Design of a multimedia system for multi-specialty medical ...
Proceedings of “SPIE Medical Imaging 1997”, SPIE Vol. 3031, pp.832-843
Design of a multimedia system for multi-specialty medical conferences
Mehran Moshfeghi1, Tony Chou2, Hein Haas3, H.K. Huang2, Bill Lord4, Joachim Schmidt5, Jun
Wang1, Thomas Wendler5, Stephen Wong1, Yuan-Pin Yu1, Christian Zellner2
Philips Research, 1070 Arastradero Rd, Palo Alto, CA 94304-1336, USA
University of California San Francisco, San Francisco, CA 94143-0628, USA
Philips Multimedia Center, 1070 Arastradero Rd, Palo Alto, CA 94304-1336, USA
Philips Research, 345 Scarborough Rd, Briarcliff Manor, NY 10510-2099, USA
Philips Research, P.O. Box 63 05 65, Rontgenstrasse 24-26, D-22315 Hamburg, Germany
In this paper we present the methods and results of a workflow study of a multi-specialty cardiology conference,
preliminary design concepts for a digital cardiac conference room, and a prototype of a component that is anticipated for a
complete implementation. Workflow studies at the University of California, San Francisco (UCSF) Medical Center were
performed to understand its traditional catheterization conference work procedures and processes. These studies involved
observing and interviewing people that prepare, present, and attend the conference. The workflow investigation gave insight
into current drawbacks. Scenarios were then generated that described potential new designs for the cardiac catheterization
conference. Knowledge gained from the workflow studies, and feedback from UCSF physicians who reviewed the digital
conference room scenarios led to the final system design. We have prototyped one of the components of the design: a
software tool for improved presentation of dynamic images. This tool has been implemented in Java and is therefore platform
Keywords: Conferencing, Cardiology, Teaching, Display, Teleconference, Workflow, User-Centered Design, Java
Conferences are an important part of the workload of physicians [1-3]. As part of a program to model and understand
electronic patient records and department information management systems, we are investigating future scenarios for multi-
specialty medical conferences. Our immediate objective is to design systems that ease the preparation and enhance the
presentation of cardiology catheterization conferences. These conferences often require presentation of multiple imaging
modalities. In this paper we report on the adult cardiac catheterization conference at the University of California, San
Francisco (UCSF) Medical Center. We will refer to this multi-specialty conference as the cath. conference in the rest of the
The primary purpose of the UCSF cath. conference is training and ongoing medical education. Typically fifty physicians
attend this weekly conference, where four or five selected cases are presented. Attendees are specialists from cardiology,
surgery, radiology, nuclear medicine, as well as fellows and students. A clinical cardiology fellow chooses the cases to be
presented and acts as the conference moderator. The physician in charge of a specific aspect of a given patient’s care makes
sure that all relevant data are brought to the conference. Conference handouts describing the cases to be presented are given to
the participants prior to the start of the meeting. The information presented in the conference typically includes radiographic
images, dynamic angiographic images (cine film), echo studies, MR images, Nuclear Medicine (NM) images, cine CT
images, EKGs, clinical reports, and reference material from the medical literature. Multiple presentation devices are used for
the presentation. These include light-boxes, overhead projectors, slide projectors, cine film projectors, and video cassette
players with large-screen TV or video projection systems. A team approach is used to present cases because different
laboratories are involved in providing specific patient services. For example, invited radiologists and nuclear medicine
specialists contribute to the analysis of cardiovascular images.
Traditional cath. conference preparation and presentation logistics are difficult. A digital conference room is a new
concept for overcoming many of these difficulties. We believe that many of the solutions we provide towards improving the
cardiac cath. conference will be equally applicable to other medical and non-medical conferences. The organization of this
paper is as follows: In section 2 we report the methodology and results of the UCSF cath. conference workflow study. In
section 3 we present scenarios for future digital conference rooms and the feedback of UCSF physicians’ on these scenarios.
The design of the digital conference room system is discussed in section 4. In section 5 we report on the implementation of a
software tool for improved presentation of dynamic images. Finally, section 6 contains some concluding remarks.
2. WORKFLOW INVESTIGATION
The purpose of workflow modeling is to understand work processes. A process is a coordinated set of activities that are
connected in order to achieve a common goal. Work redesign can begin once users’ work processes are understood [4-7].
Systems can then be built that allow users to adapt their current work processes to take full advantage of new technology.
2.1. Workflow Methodology
Our analysis of conference workflow processes included the preparation for the conference and the conference itself.
Post-conference activities were not investigated in detail. The analysis of the preparation was based on observations of
activities, and interviews with the clinical people. Notes were taken during the observations and essential steps were
documented by photographs whenever possible. The goals of these investigations were to answer the following questions:
• What activities are carried out?
• What are the goals of the activities?
• What are the inputs and outputs of activities?
• What are the regulations, habits, and constraints associated with activities?
• What are the resources needed to carry out the activities?
The conference itself was mostly analyzed by observation. Most of the conference participants do not have an active role
in the preparation or presentation of the conference. Therefore, a questionnaire was handed out to the conference participants
to gather information about them and their opinions concerning the conference. Twenty seven participants filled out the
questionnaire. The processes were formally modeled in detail using the Business Processes in Windows (BPWin) software
tool  from LogicWorks Inc. . BPWin is a graphical program which allows elaborate modeling of activities, information
exchanges, and elements that influence the process. BPWin can be used to generate reports from the model. This is especially
useful for discussions with designers and process owners/managers. BPWin implements the Integration DEFinition for
Function Modeling (IDEFO) technique . IDEFO is a well proven modeling technique which is based on the hierarchical
decomposition of activities into lower level activities. We do not present the detailed BPWin diagrams because they are
beyond the scope of this paper.
2.2. Organization Structure
A basic knowledge of the hierarchy and tiers of an organization is essential for the understanding and modeling of its
processes. This knowledge facilitates the association of roles and functions with activities, and can be used to select the right
people for interviews. The basic organization structure was elicited in interviews with members of the clinical staff. Four
departments are involved in the cath. conference: Internal Medicine, Radiology, Pathology, and Surgery. The Internal
Medicine department and the Radiology department are more involved in the conference than other departments. Departments
are sub-structured into divisions. The department of Internal Medicine has six divisions. The Cardiology division has the
leading role in the conference and is the most important organizational unit. Each division may have several laboratories. The
laboratories of the Cardiology division are important players in the preparation and running of the conference. The cath. lab.,
the echo-cardiography lab., the EKG lab., and the electro-physiology lab. contribute most of the information for the
conference. The laboratories of Cardio-Vascular Radiology and Nuclear Medicine, both of which are in the Radiology
department, also contribute to the conference.
2.3. Overview Of Supplied Information
The patients discussed in the conference typically have non-invasive investigations and/or invasive procedures performed
on them. These procedures can in turn deliver functional or anatomical information. Figure 1 gives an overview of the
information each institution provides for the cath. conference. The sequence of investigations usually starts with less
expensive non-invasive procedures. However, more expensive invasive procedures are carried out if there is a need for them.
A typical case consists of EKGs, NM scans, echo-cardiographs, cine angiograms, MR images, and chest images. The results
of all performed procedures should be available at the conference.
EKG Laboratory Catheterization Cardiography
Information: functional Information: anatomical & functional Information: functional
Procedure: non-invasive Procedure: invasive Procedure: non-invasive
Cine angiograms Echocardiography
EKGs Hemodynamic data recordings
Intravascular Adult Cardiac x-rays
Ultrasound IVUS CTs Radiology
Laboratory recording MRI Department
Information: anatomical Information: anatomical & functional
Procedure: invasive Procedure: non-invasive
NM scans Slides EP data
Nuclear Medicine Pathology Electro-Physiology
Department Department Laboratory
Information: functional Information: anatomical Information: functional
Procedure: non-invasive Procedure: invasive (postmortem) Procedure: invasive
Figure 1. Overview of supplied information for the UCSF Adult Cardiac Catheterization Conference
2.4. Overview Of The Processes
The most important parts of the process are the preparation and the conference itself. The goal of the preparation is to
have all required information ready prior to the start of the conference. The main goal of the conference is appropriate
presentation of information. The sequence of activities and flow of data are depicted in Figure 2. The first step is the selection
of suitable patient cases by the clinical cardiology fellow with input from the cardiology attending. The list of selected patient
cases is delivered to the institutions that need to contribute information. Each institution uses the list to retrieve the
appropriate information. The information is then prepared and brought to the conference room before the start of the
conference. A handout is also compiled (not shown in Figure 2) to familiarize the conference audience with the cases. The
handout contains basic information about the patient cases. Conference attendees pick up a copy of the handout as they enter
the room. The conference moderator is usually the clinical cardiology fellow. The moderator gives a short introduction for
each patient case and then invites specialists to present their results. The conference itself is an educational event as well as a
Location: Cath. Lab.
Location: Cath. Lab. Location: Cath. Lab. Location: Echo. Lab. Location: NM Lab. Location: Rad. Dep.
prepare EKGs prepare cine prepare echo prepare NM
angiograms recordings scans
Medium: Transparency Medium: 35mm film Medium: VHS tape Medium: Transparency Medium: Films
EKGs angiograms echo recordings NM scans rad. images
Location: Conf. Room.
Figure 2. Overview of activity sequences
2.5. Today’s Drawbacks
The current cath. conference suffers from many problems. The main impediment to conference preparation is the heavy
workload of the physicians and their lack of time. Very little conference preparation is carried out if the list of patient cases is
distributed too late. Access to relevant information is difficult because there is no integrated hospital information system.
Processing the information for presentation also requires a time commitment, which the physicians rarely have. Conference
presentation is hampered by hard-to-manage presentation material, sub-optimal presentation techniques, and lack of access to
additional information. The display devices which are used for presentation of dynamic images are based on old technology.
The specific problems which are listed below stem from observations and interviews:
• The list of patients chosen is often distributed close to the start of the conference. This contributes to the lack of
preparation time. The cardiology attending may also change the list of patients at the last minute. This can cause
additional work for all concerned institutions.
• The preparation phase involves labor intensive collection and transportation of multimedia materials including
transparencies, slides, charts, EKGs, sound recordings, still film images, cine film sequences, text reports, and
• Review of cine angiograms for the preparation phase requires a projector. This often involves going to another
location or moving the projector. The 35mm film does not allow editing, such as definition of loops over essential
portions. Another problem is that the films are sometimes in the wrong boxes.
• Preparing an echo study involves copying essential portions from a long VHS study tape onto another VHS tape. The
operation of using two VCRs to mark and copy essential portions is tedious. The VHS tape medium is a linear
medium. The tape does not allow annotations, looping, or comparison of two recordings.
• There are multiple presentation devices including light-boxes, overhead projectors, slide projectors, cine film
projectors, and video cassette players with large-screen TV or video projection systems. The cine film projector and
the VHS projector are not permanently installed in the conference room. They are moved to the conference room
each week. The procedures of moving, setting up, and calibration are time consuming.
• The cine film projector is at the back of the room and is operated by someone other than the presenter. Therefore, the
presenter needs to communicate with the projector operator and synchronize his explanations with the displayed
images. This often leads to confusing situations. The projector is also noisy.
• Operating the VCR with its remote control is difficult because the remote buttons are not lighted and can not be seen
in the dark conference room.
• The visibility of information for people sitting at the back of the room is insufficient. This is particularly true of x-ray
films which are presented on an overhead projector, or on a view-box located on the front wall.
• EKGs are shown on transparencies. Only one transparency can be shown at a time because of the size of the
projector and the EKG recordings. Comparison of two EKGs is therefore not possible.
• The lighting of the room can not be controlled by the presenter while he/she is standing at the podium.
• There is limited ability to change film image quality and film viewing parameters. This is particularly true for images
which are shown on the transparency overhead projector or the view-box.
• Medical professionals need to gather in one physical conference room. There is no provision for remote
• Patient materials are inaccessible for the duration of collection, presentation, and disaggregation.
2.6. Future Improvements
The people interviewed were asked about possible future improvements. Some of their remarks are listed here:
• The projectors should be permanently installed in the conference room.
• A remote control for the cine projector could be used by the presenter to operate the device.
• Digital techniques should be used to provide better preparation and presentation tools. Digital tools should allow
random access to video, looping of video segments, and dynamic viewing. Digital techniques can also be used to
display information on split screens and provide annotation utilities.
• On-line access to the information systems should be used to make the use of transparencies redundant.
• It would be nice to have access to a teaching archive and reference cases from other institutions.
3. SCENARIO GENERATION
The findings of the workflow study were used in the system design phase. Workflow investigators, ergonomists and
system designers held brainstorming sessions and generated several fictional stories with characters and environments for
digital conferences. These stories are usually referred to as scenarios. A subset of the scenarios were chosen for presentation
to the clinicians. A graphics artist then generated storyboards depicting the chosen scenarios. The storyboards consisted of
cartoon-like snapshots which captured significant possible interactions. Attendings and fellows that played significant roles in
the conference preparation and presentation were invited to a meeting and were shown the storyboards. These clinicians were
then asked to reflect on the storyboards. The clinical cardiology fellow, associate cath-lab director, director of adult echo-
cardiography laboratories, associate chief of nuclear medicine section, radiology fellow, and intravascular ultrasound fellow
attended the meeting.
Figure 3 shows some of the snapshots that were shown to the clinicians. Figure 3(a) shows a podium with a touch screen
flat-panel display. The information on the screen is separated into three categories: public, private, and controls. The public
information is projected onto a large screen and is visible by everyone. The private information is visible only to the
presenter. The intent is to keep some information hidden from the audience in order to generate discussion and make the
meeting more effective as an education tool. The controls for patient selection, folder selection, and image manipulation are
also not of interest to the audience and can be separated from the public information of interest. This diagram also shows that
a CD can be used to transport the images to the conference room as well as to other meetings. Figure 3(b) illustrates a wireless
interaction device, which can be used both as a pointer as well as a mouse. This snapshot also shows that information is
displayed with a high resolution projection device. Multimodality information is displayed side by side and is projected onto a
large screen, as shown in the figure. The snapshots generated ideas and discussion among the clinicians. Some of the
comments and opinions of the clinicians are paraphrased below:
• The clinicians responded favorably to the concept of user interfaces that partition public information from private
information and control information.
• The clinicians liked the use of a high-resolution display device.
• The idea of displaying side by side multimodality information was well received.
• The concept of a single wireless device for interaction and pointing was well received. The clinicians remarked that
they prefer to face the audience and point to the screen on the podium rather than face the main viewing screen and
have their backs to the audience.
• The attendings liked the idea of using the conference material for teaching archives.
• Some physicians stated that they would like to use a laptop to store their data and then physically take the laptop to
the conference room for presentation.
• A general comment from the clinicians was that interfacing to existing equipment and providing easy access to
distributed medical data is key to retrieving and preparing the conference .
Figure 3. Snapshots of future digital conference scenarios: (a) Podium, (b ) Combined pointing and interaction device.
4. SYSTEM DESIGN
The knowledge gained with the workflow study and the outcomes of scenario generation were utilized in the next phase
of our project: the design of the system. Figure 4 shows the architecture of the design. Most of the cardiology data is analog
and needs to be digitized. Radiology information is available digitally from the PACS, however. The methods for storage of
data are likely to be different at other sites. We are not trying to solve the interfacing problems, but are concentrating instead
on authoring and presentation. Our design uses digitizers for digitizing conference materials that are not in digital form.
Authoring modules are used to prepare and save the digital information for presentation. An Input Server is located in the data
preparation room. It is used to assemble the patient folders. Patient folders are then forwarded to the Conference Server. The
Conference Server is located in the multimedia conference room and is used to present the materials. This server is connected
to a high-resolution CRT projector, the output of which is visible on a large screen. The Conference Server has presentation
viewers for all types of information to be displayed during the conference. Presenters use a general purpose interface for
selecting cases and have information specific interfaces for presentation of their individual materials. The data flow is as
(1) The Input Server obtains patient information from the HIS and RIS, and collects CT/MR/CR chest images from the
PACS. The film digitizer is used to digitize conventional X-ray films. If the patient is not in the PACS a new folder is
created on the Input Server.
(2) Nuclear medicine images are obtained from a Macintosh computer and are downloaded to the Input Server and appended
to the patient folder.
(3) Three Analogue to Digital (A/D) converters are needed for 35 mm cine film, SVHS tapes, and documents. For the cine
film (labeled 3a) and SVHS echo tapes (labeled 3b) fellows select the complete cine canister and SVHS tape. A data
coordinator digitizes all selected dynamic images in the data preparation room. Fellows then select segments of digitized
dynamic images for the conference from the the Input Server. For EKGs, hemodynamics, and electro-physiology (labeled
3c) the conference coordinator/data coordinator digitizes the printouts with a flat bed document scanner.
(4) The Input Server forwards the complete patient folder to the Conference Server.
Direct transfer of formatted images to the Input Server, as outlined in Figure 4, generalizes the design to support
hospitals which do not have a PACS. The formatted images can be DICOM or other standards (GIF, JPEG, TIFF, PIC, etc.).
In the architecture depicted in Figure 4 the preparation is carried out in a single location. A more distributed approach is to
have the authoring for each modality carried out in separate laboratories (cath. lab, echo lab, nuclear medicine, radiology
department, etc.). A software tool for presentation of dynamic images is a required component for the final system
implementation, regardless of the detailed design of the architecture. We have started designing and implementing such a tool.
Data Preparation Multimedia Conference
Cath Lab 35mm (3a)
35mm Cine A/D
A/D Input Conference
Flat Bed (3c)
Figure 4. System design architecture
5.1. Java-based Dynamic Image Viewer
Our starting point for implementing the system has been the presentation software for the Conference Server. We have
developed a preliminary dynamic image viewer, which provides basic functions for display and manipulation of image
sequences. This tool can be used to present digital X-ray cine angiograms, color ultrasound studies, nuclear medicine images,
MR and CT dynamic studies, as well as image stacks. Our previous work for review and annotation of dynamic images was
implemented in C and was tied to a particular hardware platform . We chose to implement this viewer in Java because
applications created in Java can run on different software and hardware platforms. One can also create Java applets which run
on World Wide Web browsers, which may be useful for remote participants who want to join the conference . Our
viewer can run both as a stand-alone application and as an applet. The viewer can easily be customized for different
modalities and non-conference viewing environments.
Figure 5 shows the user interface of the dynamic image viewer. The control panel is shown in Figure 5(a). The image
window is shown in Figure 5(b). The two windows are separated. Thus, the audience see only the information of interest in
the image window without being distracted by the control panel. This is consistent with our scenario of user interfaces, which
separate public information from control information and private information. The viewer supports conventional mechanical
projector and SVHS video player functions. The control buttons are, therefore, like those of a VCR and are large in size for
easy access. The viewer also supports digital image manipulation such as brightness control, contrast control, magnifying
glass, and contrast reversal. The dynamic image viewer allows a user to load a sequence of images into memory. Each frame
is displayed while it is being loaded. Information about the current frame number and the total time for loading are also
displayed in the control panel. Once all the frames are loaded the user can change the frame rate, stop looping or playing, and
single step through individual frames. The user can also use the frame slide bar to randomly select any frame. The brightness
and contrast controls allow the users to adjust the image contrast. The magnifying glass can be used to enlarge a portion of
the image as shown in the Figure 5 (b). Image processing functions, looping, and random access to frames are not possible
with current film and tape-based systems.
Figure 5. Java dynamic image viewer user interface
This Java viewer is slow compared to compiled C and C++ programs, because it’s code is interpreted. The dynamic
image viewer is an I/O and memory intensive application. We are interested in the following performance issues: (1) loading
a sequence of images into memory; (2) displaying a sequence of images (frame rate) and; (3) performing image processing
functions. We measured the time the stand-alone application needed to load 20 frames of gray-scale images from the local
disk. The test sequence was an X-ray angiogram of 512 X 512 pixels with 8 bits/pixel. The images are stored in various
formats (GIF, lossy JPEG, and raw) on a 150 MHz Pentium PC and a 167 MHz Sun Ultra 1 Sparc Workstation. The sizes of
the memory for the PC and the Sun systems are 32 Mbytes and 64 Mbytes, respectively. The loading time results are shown in
Table 1. The Sun workstation is running version 1.02 of the Java Development Kit (JDK). The PC can run JDK, as well as
Symantec Café version 1.51 with the Just-in-time compiler. However, the performance of JDK on the PC is not acceptable.
The brightness, contrast, and magnifying glasses responses are too slow. Therefore, the results of loading time for JDK on
the PC are not listed in Table 1. The viewer can load about 1-2 frames per second for GIF or JPEG images, and about 4
frames per second for raw images. The loading times for GIF and JPEG are longer because of the decompression overhead.
Once the images are loaded, the display frame rate can be as high as 45-50 frames per second on both the Sun and the PC.
Brightness and contrast changes on still images can be performed in less than a second on both systems.
Image Format SUN Ultra 1 (JDK 1.02) Pentium PC (Symantec Café 1.51)
GIF 0.55 0.65
JPEG 0.67 0.90
RAW 0.24 0.26
Table 1. Loading time for one frame of an X-ray cine angiogram ( 512x512 with 8 bits/pixel).
The dynamic image viewer written in Java has good overall performance when using JDK on the Sun Workstation and
Symantec Café on the PC. Image loading is relatively slow, however, in both cases. One limitation of JDK 1.02 is that Java
doesn’t provide effective direct memory controls. For example, forcing garbage collection at run-time affects the performance
and does not guarantee freeing of unused memory. Another limitation of Java is that it doesn’t provide a flexible layout
manager. It is non-trivial to get all of the buttons and slide bars the right size and in the right position. Finally, the Abstract
Window Toolkit (AWT) is a relatively low-level package, thereby forcing the users to provide many basic classes themselves.
5.2. Prototype Multimedia Conference Room
We have built a prototype multimedia conference room in the Philips Multimedia Center, Palo Alto, CA. The room is
equipped with a networked Conference Server, a ceiling mounted CRT projector, a large screen, and a Philips digital speaker
system. The video output of the Conference Server is fed to the CRT projector and is visible on the large screen. The audio
output of the Server is fed to the digital speakers. Audio is used for conferencing with remote participants, as well as audio
annotations. A GyroPoint Pro pointer from Gyration Inc.  is used for pointing as well as interacting. The GyroPoint Pro is
a cordless pointer for multimedia presentations. This gives presenters the freedom to walk around in the conference room
while controlling their presentation. There is no line of sight required since it is motion-based: it uses two gyroscopes to sense
motion and allows movement of the cursor with simple hand gestures. The display attached to the Conference Server
workstation is built into the conference room podium. Therefore, presenters can control their presentation from the podium if
they choose to do so. They can use the GyroPoint Pro to point to the podium screen and interact with the information. The
audience sees the projection of the information and the pointer cursor onto the large screen, via the CRT projector. Therefore,
presenters can avoid turning their back to the audience. The dynamic image viewer has been used in laboratory prototype to
present dynamic images to an audience. Our initial results with the laboratory multimedia system are encouraging. More
system development is needed, however, before the system can be moved to a clinic for testing by physicians.
Workflow studies at the University of California, San Francisco (UCSF) Medical Center were performed to understand
its traditional cath. conference work procedures and processes. The workflow investigation gave insight into current
drawbacks, such as lack of preparation time, lack of convenient authoring tools for preparing conference material, and sub-
optimal presentation techniques (noisy projectors, lack of random access to video, inability to see the presentation controls in
the dark, and inability to see information from the back of the room).
We adhered to participatory design methods by involving physicians in generating design concepts. Knowledge gained
from workflow studies, and interactions with UCSF physicians led to scenarios for future digital conference rooms. Future
concepts that were received favorably by the physicians include the use of a large high-resolution display device, side by side
multimodality information presentation, a pointing device that can also manipulate the displayed information, CDs for storage
and presentation of dynamic images, and user interfaces that separate the information into private information (visible only to
the presenter) and public information (visible to everyone).
We designed the digital conferencing system based on our understanding of the workflow and feedback from UCSF
physicians on the scenarios. Our design uses digitizers for digitizing conference materials that are not in digital form.
Authoring modules are used to prepare and save the digital information for presentation. The design uses an Input Server to
assemble the patient folders. Patient folders are then forwarded to a Conference Server in the multimedia conference room for
presentation. This server is connected to a high-resolution CRT projector, the output of which is visible on a large screen. We
have developed a dynamic image presentation viewer for the Conference Server as a first step towards implementation of the
complete system. Initial results with a multimedia conference room prototype that has presentation capabilities are
A digital conference room is a new concept that overcomes many of the traditional problems associated with preparing
and running a conference. Implementing a complete conference room will involve the use of both off-the-shelf hardware and
software, and new technologies. We have identified areas where information management can be improved. A multimedia
conference room has two primary advantages over conventional analog presentation methods: a single display system can
replace all the old display systems, and the digital information allows for processing, setting viewing parameters, creating cine
loops, accessing data randomly, and teleconferencing applications.
We thank Thomas Ports, M.D., Nelson Schiller, M.D., Elias Botvinick, M.D., and Charles Higgins, M.D. for
participating in the workflow studies and the scenario generation work.
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