By Jennifer Jang, ASTRO Communications
Two Chicago-area organizations, Cancer Support Center and LivingWell Cancer Resource Center, were selected as ASTRO’s 2021 Survivor Circle grant winners for the services they provide to cancer patients, their families and caregivers. Each organization received a $10,000 grant late last year and were honored at the 63rd Annual Meeting in Chicago. Specifically, the Survivor Circle Grant Program provides financial gifts to two cancer support organizations in the state hosting ASTRO’s Annual Meeting. ASTRO followed up with both organizations to learn more about how the grants provided tangible aid since last fall.
The Cancer Support Center (CSC), located in Chicago, is a community-based non-profit organization with two facilities in Chicago’s Southland neighborhoods of Homewood and Mokena. CSC serves anyone seeking oncology care and focuses on a health equity initiative providing services to communities of color with high cancer morbidity rates. According to Executive Director Sue Armato, CSC uses the Five Point Model of Cancer Care, which comprises Counseling/Stress Management, Education, Nutrition, Fitness and Body Image. “Navigators,” as they call their providers, address these points at the first meeting, when the first time “participants,” as they call their clients, come in the door.
Pre-COVID-19, when a cancer patient came to CSC, they immediately met with a program navigator who began the patient support process. “We thought in person was best,” Ms. Armato said. But since COVID, they discovered that “We actually can achieve the same level of care through well-made and intentional videos.” To respond to this need, CSC chose to use the grant to develop a series of introductory videos focusing on how supportive care can improve their participants’ lives.
To date, CSC now has ready the "story" content outline for each of the three videos, identified who will be filmed and developed standard slide content. They have secured a videographer/filmmaker who understands CSC’s important work and has done previous work for them successfully. The videos will be produced this month, with the goal of having them ready for distribution and sharing by June 5, National Cancer Survivors Day. CSC has spent only a quarter of the funds thus far, limited to the development of video content and deposit for videographer. Once the remainder of the funds is spent on video development and release, CSC anticipates vast impact on future clients. After all, the videos’ reach will widen the opportunity to explain the need for supportive oncology and why it is such an important part of any cancer journey. The videos will explore how CSC supports cancer patients and what one can expect when they seek supports and resources, which will help to demystify the supportive oncology process.
Expanding their reach, CSC will share these videos on their website and with eight hospital partners along with oncology centers throughout their service area. CSC is also developing a partnership with the local community college where they will develop programs for supportive oncology care, sharing these videos as part of that effort. CSC looks forward to showing these videos ultimately to help newly diagnosed individuals, so that they may know the importance of supportive care and, for those who have been on a longer cancer journey, that CSC is a resource for them too.
Similarly, the LivingWell Cancer Resource Center, the other recipient of the 2021 Survivor Circle Grant, has also expanded their breadth of reach using the new funding, but in a more physical way. Upon receiving the funding, their social work team mobilized to support patients needing transportation to and from appointments. The grant removed a barrier to patient care in the most practical way, as many LivingWell participants tend to rely on rides from family, friends or caregivers, often scheduling appointments based on when they will have reliable rides. When rides are not available, patients often have no choice but to cancel their appointments, delaying much-needed care.
From mid-November 2021 through March 2022, LivingWell provided 51 rides, totaling $1,165. The average mileage per ride was 12.5 miles, with the longest distance being 32 miles. The majority of rides was associated with Northwestern Medicine Warrenville Cancer Center (86%), while a smaller portion was for centers in Geneva and DeKalb. To ensure grant funding was used with discretion, LivingWell social workers coordinated the rides.
The Survivor Circle Grant has helped LivingWell Cancer Resource Center reinforce their efforts to provide a foundational component of their purpose, increasing access to care. Alongside the grant, LivingWell has bolstered their efforts with other partnerships, including the American Cancer Society, which is piloting its Road to Recovery program, using community volunteers to provide rides in DuPage and Kane counties. Limitations to the pilot include the requirements that both volunteers and patients must be based in DuPage or Kane counties to participate. To compensate for this limitation, the funds from ASTRO have helped to support Uber Health, funding transportation for patients when free rides were unavailable otherwise. The grant has enabled the social workers to ensure patients are able to keep their appointments. However, the challenge of securing Uber rides remains for the DeKalb community due to a lack of available drivers. To address this issue, LivingWell has identified three local vendors, Non-Emergency Wheelchair Transport, New Era Non-Medical Transportation and Hail a Taxi, to provide future assistance for patient transportation needs. These new vendors will help provide available drivers for any future patient need and allow for the remaining funds of the grant to be used in a meaningful way.
The Cancer Support Center and LivingWell Cancer Resource Center Community have used their funds to multiply their impact. Similarly, we encourage cancer support organizations in this year’s Annual Meeting state, Texas, to consider how they too might strengthen their support. To be considered, please apply by this Friday, May 13. For questions, contact Beth Bukata.
Posted: May 11, 2022
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By Cindy Tomlinson, Senior Patient Safety and Regulatory Affairs Manager
Is your practice interested in becoming licensed to use radiopharmaceuticals? Or, are you interested in becoming an authorized user to administer radiopharmaceuticals? With new radiopharmaceuticals gaining approval from the U.S Food and Drug Administration and more in the pipeline, now is a good time to understand some practical steps to take.
Before starting the process, however, it is important to note that agreement states1 may have different forms or requirements for obtaining a license, and we recommend familiarizing yourself with those requirements to ensure compliance. Links to state radiation protection programs, as well as links to state regulations, can be found on ASTRO’s State Regulatory Library.
- If your practice or facility is already licensed to use byproduct materials, the next step is to discuss necessary license amendments with your radiation safety officer. Compliance requirements differ based on whether you have a broad scope license or a limited scope license:
- If your practice or facility has a broad scope license and changes to the license are needed, including revisions to the list of authorized users, your radiation safety officer can handle those in house. Keep in mind that these changes are subject to review during regulatory inspections.
- If your practice or facility has a limited scope license, you will need to submit the specific training and experience for each proposed user, and the facilities and equipment available to support each proposed use, to the appropriate regulatory agency (either the Nuclear Regulatory Commission (NRC) or the agreement state) for review and approval. If the licensee wishes to make changes, such as adding or removing an authorized user, the regulatory agency must approve the requested change. In this case, the NRC has forms for licensees to fill out, while agreement states may have their own forms, so it is important to contact your state’s radiation protection program to find out what forms are applicable to your situation.
- If your practice or facility is not already licensed to use byproduct material, you must submit an application to the NRC or your agreement state. Fees are assigned to each license type as are program codes for medical facilities, practices and laboratories.
ASTRO believes that it is important for radiation oncologists to expand their scope of practice to include radiopharmaceuticals. ASTRO has worked with Congress and the NRC to ensure that appropriate training and experience requirements for radiopharmaceuticals remain intact.
If you have any questions, please contact Cindy Tomlinson.
 Agreement states
are those states who have entered into an agreement with the NRC effectively assuming the role of the NRC.
Posted: April 26, 2022
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By Kelly Paradis, PhD
Our first child was born in the summer of 2018. It had been an arduous road to get to that point, but we were ecstatic at the arrival of this tiny little girl who came screaming into the world. My husband Eric, a professor of physics, was amidst his summer semester and covertly disappeared into our rainy bubble of chaos, laughter, tears and precious few hours of sleep. I soon became convinced that parenthood was a conspiracy — how had I not realized how difficult this would be? I googled a thousand iterations of, “is it normal if baby poop looks like…” and crumbled into tears if I dropped clean laundry on the ground (this would later be diagnosed as postpartum anxiety). I took the equivalent of 12 paid weeks of leave from my job as a clinical medical physicist: Six weeks at 0% effort, and then another six staggered over several months. It was classified as “extended sick” time. Though six weeks of parental leave for the birth of a child was included in Eric’s contract, the implications were clear that taking it would impact his chances of achieving tenure. He returned to work full time in the fall. Meanwhile, I considered never leaving the couch again.
Our second child was born in late summer of 2020, a time characterized by a haze of masks and nasal swabs and rooms drenched in bleach. It was 3:00 a.m. when I nudged Eric to tell him I thought we might need to go to the hospital. The next two hours were a rush of drowsy toddler, quiet city streets lit by dim lamplight, frantic phone calls to colleagues and Eric arriving moments before the birth of our second daughter. I was desperate to leave the hospital, where every interaction seemed dangerous and every surface menacing. At one point, while clutching my day-old child to my chest and standing barefoot in a half-tied hospital gown, I declared, “I think we are going to go home now,” to which our very patient nurse replied, “Ma’am, that’s not how this works.”
During this second rodeo, I took 12 consecutive weeks of what was then newly classified as maternity/parental leave by my institution. Eric, tenure in hand, negotiated a modified fall schedule that was the equivalent of six weeks of leave. We were largely alone, my family too far away to travel safely, and Eric’s family forcibly separated from us by border closings. Months earlier I’d had a phone conversation with a U.S. Customs and Border Patrol officer about whether Eric’s mother crossing the Canadian border a few weeks before my due date to ensure Eric could be there for the birth of our child constituted as “essential travel” (it did not). Together, we did the best we could with the resources we had. And, I have to acknowledge how incredibly privileged we were to have access to paid parental leave at all, as many in the United States still do not.
While sufficient paid leave for the birthing partner is critical, the fact that leave for non-birthing partners is frequently ignored is a clever assault on gender equity. It defaults mothers to caregiving-focused roles, where their careers are deemed less important compared to their partners’, and exacerbates biases in hiring, the gender pay gap, the dearth of women in leadership roles and attrition. If we must make a “business” argument, academic medical institutions know how extraordinarily expensive it is to replace faculty. Equal and adequate paid leave for both partners when a child is added to the family, beyond simply being humane, is also the economically sound path.
The stigma against men who take parental leave remains a significant barrier. U.S. Secretary of Transportation Pete Buttigieg recently had to defend attacks against him for taking parental leave after he and his partner adopted twins. Palantir co-founder Joe Lonsdale articulately responded that any man taking six months of leave was a “loser.” Relatedly, a 2019 study published in JAMA Network Open found that in a survey of 844 physician mothers, less than 10% of partners took leave from work, and only 3% took more than two weeks. For non-birthing partners with access to paid leave who returned to work early, 44.9% of first-time parents cited a personal preference to return to work earlier, and 33.3% had intrinsic feelings to not take leave because others did not take paternity/domestic partner leave.1 Clearly, there is work to do.
I am grateful to the American Board of Medical Specialties for their new policy stating, “Member Boards must allow all new parents, including birthing and non-birthing parents, adoptive/foster parents, and surrogates to take parental leave.” In the 21st century, it should be embarrassing for an institution to have varying leave policies dependent on a parent’s gender or specific path to parenthood.
Four years ago, when I was pregnant for the first time, my mother gently said to me that I didn’t realize how lucky I was that Eric would be home with me for the first few months after our baby was born. She was right, not only in that I didn’t realize this (how hard could it be?), but also about the impact that it would have on our family for years to come. What’s more, without him at home, I’m not sure I would have returned to work at all. Eric, you’re my hero. Thank you for changing all the diapers while I cried about the laundry.
Kelly C. Paradis, PhD, is an associate professor of Medical Physics and associate chair of Equity and Wellness in the Department of Radiation Oncology at Michigan Medicine.
- Juengst SB, Royston R, Huang I, and Wright, B. Family Leave and Return-to-Work Experiences of Physician Mothers. JAMA Netw Open. 2019;2(10):e1913054.
Posted: April 20, 2022
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By Suzanne Evans, MD and Sheri Weintraub, PhD
RO-ILS: Radiation Oncology Incident Learning System® releases regular reports and education to the radiation oncology community based on safety events and errors submitted by participating U.S. practices. Aggregate data trends held steady over the past eight years, with expected fluctuations associated with data element changes (e.g., when a data element became required, new answer options were added). That was, until now. The RO-ILS Q4 2021 Aggregate Data Report indicates a striking new trend in 2021 related to the workflow step in which events occurred.
Between 2017 and 2020, when data element 208. Occurred Workflow was required, event occurrence during treatment delivery (including imaging) has traditionally comprised an average of 26% (Figure 1). However, for 2021 that number was 41%. This represents a 58% increase over historical norms. Fewer events were seen to occur in treatment planning and pre-treatment quality assurance (QA) and review, whereas other domains remained stable relative to historical norms.
Unsurprisingly, the downstream metric for where the event was discovered (207. Discovered_Workflow) similarly shifted to the right, with 29% of events discovered at on-treatment QA compared to a historical average of 11% (Figure 2).
Why are we seeing this change in RO-ILS data? Did more events actually occur at the linear accelerator (linac) and if so, why? Did fewer errors happen during treatment planning and why might that be the case? Or are there other factors that impact the data?
It is important to understand there are two basic interpretations of this finding: that this is real, or that this is artifactual. Perhaps there really is a shift in where in the workflow errors occurred in 2021 (e.g., more events happened at treatment delivery). Conversely, it could be artifactual — that the events occurring at treatment delivery are stagnant in number, but that we are seeing a relative percentage increase in these events due to selective non-reporting of more upstream events, a risk of any voluntary incident reporting program. Although more analysis is needed, we have some initial thoughts as members of the Radiation Oncology Healthcare Advisory Council (RO-HAC) who review and analyze RO-ILS data.
First, let's consider interpretation 1: More events are happening at treatment delivery, fewer events at other workflow steps. This real trend could either be a positive or negative indicator of safety.
Let’s be optimistic and consider that this is a real trend and is actually a good thing. Perhaps advancement in technology may explain this phenomenon. For example, with the rise of new equipment like surface guided radiation therapy (SGRT), practices may be better able to detect errors occurring during treatment that were otherwise opaque before. SGRT can be very helpful in detecting the improper application of shifts, which has been demonstrated in the RO-ILS data to be a major pathway of significant errors. Additionally, there has been a move toward increased automation of treatment planning processes, which may result in a reduction in errors occurring earlier in the process of care. If enough practices acquired or implemented SGRT and/or knowledge-based planning tools between 2020 and 2021, then this could result in a shift in where in the process events are occurring.
How about the impact of the pandemic? That has certainly brought about a dramatic shift in a short period of time. COVID-19 affected the ability of certain staff members to work from home initially, which then brought on a wave of employees seeking work from home or hybrid arrangements as part of routine practice. As treatment planning can be done remotely, this may have altered the work environment for dosimetrists more than for other members of the radiation oncology team. Are at-home work environments for dosimetrists conducive to higher safety standards, leading to fewer errors in treatment planning?
Importantly, incident learning systems, including RO-ILS, encourage reporting. More events can indicate heightened awareness within that process of care, a strong culture of safety and the desire to address issues, no matter how trivial. Technology advancements such as adaptive radiation therapy are increasing the complexity of treatment delivery. With the adoption of new systems, an increase of events is expected as practices work to perfect processes. More events within a given process could result in an increased detection of errors that otherwise would have been hidden or unknown.
Now, let us consider that this trend is real, but that it’s actually a bad thing. Multiple waves of COVID-19 in 2021 left many practices with significant numbers of staff out at one time for various reasons (e.g., personal, family illness, quarantine). This lack could have resulted in temporary deviations in the staffing policies of two radiation therapists per linac or fewer on-site physician or physics staff available to draw upon for guidance with a challenging setup. COVID-19 had a heightened impact on radiation therapists, as they were required to continuously support treatment delivery on site, while other professional roles may have been able to limit their public and workplace exposures for at least some portion of time. The compounded stress may have impacted performance, team relations and the work environment. This could result in COVID-19’s influence on safety being greater in the treatment delivery space than in the treatment planning space.
Now, let's consider interpretation 2: The number of events happening at treatment delivery is stable, but there are other confounding factors that skew the data.
In the United States, incident learning is voluntary, a crux of the legal protections afforded by the Patient Safety and Quality Improvement Act of 2005 and through participation in patient safety organizations (PSO). Estimates are that voluntary reporting only accounts for approximately 10% of the events that actually occur. Therefore, we must be careful when analyzing the data to ensure we appreciate this limitation. If PSO protections were not present, we would see even fewer of the events that occur, so it is essential that the anonymous, confidential work of the PSO remains supported.
One can imagine that the radiation oncology workforce is tired. With so many constraints on their time, in the second year of the pandemic, incident learning may have become a lower priority. RO-ILS recommends reporting any error that passes through the first checkpoint, regardless of whether it reaches the patient or is caught further downstream at a later safety check. However, we know not all practices are able to do this and that not all staff work in a culture of safety that supports this.
Although the number of events reported to RO-ILS has been fairly stable, the incident learning system has been functioning in an environment with staffing shortages, disrupted processes and individuals dealing with the mental task load of the pandemic. It is plausible that events occurring during treatment planning and on-treatment QA, which can be caught by normal QA, are deemed less of a priority to report than events happening at the linac. Therefore, with an underreporting of treatment planning and on-treatment QA occurring events, the relative percentage of events occurring at the linac would appear to rise.
In addition to practice-specific reporting thresholds, it is possible that changes in reporting patterns among RO-ILS enrolled practices have impacted the overall national trends. The extent to which some practices are reporting to the PSO cannot be ruled out as a cause of this trend.
What do you think? Which interpretation is more plausible to you? Importantly, are you seeing the same trends in your local practice’s incident learning data? As an individual practice, with knowledge of your practice-specific circumstances (e.g., staff, technology advancements, culture) the meaning of incident learning trends can be better postulated.
With support from the PSO, RO-HAC will dig deeper into the RO-ILS data to try to better understand possible contributing factors to this national trend. In the meantime, why do you think we are seeing this shift in the national data? Please comment below with your observations and thoughts.
Posted: April 12, 2022
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This article was originally published in the American Association for Physicists in Medicine (AAPM) March/April newsletter.
By Eric Ford, PhD, FASTRO, Sue Evans, MD, MPH, and Jean Wright, MD
Patient Safety Awareness Week (PSAW) began in 2002 as annual event intended to encourage a continued focus on health care safety. This year it is observed March 13-19 and serves as a national education campaign for promoting patient safety practices. We know that quality and safety are priorities for medical physicists every day, and this week is an opportunity to increase awareness within your practice.
Patient safety was at the center of most radiation oncology discussions after the 2010 New York Times article, and tremendous progress has been achieved since that time. However, much like quality, safety assessments and improvements are an ongoing exercise. In the wake of the 2010 events, the American Society for Radiation Oncology (ASTRO) and the American Association of Physicists in Medicine (AAPM) collaborated to develop a national radiation oncology incident learning system (ILS), RO-ILS, to facilitate safer and higher quality care in a secure and non-punitive environment. In 2014, using the guidance in Safety is No Accident, ASTRO created its own radiation oncology-specific practice accreditation program. ASTRO’s APEx - Accreditation Program for Excellence® builds on consensus statements, AAPM Task Group reports and technical standards to support safety and quality.
Medical physicist, Eric Ford, PhD, FASTRO, from University of Washington, Seattle, along with radiation oncologists, Sue Evans, MD, Yale School of Medicine, and Jean Wright, MD, Johns Hopkins Medicine, are well known contributors to the topic of quality and safety within radiation oncology. In light of the upcoming PSAW, these leaders recently discussed quality and safety initiatives that resonate with them, including incident learning, accreditation and the importance of safety culture.
Eric: Let’s start off by talking about one of my areas of focus, ILSs. Active engagement in programs such as RO-ILS can directly benefit our patients, and everyone has a role to play.
Sue: Certainly, and there is a central and pivotal role that medical physicists play in supporting quality improvement, especially in incident learning. I believe that if a physicist is not advocating for and engaging with an ILS, it will simply fail. We need the thoughtful analysis from the physics perspective to make our systems stronger and there’s nobody else better suited to speak to all the processes involved in an incident.
Eric: I know I feel that way, but it’s so important to hear those kinds of affirmations from our colleagues.
Sue: I’m reminded how the late Peter Dunscombe used to quibble and call it an incident teaching system, because he would say that the learning is up to you. Those of us in radiation oncology know the same sorts of incidents keep happening and sometimes they fail in new and exciting ways, and sometimes they fail in the same old boring ways. Having data in a national system enables us to explore this further, identify trends and work with community partners, such as vendors, to resolve some of these error pathways. Varian and Sun Nuclear Corporation have been long standing supporters of RO-ILS and hopefully other vendors will join the effort.
Eric: The practice culture underpins everything that happens, and PSAW presents an opportunity to improve it. How does RO-ILS support safety culture?
Sue: One of my favorite ways is creating a safe space to talk about errors. It’s easier to discuss an error that occurred somewhere else, so practices can start with RO-ILS education and then analyze the data in their local RO-ILS system. It is helpful to not feel alone; to know that on the national level, they might be seeing the same thing that happened at your practice. I do think it's a way to normalize errors and to allow people to be more open about it and foster safety culture from that aspect. In 2021, RO-ILS added safety check questions in the educational resources to encourage more active reading, reflection and spark conversations.
Jean: Incident learning is a forward-thinking approach. Rather than focusing on what happened to assign blame, we must investigate the contributing factors and understand why the error occurred. This allows us to appreciate how errors happen and then work to address it, so it doesn’t happen again. I think all the resources that come with RO-ILS really convey that message and make it easy. You can have a discussion and go over the errors as a group.
We [Johns Hopkins Medicine Department of Radiation Oncology] are in the process of transitioning fully to RO-ILS. One of the reasons we wanted to change from our internal program is that the participation at the national level is more impactful and gives us the ability to learn from others and provide more information back to the community in a safe, protected way. But we’ve known that for a long time. To be honest, I'd say the biggest driver for us is the ability to do the analytics in a way that's more ready-made. Once you learn the features of RO-ILS, you realize that it has options to tailor reports.
Eric: Accreditation is another initiative that gives practices an opportunity to review their specific reports, promote safety and should be celebrated for PSAW.
Sue: I think we all understand that the same basic processes happen in each radiation oncology practice, regardless of our vendor equipment and our individual workflows. In our APEx assessment, we found areas that required more standardization and where we could beef up our processes. I know when we went through APEx, it was amazing how many processes that we thought were buttoned up well, but in reality hadn't been revised in three or four years. Also, it showed us where we didn’t have a defined process.
Jean: Another thing I want to highlight about APEx is that there are two phases — this is the crux of the program. It has the self-assessment phase and then the site visit. The self-assessment phase consists of an initial review where practices conduct an internal assessment of their own medical records policies, procedures and other forms of documentation. As a result, you have the opportunity to identify areas that you may want to improve on prior to the site visit like Sue just talked about, where they didn't even know there was a problem. That definitely happens with APEx. The self-assessment helps you realize you don't have something in place.
Eric: Jean, how are the physics elements assessed in APEx?
Jean: The APEx medical record review is fairly equally weighted between physician medical notes and physics documentation that supports quality assurance (QA) for patient safety. Another substantial component of the program is the document review. APEx assesses individual specifications for machines like commissioning documentation, results of annual and monthly testing, and all the different QA checks are done at the machine level. It's really a physics-driven process in a lot of ways.
Sue: The other thing that I'll add to that, Jean, is from my understanding of having friends at other institutions going through this process, they've actually found the accreditation process to be very helpful when they're in discussions with their hospital or funding source because sometimes you'll have an accreditation notation and say the QA process you have for this modality is certainly adequate, but it’s recommended that you look at adding an aspect that requires new equipment acquisition. A lot of organizations that I know have been able to successfully lobby their hospital or parent institution and say APEx told us that we were OK, but if we really want to be excellent, we need to add something. The institution or organization will really listen to that. Accreditation helps advocate for you in terms of really elevating your game.
Eric: I’ve witnessed this as well. Accreditation can be an ally for physicists.
Jean: The APEx Standards are very clearly delineated so practices know what is going to be evaluated and there is no mystery. Because of the Self-Assessment, you’ll have a very clear sense of how you will do even before the surveyors arrive.
Eric: I agree. In reviewing the APEx Standards, I think the requirements should not come as a surprise to any medical physicists. These are well documented, well accepted standards that are published and align with AAPM Task Group reports and other professional recommendations. Practice accreditation is doing what we all know is right and confirming it’s effective.
Sue: I think that's why accreditation can be undervalued. People look at the requirements and say to themselves, well, of course we do that. But one of the things that we discovered when we went through APEx was that while we do a lot of those things, the process of having a deadline, a formal assessment, an outside evaluator meant that we still discovered new things. Everything just got squared away with the accreditation process, and it was extremely informative.
Patient safety is a key aspect of radiation therapy every day; however, PSAW presents a chance to assess your own practice. Many tools, like RO-ILS and APEx, are used by radiation oncology practices around the country to measure and improve the consistency and effectiveness of daily practice. ASTRO challenges you to take advantage of PSAW to evaluate your own practice and learn how RO-ILS and APEx can help with your patient care.
Posted: March 15, 2022
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