Examining the potential evolution of eHealth systems architectures by 2020 Abstract A masterclass event was hosted by the Yorkshire Centre for Health Informatics, Institute of Health Sciences at the University of Leeds, to examine the potential evolution of eHealth systems architectures by 2020. The purpose of the event was to: Review research and innovation in computing architectures Explore the impact of digital development on healthcare delivery Identify next steps in e-health transformation Identify the requirements for interoperability within a global health economy Provide a long-term planning horizon for eHealth systems designers. The event was supported by keynote presentations on major themes, plus invited short presentations leading to round-table discussions and synthesis. The output will contribute to a four-day programme on eHealth funded by Yorkshire Forward leading to a Masters degree in Health Informatics at the University of Leeds. Introduction On the 4th February 2009 the Yorkshire Centre for Health Informatics (YCHI), Institute of Health Sciences, University of Leeds, hosted a CPD4HealthInnovation event on “Future eHealth Systems”. The event was attended by over 50 influential healthcare professionals from a diverse range of backgrounds including academe, healthcare providers including Connecting for Health (CfH), the National Health Service (NHS), and major healthcare suppliers including British Telecom (BT), Cerner, Computer Sciences Corporation (CSC), and Egton Medical Information Systems (EMIS). The aim was to examine the potential evolution of eHealth systems architectures by the year 2020, complementing the mission statement of the Continua Healthcare Alliance1: 1 Continua Health Alliance available at: http://www.continuaalliance.org/ To establish a system of interoperable personal telehealth solutions that fosters independence and empowers people and organizations to better manage health and wellness. The purpose of the event was to review research and innovation in healthcare computing architectures and to explore the impact of digital development on future healthcare delivery. Through this analysis it was hoped that the “next steps” in eHealth transformation would be identified and requirements for interoperability within a global health economy would be mapped onto a long-term planning horizon for eHealth systems designers. The event was supported by Yorkshire Forward, one of the country‟s largest Regional Development agencies, with responsibility for driving the growth and regeneration of some of Britain‟s most successful industry sectors in Yorkshire and The Humber (Y&H). Y&H is one of the most important regions in the UK with respect to medical devices and offers significant opportunities in other health- related sub-sectors which continue to grow. The Y&H region employs approximately 10,000 with a resulting Gross Value Added (GVA) of £0.5billion. Yorkshire Forward‟s vision is for healthcare technologies in Y&H to be at the forefront of developments in innovative healthcare applications which it hopes to achieve through increasing the critical mass of healthcare technology businesses in the region. Future initiatives focus on building network capacity, supporting strategic partnership working and raising the profile of the region. The output will contribute towards a four-day programme on “Designing Future eHealth Systems” funded by Yorkshire Forward and leading to a Masters degree in Health Informatics provided by YHCI. It is also hoped that more master classes will be run in the future to extend the discussions and to address specific topics such as e-science architectures (with the e-Science Institute2 led my Malcolm Atkinson leading in this area), ethics and information governance in detail. Methods Primary research was conducted via a one-day master class event which was organised into four key themes: health provider needs; health supplier needs; architectures of the future; and, accounting for globalisation and interoperability. The themes were separated by a morning keynote presentation by Dr. Justin Whatling, BT, on “Business Models in Healthcare and Health ICT” and an afternoon keynote presentation by Professor Justin Keen on “Information Architectures”. Each theme was approximately 1-hour long and consisted of a keynote presentation plus invited short presentations 2 E-Science Institute available at: http://www.nesc.ac.uk/esi/ leading to round table discussions and synthesis. During the day a number of attendees also took part in a “video diary” where questions were posed on their predictions on the future of eHealth. Audio was recorded throughout the day to accompany presentations and discussion, along with flipchart notes on key issues and challenges. Results Whatling presented on the changing healthcare environment and current and future business models and challenges. The sustainability of the healthcare system has become “critically dependent” on successful prevention models whereby maintaining health and productivity is crucial to long-term economic stability. Figure 1 Current Healthcare Challenges (Whatling, 2009) We continue to see mismatch between the supply and demand sides of healthcare interactions (see Figure 1). Health information and communications technology (ICT) has a critical role to play in transforming the economics of such interactions illustrated within the eHealth semi-circle (see Figure 1). The inherent flexibility of IT can catalyse the service innovations required to sustain an increasingly complex web of care, but are compounded by the difficulty to predict technology and service configurations and limited by risk aversive behaviour. “Pilotitis” is endemic to satisfy whole system business models which, though likely to be sustainable, require high up-front investments. The consumer healthcare industry is emergent, fragmented and investment driven but there is no strong lead customer to provide the impetus for mass adoption. Whatling debated that the NHS does not have the money or experience to drive changes and that we must collectively go through the delivery, innovation and deployment processes for the future healthcare delivery business models. Our approach to health ICT to date has been built around the needs of organisation and staff across consumer, payer/provider and social care markets. Figure 2 Convergence of Health and Wellness Markets in Future eHealth Delivery (Whatling, 2009) By re-dressing ownership of health and wellbeing across consumer and healthcare institution paradigms we can begin to create convergence between health and wellness markets. These markets will be driven by multiple factors focused on outcomes and empowerment (see Figure 2). The convergence of these markets will create new and exciting opportunities including shared care assessment, outcomes management, co-creation of content, shared decision-making, second opinion services, telecare, means testing and personal budgets. Figure 3 The Shift in Information Economy in the Machine World (Whatling, 2009) Socially, the information economy will largely move into the machine world (see Figure 3) where people will have access to machine enhancement to extend their own creativity. In tomorrow‟s world, technology will allow people to be more effective people and will not be seen as a replacement to human endeavour. This will have major implications on the “currency” of healthcare which will produce transformational changes in the business models operating in healthcare and in health ICT. Focus will shift from data- and information-centricity to knowledge centricity around the needs of the patient based on integrated care pathways and care cycles. Figure 4 Current Business/Service Delivery Models (Whatling, 2009) A number of current business service delivery models and challenges were presented (See Figure 4) which focus around patients, healthcare payers and providers, and ICT suppliers across four key relationships: care services, ICT products/services, funds and evidence of delivery. The four approaches (from top left to bottom right) are: Integration of ICT services into existing delivery channels as they are viewed as logical extensions of a healthcare organisation‟s portfolio. Cash flow follows well-established paths and there is no disruption of present delivery structures. Combining medical service provision and IT support where ICT services are not delivered in the context of conventional healthcare structures. Such offerings are seen as a threat by established healthcare providers. Managed care approach with “disease management concepts” is becoming an interesting option, but has legal constraints and opposition by health care providers. Private market approaches with direct payment by patients which are rare outside of countries with developed national health systems but are expected to increase. A report published by the European Commission‟s ICT for Health Unit following a „procuring for health benefits‟ telehealth workshop3 suggests there is a lack of appropriate business models in health. For hardware, buying or leasing may offer a more flexible local solution and may be best for long- term monitoring, though has a high initial cost, and a need for replacement and staff training. In comparison, buying services has a low initial cost, but has a high recurring cost and less flexible service. New business models are beginning to evolve through information arbitrage, infomediary, and metamediary services. Adopting an “ecosystem” approach may be the answer, where environments can be simulated experimented in to analyse successful business models for innovative eHealth applications, focusing on financing, longer term sustainability, incentives of all the stakeholders and on the role of procurers. Figure 5 Think Differently Scenarios (Rayner and Jessop, 2009) John Rayner and Eileen Jessop, Director and Assistant Director at The Health Informatics Service, presented four scenarios for future healthcare and well-being systems in 2020 (See Figure 5). The 3 “Report on Telehealth Workshop” available at: http://www.ehealtheurope.net/news/4439/report_on_telehealth_worshop_published scenarios were developed to encourage more focused and resilient strategy development in response to change drivers such as the aging population, demanding and sophisticated consumers and the exhaustion of traditional methods and tools for containing cost. Each scenario also included a set of key technology deliverables. 1. “Approved Cures” focused on treatment, care and cure with power being with the state. Government restricts the number provided by the NHS and Voluntary Clinical Care enhancement schemes are created alongside significant increases in private insurance. Universal broadband access is available to all and highly secure next-generation networks ensure seamless and robust operations of highly complex information structures between NHS and private sector systems. The best possible use of scarce resources is achieved by taking collective decisions about what individuals deserve and therefore have a right to, if individuals want more than this, they will have to make their own arrangements. 2. “Consumer-Led Cures” also focused on treatment, care and cure but with power being with the consumer. Government encourages greater consumer choice with bespoke care, and in some cases branded, packages. Primary Care Trusts (PCTs) are re-born as Consumer Care Trusts (CCTs) which help patients to micro-purchase service packages. Telemedicine, virtual worlds, decision aids and self-service are widely adopted. Central to this will be a fundamental shift in power and control away from clinicians and experts more generally toward the informed and assertive consumer. 3. “Mass Health Surveillance” where rising health care costs and a declining economy call for mass public health interventions. The primary responsibility for health lies with the individual and the family and full and mandatory public engagement is supported by online Health Action Plans with government health targets. NHS services are only made available to those who can demonstrate a year-on-year improvement devolved from integrated information systems recording patient metrics and citizen information. Basic telemonitoring and gaming technologies are a normal part of daily life. Those who do not care for themselves cannot expect those who are more responsible to do so. 4. “Personal Health Environments” where sophisticated health care supports the achievement of full human potential through advanced personal biometric information monitoring for the wealthy, and municipal biometrics in health centres for less well off. Government introduces personal “well-being budgets” and rejects institutionalised offerings in favour of bespoke and “boutique” packages of advice and support. Fusing new technologies with the insight of the ancients, the discerning consumer can develop a package of wellbeing services, addressing the mind, body and spirit, sustaining the perfect balance to optimum health. Marlene Winfield, Director for Patients and Public at NHS Connecting for Health, presented from the perspective of the patient on what they require as health care consumers. The presentation was opened with a quote from Dr. Richard Fitton: “Patients and information are the two most under-used resources in the NHS”. Patients are spending an increasingly smaller amount of time with health professionals and are provided with little (accurate and safe) information to manage their health. This parent/child relationship has been apparent throughout the history of the NHS but tools are now being developed that harness the power of patients and information. For example, NHS Choices4 and HealthSpace5 act as secure portals of consumer health information enabling patients to access medical records online, interact with their General Practitioner (GP) and get reminders on tests, appointments and screening to name just a few services. Eldorna Smith, a fictitious patient of the future: Jointly holds and contributes to her medical records and interactive Care Plan, manages tests, appointments, screening and prescriptions online. Sees her test results instantly, self-monitors and gets feedback directly from her GP. Researches her health information using blogs and online social networks through securely sharing her medical records with others across the world in a “Wiki Health” environment. Gives feedback on online and offline NHS services and how they can be improved. Dr. Mohammad Al-Ubaydli, Director at Patients Know Best6, believes it is worth stating beliefs to save ourselves from argument and to consider their conclusions. “The NHS is full of good IT work” exemplified by innovations such as PAERS7, MyFamilyHealth8, t+ Medical9 and the 3G Doctor10. Dr. Al-Ubaydli argued the following beliefs he had about the NHS: 4 NHS Choices available at: http://www.nhs.uk/ 5 HealthSpace available at: https://www.healthspace.nhs.uk/ 6 Patients Know Best available at: http://www.patientsknowbest.com/ 7 PAERS available at: http://www.paers.net/ 8 MyFamilyHealth available at: http://www.myfamilyhealth.com/ The NHS exists to serve patients, although the best way to serve these patients has not been invented yet. Most inventors do not, and never will, work for the NHS. Equally in the private sector, most inventors do not, and never will, work for a large company because most quit their jobs to start a new company. Inventors love accountability but hate committees. Patients know best (if we let them). If patients begin to understand medical notes and see benefits in personal health records, you switch from paternalistic medicine to participatory medicine. Mark Hawker, Teaching Development Officer at YCHI, continued the theme by presenting on the new wave of digital consumers and how a typical digital consumer uses technology in their everyday life, including online services and devices. Hawker presented on the applications of Web 2.0 technologies and ubiquitous digital devices that he uses and how many integrate seamlessly with one another through robust Application Programming Interfaces (APIs). A key question is how the healthcare industry is going to react to the growing “Generation Us” population who expect seamless integration of service, and lighting-fast speed of response. The afternoon session was opened with a keynote presentation from Professor Justin Keen, Director of the NIHR CLAHRC11 for Leeds, York and Bradford, on information architectures and sources and consequences of complexity. Professor Keen suggested three sources of health care ICT complexity: Health care in itself is inherently complex with many independent agents each interacting with each other, occasionally inducing changes, and creating complex adaptive systems containing emergent properties. The “language” and ordering of processes are fraught with fundamental problems which are impossible to predict. Tensions between governments and the medical profession have existed for many years and even today the UK Government is unclear what kind of NHS it wants. Activity on the ground is not connected with policy making. Investments such as the National Programme for IT 9 T+ Medical available at: http://www.tplusmedical.com/ 10 3G Doctor available at: http://www.3gdoctor.com/ 11 Collaboration for Leadership in Applied Health Research and Care (NPfIT) have increased the pressures on medical professionals to co-ordinate their activities and demand compliance with structured pathways. These two factors coupled with moving from a producer-driven to a consumer-driven model of health care have resulted in a fundamental shift in working practices. Large scale complexity as presented in an EPSRC Large Scale Complex IT Systems Programme12. Key themes: System Understanding. The principal functional and non- functional properties of complex IT systems cannot be completely understood by existing “reductionist” approaches; System Interactions. Systems interact with their operational environments in many different ways; and, Systems and Organisations. Complex IT systems are specified, developed, used and maintained within organisations that may themselves be thought of as complex systems. The development, deployment, evolution and use of the IT systems are thus influenced by human, organisational, business, social and political factors. These sources create environments where ICT is assumed to provide solutions for increasing complexity but such integration can actually increase the “transmission” of risks across networks, create new issues and challenges, and undermine central control. This has meant historical plans for solutions such as electronic health records, for example, are now understood to be naïve. Professor Keen presented suggestions for the future of health care, focused around a “regulated ecology”. He proposed suffixing “Research and Development” to the National Programme for Information Technology (NPfIT) to change the nature of its progression, having major effects on how contracts would be awarded and managed. Implementing this change would require a far better understanding of clinical processes, inter-operability standards matching those of countries such as Denmark, and enabling the state to relinquish access to personal data (and data about doctors‟ work). Dr. Duncan Russell and Dr. Colin Venters from the School of Computing‟s Distributed Systems and Services Group, University of Leeds, presented an overview of “Architectures for the Future: Service Oriented Architectures (SOA) and Beyond”. They discussed what they expected architectures to look like in 2020 along with approaches to managing change over time and evaluating business value of IT investments. Key discussion included the need for dynamic architectures that enable multiple independent systems to interact in a dependable way, with challenges surrounding connectivity and message transfer irrespective of underlying implementations. Grid computing was seen as an important technology in the future alongside “cloud” or service-oriented architectures with peer-to- 12 Large Scale Complex IT Systems available at: http://www.lscits.org/ peer discovery of services. They hope to improve the mechanisms of what was promised by service- oriented architectures to implement dynamic discovery, and further explore the potentials of the underlying technologies around grid computing where they are currently building a catalogue of architectural styles across military systems and the attributes of those styles in terms of dependability and scalability as well as many others. By providing mechanisms to enable secure interconnection of services we can aim to create high-level, dependant, intelligent systems across the healthcare domain with technologies supporting clinical processes. Joseph Waller, Lead Spine-Wide Architect at BT13, presented overviews of the NPfIT, The Spine, how they interact currently, and how this may evolve in the future. The NPfIT is the world‟s largest civilian IT project14. Managed by NHS Connecting for Health, it aims to improve patient care by enabling clinicians and other NHS staff to increase their efficiency and effectiveness by giving them access to patient information safely, securely and easily. A key element of the programme is creating an NHS Care Records Service (CRS) to improve the sharing of patients‟ records across the NHS with their consent. BT plays a prominent role on the NPfIT and is delivering three of its major contracts: The Spine – a £700m investment over 10 years providing the core to user-facing delivery programmes including a national electronic patient records database, electronic booking, transfer of prescriptions and messaging. N3 – the fast, secure, national broadband network connecting all NHS locations in England, supporting new applications and enabling data, now including voice services, to be transferred quickly and easily. London Local Service Provider (LSP) – integrating healthcare information systems with electronic records across hospitals, GP surgeries and clinics at around 2,600 sites to support the NHS CRS in England. Several tensions were identified surrounding current architectures and future developments. These included whether services should be centralised or distributed, and whether centralisation should be logical or physical, the challenge of shared records and their structure, information governance, and data integrity through push and pull architectural models. 13 BT and the NHS National Programme for IT available at: http://www.btplc.com/Health/NHSIT/ 14 Brennan (2005) “The NHS IT project” Rik Smithies, Chair of Health Level 7 (HL7) UK15, presented on interoperability in health systems. He began by outlining what interoperability is, and why people need it. Interoperability is a way of sharing data across multiple systems as it is impractical to hold everything inside one big system. We need interoperability standards as there are many computer systems across the “patient journey” creating “islands” or “silos” of information. Often these systems have many differences such as granularity, platform, specialties etc. which may hold data about the same patient, but cannot be identified uniformly throughout. Semantic interoperability is a way of systems understanding messages that are passed between systems and so can interpret how that message should be processed and shared. The goal of HL7 is to achieve semantic interoperability of medical systems, mostly through messaging, where clinical data is shared using structured formats that can be understood by both clinical computing systems. Clinical data is more than just medical facts, and should contain meta-data elements such as dates, times, data types and identifiers as well as “relationships” to represent causation, ordering and groupings and timings. So far, HL7 has created basic data types and structuring of medical “facts” along with a standard “terminology” to interoperate with multiple coding systems. A terminology is like a dictionary of medical facts or concepts such as diseases and symptoms which are allocated an arbitrary number (code) which eliminates language ambiguity. Terminologies that are used as simple lists of codes have proved inadequate as they lack structure and reference to real-world meaning. Structure allows computers to make inferences allowing generalisation for example, and features such as post-coordination allows new terms to be built out of others. One of the most complete and sophisticated terminologies is the Systematised Nomenclature of Medicine Clinical Terms (SNOMED-CT) which is owned and managed by the International Health Terminology Standards Development Organisation (IHTSDO). Other successful terminologies exist including Read codes in the UK and Logical Observation Identifiers Names and Codes (LOINC). Together, HL7 and SNOMED-CT promise to solve interoperability problems, although there are still lots of practical issues to solve: Neither standard is 100% complete in coverage, or perfect for all clinical use cases. Many organisational issues exist such as never having enough resources, or adequate funding, which makes it difficult to respond quickly to new matters arising. 15 Health Level 7 available at: http://www.hl7.org.uk/ Billion dollar programmes depend on the organisations described above, which often rely heavily on only a few key individuals. Both standards are technically difficult to use and implement. Interoperability standards themselves need to interoperate. This is exacerbated by the fact you cannot get organisations to adopt the same interoperability platform (compounded by mapping difficulties), organisations adopting standards at different times (if at all), and migrations such as between HL7 Versions 2 and 3 are not always easy. Short-term future projections for HL7 include building archetypes and templates which will allow system interfaces to adapt better to what clinicians need. Such systems will allow clinicians to sketch input screens and allow data to be collected and saved as a definition. This definition will then be interpreted and executed as if it were embedded in the program code. Before this can be achieved, there are hurdles such as competing standards for archetypes, mapping to open source systems like OpenEHR16, current systems not supporting configurations and the risk that “templated” data is only usable in the context it was captured in. Long-term projections are for a globally accessible, fully connected Electronic Health Record (EHR) which can be accessed anywhere via any device, and greatly increased speed of development and deployment of health systems with seamless integration and “pluggable” health software. Tony Solomonides, Director of Postgraduate Research at the University of the West of England and active member of HealthGrid17, presented on the application of grids for biomedical research and healthcare. Grids are “distributed software environments based on open standards and protocols that enable the sharing of disparate, loosely coupled IT resources across organisations and geographies” which are capable of being dynamically allocated dependent on resource need. A HealthGrid is an infrastructure that combines grid and e-science18 concepts oriented towards biomedical advances with early examples including MammoGrid, WISDOM and GEMSS. The SHARE project19, funded by the European Commission, aims to promote the deployment and adoption of healthgrids across Europe 16 OpenEHR available at: http://www.openehr.org/ 17 HealthGrid available at: http://community.healthgrid.org/ 18 E-Science definition available at: http://en.wikipedia.org/wiki/E-Science 19 The SHARE Project available at: http://www.eu-share.org/ addressing technical challenges including integration, standards, deployment and trust and acceptance. Ethical, legal and socio-economic factors also exist around ownership of data, best practices, awareness, trust and acceptance and change management. Discussion Throughout the day, several themes, issues and challenges were discussed, supported by the presentations, discussion and video diaries. These have been split into six categories: Evolving Role of the Patient Due to the increased availability of clinical information online and increased access to resources, patients are using the World Wide Web more than ever in the management of their own health. The shift from treatment and care to health and well-being will see “expert” patients joining clinicians as co-pilots in managing their health service interactions. How do we best educate patients on how best to search for, and act appropriately on, information they find online? Evolution of Architectures Distributed and Service-Oriented Architectures are helping overcome barriers of logical and physical centralisation of services. This includes new approaches to dynamic systems, where independent systems from multiple vendors can be integrated in a coherent architecture which is dependable and supports evolution of systems. Providing mechanisms to enable secure interconnection of services can create high-level, dependant, intelligent systems across the healthcare domain with technologies supporting clinical processes. The role of pervasive computing, combining network technologies with wireless computing, voice recognition, Internet capability and artificial intelligence, will create an environment where the connectivity of devices is seamless and always available. What lessons can be learnt from Computer Science and applied to future healthcare systems? Changing Nature of Clinical Processes Several implications exist around technology design, record keeping and clinician/patients relationships and whether ICT solutions reduce human interactions in care delivery. A better understanding of clinical and diagnostic processes will help reduce inefficiencies and promote local innovation. Tas Hind, Business Process and Functional Design Team Lead at CSC, works closely analysing the impact of technologies on business processes and how management of organisational journeys can aid care delivery. Hind presented a process model for renal care which demonstrated the complexity involved in mapping even a single process. By involving stakeholders at each level of the design process, we can understand more closely the implications future eHealth systems have on the changing nature of clinical processes. How do we embed process-driven design into new and existing healthcare innovations? Standards and Interoperability Whilst agreements were made of the benefits of coding when used by all, it was difficult to see how this could be achieved using current methods of adoption. Suggestions were made on the role of central arbiters who would control “standards for standards” with a move to a more open standard format at a national level. The use of semantics and ontology-based definitions may be the answer to alleviate a “one size fits all” mentality. A key challenge is how information can be presented in different contexts and still be understood e.g. the use of clinical data for research. For this, we will require common formats and communication standards and for these to be adopted globally. But who will govern, manage, own and enforce these standards? Governance and Security There needs to be greater studies into the effects of risk transmission through networks and what the implications of sharing data across multiple organisations are. Suggestions were made around increasing the professionalism around security standards e.g. ISO27000 compliance and on what the best models of security will be in the future. These models surrounded access protocols and whether “alarms” or “locks” would be most appropriate, as well as personal data security and ownership and responsibility of electronic medical records. Due to the evolving role of the patient and changing nature of clinical processes will the Data Protection Act in its current form be sufficient in covering the governance issues surrounding access? Government Pressures One of the main inhibitors of innovation is political pressures for short-term results where, for over 15 years, the government and medical profession are unable to agree on what technology they want, what they want it for, and whether either side trusts each other. Target-driven, “surveillance society” cultures may prevent any form of evolution of eHealth systems, or the sheer ferocity of technological innovation may prevail over Governmental control. Are current policies working or do we need to challenge and rethink the relationships between Government, suppliers and health professionals? Conclusion We concluded that there has been insufficient intellectual debate on the future of eHealth systems architectures, and that there is not one unified vision for the future. Many key issues and challenges remain to be addressed before we can look towards a “blue sky” vision of full electronic patient record implementation, for example. The masterclass has set the ball rolling for a new Masters-level module of the same title and a series of continuing professional development (CPD) courses being delivered by the Yorkshire Centre for Health Informatics (YCHI). More discussion and debate is needed on the presentation of high fidelity concepts related to environmental, ethical, legal, political, social, and technological challenges including next-generation architectures, standards and interoperability and information governance. Acknowledgements The Yorkshire Centre for Health Informatics is a leading international centre for health informatics expertise, collaboration and research. Our mission is to improve heath care practice through high quality research and evidence based education and training. The centre brings together partners from the University, NHS and Industry to help meet the challenges in handling health information. Our objectives are to develop knowledge through multidisciplinary research; develop „best practice‟ and quality assurance within health informatics processes; disseminate „best practice‟ through education and training; facilitate knowledge transfer by bridging the gap between health informatics researchers, healthcare providers and health IT industries. This paper was written by Mark Hawker, Owen Johnson and Dr Rick Jones. We are grateful to the respondents, speakers and participants for their lively debate and contributions to the masterclass and this publication.
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