1
|
Vestergaard T, Andersen MK, Bygum A. Acceptance of Teledermoscopy by General Practitioners and Dermatologists in Denmark. Dermatol Pract Concept 2021; 11:e2021033. [PMID: 33954016 DOI: 10.5826/dpc.1102a33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 01/17/2023] Open
Abstract
Background Teledermoscopy can be used to triage referrals of suspected skin cancers, thereby reducing waiting time and number of face-to-face consultations with a dermatologist. However, the success of the implementation of this technology in part relies on the acceptance of the providers. Objectives This study assessed the attitudes towards teledermoscopy of referring general practitioners and consultant dermatologists. Methods General practitioners from 48 practices and 3 dermatologists in the region of Southern Denmark, who had previous experience with teledermoscopy, were invited to answer questionnaires on their acceptance of the technology. Results General practitioners from 23 practices responded. All domains of the questionnaire received high scores, indicating a high degree of acceptance of teledermoscopy among respondents. All 3 dermatologists agreed that teledermoscopy was useful for triaging referrals, but they were less confident in their diagnoses and management plans proposed by teledermoscopy than in traditional face-to-face evaluations of patients. Two of the 3 dermatologists were satisfied with using teledermoscopy as a consult method. Conclusions This study reports high levels of provider acceptance of teledermoscopy. However, a low response rate among general practitioners may limit its generalizability.
Collapse
Affiliation(s)
- Tine Vestergaard
- Department of Dermatology and Allergy Centre & Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Merethe K Andersen
- Audit Project Odense, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| |
Collapse
|
2
|
Martin A, Guitera P. Teledermatology for Skin Cancer: The Australian Experience. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00291-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
3
|
Rollin A, Ridout B, Campbell A. Digital Health in Melanoma Posttreatment Care in Rural and Remote Australia: Systematic Review. J Med Internet Res 2018; 20:e11547. [PMID: 30249578 PMCID: PMC6231739 DOI: 10.2196/11547] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services. Objective The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas. Methods A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes. Results Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers’ acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare. Conclusions Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.
Collapse
Affiliation(s)
- Audrey Rollin
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Brad Ridout
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Andrew Campbell
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| |
Collapse
|
4
|
Granja C, Janssen W, Johansen MA. Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature. J Med Internet Res 2018; 20:e10235. [PMID: 29716883 PMCID: PMC5954232 DOI: 10.2196/10235] [Citation(s) in RCA: 278] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/09/2018] [Indexed: 01/18/2023] Open
Abstract
Background eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality. Objective Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure. Methods We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles. Results Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1). Conclusions The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.
Collapse
Affiliation(s)
- Conceição Granja
- Future Journal, Norwegian Centre for E-health Research, Tromsø, Norway
| | - Wouter Janssen
- Telemedicine and E-health Research Group, University of Tromsø-The Artic University of Norway, Tromsø, Norway
| | - Monika Alise Johansen
- Future Journal, Norwegian Centre for E-health Research, Tromsø, Norway.,Telemedicine and E-health Research Group, University of Tromsø-The Artic University of Norway, Tromsø, Norway
| |
Collapse
|
5
|
The promise and the reality: a mental health workforce perspective on technology-enhanced youth mental health service delivery. BMC Health Serv Res 2016; 16:562. [PMID: 27724951 PMCID: PMC5057226 DOI: 10.1186/s12913-016-1790-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 09/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Digital technologies show promise for reversing poor engagement of youth (16-24 years) with mental health services. In particular, mobile and internet based applications with communication capabilities can augment face-to-face mental health service provision. The literature in this field, however, fails to adequately capture the perspectives of the youth mental health workforce regarding utility and acceptability of technology for this purpose. METHODS This paper describes results of in-depth qualitative data drawn from various stakeholders involved in provision of youth mental health services in one Australian rural region. Data were obtained using focus groups and semi-structured interviews with regional youth mental health clinicians, youth workers and support/management staff (n = 4 focus groups; n = 8 interviews) and analysed via inductive thematic analysis. RESULTS Results question the acceptability of technology to engage clients within youth mental health services. Six main themes were identified: young people in a digital age, personal connection, power and vulnerability, professional identity, individual factors and organisational legitimacy. CONCLUSIONS These findings deepen the understanding of risks and challenges faced when adopting new technologies in mental healthcare. Recommendations for technology design and implementation in mental health services are made.
Collapse
|
6
|
Horsham C, Loescher L, Whiteman D, Soyer H, Janda M. Consumer acceptance of patient-performed mobile teledermoscopy for the early detection of melanoma. Br J Dermatol 2016; 175:1301-1310. [DOI: 10.1111/bjd.14630] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2016] [Indexed: 11/26/2022]
Affiliation(s)
- C. Horsham
- Institute of Health and Biomedical Innovation; School of Public Health and Social Work; Queensland University of Technology; Queensland Australia
| | - L.J. Loescher
- The University of Arizona Colleges of Nursing and Public Health; Tucson AZ U.S.A
| | - D.C. Whiteman
- Department of Population Health; QIMR Berghofer Medical Research Institute; Brisbane Queensland Australia
| | - H.P. Soyer
- Dermatology Research Centre; The University of Queensland; School of Medicine; Translational Research Institute; Brisbane Queensland Australia
| | - M. Janda
- Institute of Health and Biomedical Innovation; School of Public Health and Social Work; Queensland University of Technology; Queensland Australia
| |
Collapse
|
7
|
What is the extent of research on the characteristics, behaviors, and impacts of health information technology champions? A scoping review. BMC Med Inform Decis Mak 2016; 16:2. [PMID: 26754739 PMCID: PMC4709871 DOI: 10.1186/s12911-016-0240-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 01/05/2016] [Indexed: 01/03/2023] Open
Abstract
Background Although champions are commonly employed in health information technology (HIT) implementations, the state of empirical literature on HIT champions’ is unclear. The purpose of our review was to synthesize quantitative and qualitative studies to identify the extent of research on the characteristics, behaviors, and impacts of HIT champions. Ultimately, our goal was to identify gaps in the literature and inform implementation science. Methods Our review employed a broad search strategy using multiple databases—Embase, Pubmed, Cinahl, PsychInfo, Web of Science, and the Cochrane library. We identified 1728 candidate articles, of which 42 were retained for full-text review. Results Of the 42 studies included, fourteen studies employed a multiple-case study design (33 %), 12 additional articles employed a single-case study design (29 %), five used quantitative methods (12 %), two used mixed-methods (5 %), and one used a Delphi methodology (2 %). Our review revealed multiple categories and characteristics of champions as well as influence tactics they used to promote an HIT project. Furthermore, studies have assessed three general types of HIT champion impacts: (1) impacts on the implementation process of a specific HIT; (2) impacts on usage behavior or overall success of a specific HIT; and (3) impacts on general organizational-level innovativeness. However the extent to which HIT projects fail even with a champion and why such failures occur is not clear. Also unclear is whether all organizations require a champion for successful HIT project implementation. In other words, we currently do not know enough about the conditions under which (1) a health IT champion is needed, (2) multiple champions are needed, and (3) an appointed champion—as opposed to an emergent champion—can be successful. Conclusions Although champions appear to have contributed to successful implementation of HIT projects, simply measuring the presence or absence of a champion is not sufficient for assessing impacts. Future research should aim for answers to questions about who champions should be, when they should be engaged, what they should do, how management can support their efforts, and what their impact is given the organizational context.
Collapse
|
8
|
Wade VA, Eliott JA, Hiller JE. Clinician acceptance is the key factor for sustainable telehealth services. QUALITATIVE HEALTH RESEARCH 2014; 24:682-94. [PMID: 24685708 DOI: 10.1177/1049732314528809] [Citation(s) in RCA: 220] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Telehealth, the delivery of health care services at a distance using information and communications technology, has been slow to be adopted and difficult to sustain. Researchers developing theories concerning the introduction of complex change into health care usually take a multifactorial approach; we intentionally sought a single point of intervention that would have maximum impact on implementation. We conducted a qualitative interview study of 36 Australian telehealth services, sampled for maximum variation, and used grounded theory methods to develop a model from which we chose the most important factor affecting the success of telehealth. We propose that clinician acceptance explains much of the variation in the uptake, expansion, and sustainability of Australian telehealth services, and that clinician acceptance could, in most circumstances, overcome low demand, technology problems, workforce pressure, and lack of resourcing. We conclude that our model offers practical advice to those seeking to implement change with limited resources.
Collapse
Affiliation(s)
- Victoria A Wade
- 1The University of Adelaide, Adelaide, South Australia, Australia
| | | | | |
Collapse
|
9
|
Cua FC, Reames S. Theory versus Application. INTERNATIONAL JOURNAL OF INFORMATION SYSTEMS IN THE SERVICE SECTOR 2013. [DOI: 10.4018/ijisss.2013100104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This paper discusses the critical use and lessons learned from the single case model while implementing an Enterprise Resource Planning (ERP) system at a leading university. The researcher examined one university’s business ERP in the deployment of a new enterprise system, a complex phenomenon which took place over several stages and involved different players at each stage. The paper discusses the case system inclusive of the grounded case theory, diffusion of innovation theory, innovation-process theory and their application during the ERP system implementation.
Collapse
Affiliation(s)
- Francisco Chia Cua
- Bang College of Business, Kazakhstan Institute of Management, Economics and Strategic Research (KIMEP), Almaty, Kazakhstan
| | - Steve Reames
- Department of Management and Marketing, College of Business, Angelo State University, San Angelo, TX, USA
| |
Collapse
|
10
|
Li J, Talaei-Khoei A, Seale H, Ray P, Macintyre CR. Health Care Provider Adoption of eHealth: Systematic Literature Review. Interact J Med Res 2013; 2:e7. [PMID: 23608679 PMCID: PMC3628149 DOI: 10.2196/ijmr.2468] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 02/04/2013] [Accepted: 03/09/2013] [Indexed: 11/13/2022] Open
Abstract
Background eHealth is an application of information and communication technologies across the whole range of functions that affect health. The benefits of eHealth (eg, improvement of health care operational efficiency and quality of patient care) have previously been documented in the literature. Health care providers (eg, medical doctors) are the key driving force in pushing eHealth initiatives. Without their acceptance and actual use, those eHealth benefits would be unlikely to be reaped. Objective To identify and synthesize influential factors to health care providers’ acceptance of various eHealth systems. Methods This systematic literature review was conducted in four steps. The first two steps facilitated the location and identification of relevant articles. The third step extracted key information from those articles including the studies’ characteristics and results. In the last step, identified factors were analyzed and grouped in accordance with the Unified Theory of Acceptance and Use of Technology (UTAUT). Results This study included 93 papers that have studied health care providers’ acceptance of eHealth. From these papers, 40 factors were identified and grouped into 7 clusters: (1) health care provider characteristics, (2) medical practice characteristics, (3) voluntariness of use, (4) performance expectancy, (5) effort expectancy, (6) social influence, and (7) facilitating or inhibiting conditions. Conclusions The grouping results demonstrated that the UTAUT model is useful for organizing the literature but has its limitations. Due to the complex contextual dynamics of health care settings, our work suggested that there would be potential to extend theories on information technology adoption, which is of great benefit to readers interested in learning more on the topic. Practically, these findings may help health care decision makers proactively introduce interventions to encourage acceptance of eHealth and may also assist health policy makers refine relevant policies to promote the eHealth innovation.
Collapse
Affiliation(s)
- Junhua Li
- Asia-Pacific ubiquitous Healthcare research Centre (APuHC), The University of New South Wales, Sydney, Australia.
| | | | | | | | | |
Collapse
|
11
|
Orruño E, Gagnon MP, Asua J, Abdeljelil AB. Evaluation of teledermatology adoption by health-care professionals using a modified Technology Acceptance Model. J Telemed Telecare 2011; 17:303-7. [DOI: 10.1258/jtt.2011.101101] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We examined the main factors affecting the intention of physicians to use teledermatology using a modified Technology Acceptance Model (TAM). The investigation was carried out during a teledermatology pilot study conducted in Spain. A total of 276 questionnaires were sent to physicians by email and 171 responded (62%). Cronbach's alpha was acceptably high for all constructs. Theoretical variables were well correlated with each other and with the dependent variable (Intention to Use). Logistic regression indicated that the original TAM model was good at predicting physicians' intention to use teledermatology and that the variables Perceived Usefulness and Perceived Ease of Use were both significant (odds ratios of 8.4 and 7.4, respectively). When other theoretical variables were added, the model was still significant and it also became more powerful. However, the only significant predictor in the modified model was Facilitators with an odds ratio of 9.9. Thus the TAM was good at predicting physicians' intention to use teledermatology. However, the most important variable was the perception of Facilitators to using the technology (e.g. infrastructure, training and support).
Collapse
Affiliation(s)
- Estibalitz Orruño
- Office for Health Technology Assessment, Department of Health and Consumer Affairs, Basque Government, Vitoria-Gasteiz, Spain
| | - Marie Pierre Gagnon
- Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada
- Faculty of Nursing Sciences, Université Laval, Québec, Canada
| | - José Asua
- Direction of Knowledge Management and Evaluation, Department of Health and Consumer Affairs, Basque Government, Vitoria-Gasteiz, Spain
| | - Anis Ben Abdeljelil
- Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada
| |
Collapse
|
12
|
Gagnon MP, Desmartis M, Labrecque M, Car J, Pagliari C, Pluye P, Frémont P, Gagnon J, Tremblay N, Légaré F. Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. J Med Syst 2010; 36:241-77. [PMID: 20703721 DOI: 10.1007/s10916-010-9473-4] [Citation(s) in RCA: 284] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/08/2010] [Indexed: 01/18/2023]
Abstract
This systematic review of mixed methods studies focuses on factors that can facilitate or limit the implementation of information and communication technologies (ICTs) in clinical settings. Systematic searches of relevant bibliographic databases identified studies about interventions promoting ICT adoption by healthcare professionals. Content analysis was performed by two reviewers using a specific grid. One hundred and one (101) studies were included in the review. Perception of the benefits of the innovation (system usefulness) was the most common facilitating factor, followed by ease of use. Issues regarding design, technical concerns, familiarity with ICT, and time were the most frequent limiting factors identified. Our results suggest strategies that could effectively promote the successful adoption of ICT in healthcare professional practices.
Collapse
|
13
|
Vuononvirta T, Timonen M, Keinänen-Kiukaanniemi S, Timonen O, Ylitalo K, Kanste O, Taanila A. The attitudes of multiprofessional teams to telehealth adoption in northern Finland health centres. J Telemed Telecare 2010; 15:290-6. [PMID: 19720766 DOI: 10.1258/jtt.2009.090108] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
A telehealth network was established between seven health centres, the local university and the university hospital in the Oulu Arc Subregion in a rural area of northern Finland. During the period 2004-2007, the videophone network was used for different types of teleconsultation (orthopaedics, psychiatry, diabetes, rehabilitation), continuing education and various patient care and administrative meetings. Qualitative research with observation and interviews with 30 professionals (physicians, nurses, psychiatric nurses, physiotherapists) was carried out in early 2007 to find out health-care professionals' attitudes toward telehealth and to see how the attitudes were connected to telehealth usage. Overall, the attitudes were more positive than negative, ranging from negative to enthusiastically positive. Diversity of attitudes occurred in relation to time, situation, profession, health centre and telehealth application. Ten different types of telehealth adopters were recognized: enthusiastic user, positive user, critical user, hesitant user, positive participant, hesitant participant, critical participant, neutral participant, negative participant and positive non-participant. Telehealth was especially well accepted in continuing education and in diabetes teleconsultations. The study showed that a negative attitude was not a definite barrier to telehealth adoption, but it did require additional attention from project workers and managers. Project staff and managers need to take into account the diverse attitudes of health professionals, because different people require different actions to adopt telehealth in their work.
Collapse
Affiliation(s)
- Tiina Vuononvirta
- Institute of Health Sciences, University of Oulu, FIN-91100, Finland.
| | | | | | | | | | | | | |
Collapse
|
14
|
|
15
|
Armstrong AW, Dorer DJ, Lugn NE, Kvedar JC. Economic evaluation of interactive teledermatology compared with conventional care. Telemed J E Health 2007; 13:91-9. [PMID: 17489695 DOI: 10.1089/tmj.2006.0035] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Teledermatology offers a means of providing specialist care to underserved patients. The objectives of this study were to compare the costs of interactive teledermatology with conventional care, and to evaluate from a healthcare provider perspective whether interactive teledermatology is economically viable in the northeastern region of the United States. We studied the interactive teledermatology practice at Nantucket Cottage Hospital on Nantucket Island and the ambulatory clinics at the Massachusetts General Hospital in Boston, Massachusetts. The cost-minimization analysis compared the costs of an interactive teledermatology practice with that of a face-to-face dermatology clinic. One-way sensitivity analyses examined the effect of varying the costs of technology, physician compensation, or clinic space on the overall cost of interactive teledermatology. We also assessed the economic viability of the interactive teledermatology practice by comparing the operating costs with reimbursements. The total hourly operating costs for the interactive teledermatology practice on Nantucket Island and the face-to-face clinic in Boston were $274 and $346, respectively. Three separate one-way sensitivity analyses showed that, for the cost of the teledermatology practice to equal that of the conventional clinic, the cost of teledermatology technology could increase by 9.3-fold, dermatologists working at the teledermatology practice could be compensated up to $197 an hour, or the cost of teledermatology clinic space could reach $57 an hour. Our analysis also showed that the hourly reimbursement for the teledermatology practice was $487, which exceeded its hourly operating cost of $274. The cost of operating an interactive teledermatology practice in a remote region may be less than that of a conventional clinic in a nearby urban center in the northeastern area of the United States. From a healthcare provider perspective, interactive teledermatology can be an economically viable means of providing dermatological care to remote regions.
Collapse
Affiliation(s)
- April W Armstrong
- Department of Dermatology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | | | | | | |
Collapse
|