the returns from the drug discovery and development process means that a single drug can deliver corporate success at least in the short to medium term. Visit to Roche Pakistan Limited Roche is a huge global Pharmaceutical and Bio Tech organization head quartered in Switzerland. The business of the company is across the globe in almost all continents with major manufacturing sites in Basel, Shanghai, Dee Why, Karachi and Dhaka. The group of the students visited Roche Pakistan Limited situated in Korangi Industrial Area, Karachi. The group was entertained by the Manufacturing Manager of the company Mr. Asif Mansoor. Production Department, Quality Assurance & Control and Warehouse were visited by the group. The production department is equipped with state of the art manufacturing equipment having a dedicated facility for the Alcoholic Granulation of chewable vitamin tablets. These tablets are called draggers and they fall in the non-prescription type of medicines also known as OTC products (over the counter products). The facility is called Moretz and consists of steam jacketed vessel, a huge condenser and a vacuum system. The facility is designed to recycle the alcohol used in the granulation process to cut down the manufacturing costs and generate more revenues with less expenditure. The Lab of the company is also furnished with some of the most modern laboratory equipments. These equipments are used in the testing of raw materials, finished and 16

intermediate products. The lab is equipped with instruments like HPLC, Atomic Absorption Spectrometer & FTIR etc. Talking to the students QC Manager Dr. Irfan Michael Roy said, Marketing pharmaceutical products without a full scale investigation regarding their quality is nothing less than putting thousands of lives at risk. The physician ensures that the patients get the right kind of treatment and we perform an equally critical role by ensuring that the product being taken by the patients is risk free and is in strict accordance with the standard manufacturing guidelines set by the authorities like FDA. The Head of QC / QA of Roche Pakistan Limited Mr. Tahir Nabi Mirza expressed his views in the context of implication of Technology in Healthcare in the following words. Competitive and technological changes in the pharmaceutical industry-from powerful new drug chemistries to innovative R&D partnerships and marketing plans-are reshaping the business strategies of many pharmaceutical and biotechnology companies. According to me many companies today are searching for ways to increase productivity, decrease costs, and develop new treatment modalities that will enhance profitability. Strategies that seem to be working best for successful pharmaceutical and biotech companies when it comes to the productivity of drug discovery and the time it takes to develop new drugs; investment in R&D projects; manufacturing processes; and OTC switching. The benchmarks that you can use to compare your company practices are drug discovery, clinical trials, and manufacturing metrics to those of the most successful companies. These are among the issues which we will explore in "The New Millennium Pharmaceutical Industry. In addition to exploring strategic issues in pharmaceutical and biotechnology R&D, manufacturing, drug development, costs of capital, and the economics of new pharmaceutical marketplaces, companies should look at the prospects for changes in regulatory policies and competition.

RISING COST OF TREATMENT (Heightened Divide in Health Status of Different Communities)

As health care costs have gone up, it is increasingly important to make sure we are realizing the full value of the new medical technologies that we create. Maximizing our public health gains and our economic gains from new medical technology also requires that we encourage high value innovations and also realize more value from 17

the products that we use. This is important for the future, because while the cost of new medical technologies may continue to rise, the potential benefits of new treatments could grow even more dramatically. We must find better ways to increase value, to keep modern care affordable, while still encouraging medical innovation. With these unprecedented technological achievements have also come unprecedented concerns about the total spending on healthcare and, in particular, about the rising spending on these new medical technologies. Many worry that, even if these new technologies come along, they will not benefit because they will not be able to afford the high cost. While we need to take new steps to address the problem of health care affordability, we need to do it carefully. We must address this issue in a way that will not risk the tremendous potential for public health and economic benefits from continuing medical innovation by putting significant new limits on the payments or the intellectual property protections of innovative treatments that have made it through an increasingly long and costly development process. Growing costs of healthcare is also a huge concern for governments of developing countries. This has heightened the divide between the health statuses of various communities and is putting an increasing impact on governments to find ways of containing the costs of healthcare so that the latest medical technologies could be equally provided to people belonging to the low income groups. The facilities provided by public healthcare institutions are well below the level of facilities provided by the private healthcare organizations. The poorer populations are finding it extremely difficult to afford the healthcare costs even if its only preventive primary healthcare. Curative healthcare is far beyond the reach of these poor people in developing countries. NGOs are playing a very vital role in order to reduce this heightened divide by developing institutions which provide healthcare at more affordable terms for the low income populations. Sky rocketing costs of healthcare is now not only the problem of developing countries but developed countries like Australia, Canada and New Zealand are also having the difficulty of this heightened divide in the context of health status. The following table gives a good picture of the current disparity of health status in these developed countries.

Health Status by Income Level

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DO THE BENEFTS OF TECHNOLOGY WEIGH ITS DRAWBACKS ON HEALTH CARE?

The answer to the above question is perhaps an emphatic YES. Despite association of certain drawbacks with the use of mind boggling technology in healthcare its advantages still out weigh the drawbacks. Be it Information Technology, Electronics, Telecommunication or anything else, healthcare is probably the area which has benefited the most with the advent of modern technology. Increased awareness of the physicians, surgeons or other healthcare professionals has been a blessing for those who are suffering from diseases either it is chronic, non-chronic or life threatening. However use of a specific technology may cause complications when treating a certain problem but thanks to huge amount of information available for the doctors through they have become able to minimize the anticipated effects of treatments over their patients. On the contrary the use of technology has created some social problems in almost every part of the world, be it developed countries or underdeveloped parts of the globe. These Socioeconomic problems include the disparities in health status depending upon the income levels of the people which have been discussed in the earlier part of the report. All in all the connection between technology and healthcare is so strong now that it has evolved the term Healthcare Technology, which is a complete science in itself is and it is still on the go on its way to limits which are perhaps beyond the imagination of the existing human race.

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Bibliography
Definition of technology. Merriam-Webster <.http://en.wikipedia.org/wiki/Merriam-Webster > (Retrieved on 17 March 2008). Intute: Science, Engineering and Technology. Technology War < http://www.intute.ac.uk/sciences > (Retrieved on 15 March 2008). Definition of Health Care. Encyclopedia of Public Health <http://www.answers.com/library/Public+Health+Encyclopedia-cid-37082 > (Retrieved on 15 March 2008). World Heath Organization Report, 2000 Annual Report. Why do health systems matter? 20

Other References:
1. http://www.ahrq.gov/qual/nhdr05/nhdr05.pdf 2. http://www.pwcglobal.com/uk/eng/about/svcs/insights/pharma/pwc_sect2col.pdf 3. www.eweek.com/category2/0,1738,1478354,00.asp 4. content.healthaffairs.org/cgi/reprint/25/6/w516.pdf 5.www.healthcarevox.com/technology_and_healthcare 6.www.ser.com/xres/uploads/documents/Understanding_the_Benefits_of_Speech_An alytics_Solutions.pdf 7. ww.medicine.uottawa.ca/epid/pdf/EPI%205189%20fall%2006%20

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