2021 Tuesday Program

41st Annual Conference of the
Canadian Healthcare Engineering Society

September 28 – 29, 2021



All times quoted in Central Time

1000-1005  Introduction / Welcome
1005-1050 TRACK 1: Concurrent Sessions 1A, 1B, 1C
TRACK 1A Building an Improved Patient Experience
Speaker: Jerald Peters, Architect, AAA, AIBC, MAA, OAA, SAA, FRAIC, LEED AP, Principal, ft3 Architecture Landscape Interior Design, Winnipeg MB
Overview: Acute Care environments are stressful and confusing for patients and their families. From the Emergency Department to Patient Rooms, what are the issues to consider in designing and renovating hospitals that will improve the patient experience and ultimately improve patient outcomes?From the moment a patient arrives on the hospital site, stress and confusion are the dominant feelings which overwhelm the patient and their families. Stress and confusion regarding their health and prognosis. Uncertainty about their immediate concerns that brought them to the hospital and what the future holds. Questions regarding where they should be going and who they should be seeing. Anxiety with entering a busy and complicated campus. Feelings of hopelessness and aloneness.

The Emergency Department is often the entry to the hospital environment for many people.
What are the key factors to improving the patient experience that we can design into new and renovated emergency departments?
• Clarity of where to go
• Reduced frustration associated with waiting
• Improved opportunities for communication
• Discharged with confidence

Too often hospitals make us feel sick. And sometimes our heath is impacted negatively by the environment. What are some things we can address during design that will improve the health outcomes of patients?
• Infection control, i.e. sinks in the right locations, clean air, cleanable finishes
• Clean vs clutter
• Daylight and views of the outdoors/biophilia affects us all
• Colour impacts our mood and wellness
• Acoustic control for privacy, dignity and stress reduction
• Lighting opportunities and challenges from circadian rhythms to glare and reflection

Work arounds are commonplace in all healthcare environments. Implementation of process
improvement measures not only increases efficiency and enhances the work experience of the health care provider, it leads to better experiences for patients and families:
• Reduced wait times
• Improved communication
• Reduced errors
• Technology planning

Objectives: At the end of the session participants will be able to:
•  Identify the issues related to patient experience that arise most often in our design experience
•  Explore the opportunities to change how we design things for improved patient outcomes
•  Challenge operational procedures with balancing LEAN processes and patient experience
TRACK 1B Lessons in Relation to O2 From COVID-19: What did we learn from the very high load demands? 
 Speakers: Roger Holliss, P.Eng., President, Holliss Consulting Inc.
Alan R. Pinkerton, President, P.M.G. Systems Ltd. (Pinkerton Medical Gas Systems)
Mark Allen
Edward Hood, P.Eng., B.Eng., Mechanical Technical Leader, H.H. Angus & Associates Limited Consulting Engineers
Faisal Qureshi, Manager, MGS & Sales Ontario, Air Liquide Healthcare
Sarah Thorn, Senior Project Manager, Facilities Management Capital Project Fraser Health
Overview: Members of the CSA Medical Gas Piping technical sub-committee will be sharing updated information from the Jun./2021 webinar to help you better manage O2 challenges like adding O2 generators, de-icing issues, changing clinical occupancy needs & more.
TRACK 1C New Construction/Renovation and IAQ – Build or fix it right… the first time!
Speaker: David Muise, OHST, National Practice Leader, Indoor Environmental Quality, Pinchin Ltd.
Overview: Construction of a new building, or renovating an old one, is an opportunity to start fresh, install new and efficient building technologies, and provide the best possible occupant experience. The sustainable building industry has brought focus on occupant experience, what could possibly go wrong? Even with the best intentions, simple risk items are overlooked. Mould-susceptible building materials frequently get wet during construction. Construction dust is not managed effectively resulting in cross-contamination. Materials arrive on site, or are brought in by trades that can have a negative impact on the occupied IAQ of the building. It takes a keen eye looking around a construction site to spot these issues, but once you know how, success is a sure thing!Key Take Aways:
• Supply chain management and how to inspect building materials before they arrive on site.
• Proper construction phasing and protection of mould-susceptible materials.
• Construction dust management strategies.
• Responding to construction problems, and getting back on track.
Objectives: At the end of the session participants will be able to:
•  Share lessons learned from new construction and renovation projects gone wrong.
•  The phasing, sourcing and protection of building materials can have a significant impact on final occupancy conditions in a building. When executed poorly these issues can result in scheduling delays, rework and concerned occupants. Not to mention the potential for cost over runs.
1050-1100 Transition / Break
The Success Energy Equation: How to Regain Focus, Recharge Your Life, and Really Get Sh!t Done
Speaker: Michelle Cederberg, BA, MA, Certified Exercise Physiologist, Certified Professional Co-Active Life Coach, Author, Live Out Loud, Inc., Calgary AB
Cederberg 150x187 In an age of disengagement, distraction and fatigue exacerbated by the on-going pandemic, how we work and live has been tested. We’re busy, stretched and stressed, and as we navigate the constant change and uncertainty of it all, it can feel difficult to stay focused, and do our best work.In this thought-provoking session, Cederberg shares research from her new book The Success-Energy Equation that will help you regain focus, recharge your life, and move forward with confidence and positivity, even during these challenging times.

In this high-energy keynote you will:
• Get clear on your own definition of success; what really matters to you in work and life, and what drives you to do what you do – even as we ride out COVID-19.
• Look at typical barriers that get in the way of success, and how you can effectively navigate them.
• Discover four science-backed variables that contribute to higher levels of goal success and overall well-being and how to make them work for you.
• Embrace a simple but powerful habit you must do daily to ensure on-going success with everything you do that’s important to you.

Full of hilarious stories, anecdotes, and innovative strategies, you’ll leave this session with a renewed sense that it’s possible to break free from stress and drive your own success, through the pandemic and beyond. That’s Success-Energy, and it’s a formula worth calculating.

1150-1200 Transition / Break
TRACK 3A  Medical Air in Healthcare Institutions: A chemical and biological study
Speaker: Paul Edwards, Vice President, Sales & Marketing, VitalAire Canada Inc.
Overview: A significant proportion of hospitalized patients are dependent on medical air. Medical air is commonly produces on-site from filtered and compressed external air before delivery to patients through centralized piping. Little is known about how outside ambient air composition can affect medical air quality. This study examined how chemical and microbial content or medical air varied at the delivery ports as a function of ambient air. The chemical composition was monitored near the outdoor air intake and at the indoor outlet in a patient room of a healthcare center. The microbial content was determined twice weekly using a custom-made impaction device designed for pressurized systems.Results revealed some chemical gasses are not well filtered by the medical air system; the average concentrations, indicating that these gases pass freely to bedside outlets. NOx and O3 are only 40% removed yielding average concentrations of 16 and 10ppb in this medical air. Trace metals could also be detected. Bacteria were detected, but at concentrations significantly lower than 1 colony forming unit (CFU) per m3 of medical air sampled; these consisted predominantly or non-pathogenic bacteria. This study highlights the impact of changes in outdoor air quality on the composition of medical air delivered to patients, and the importance of monitoring and regulating the quality of medical air.
TRACK 3B Critical Power Upgrades – Building an Electrical Substation for the Future
Speaker: Phillip Chow, Senior Project Manager/Engineer, H.H. Angus & Associates Ltd., Toronto ON
Michael McRitchie, CFM, CCHFM, Director of Plant Operations and Maintenance, Sunnybrook Health Sciences Centre
Overview: With an existing electrical substation dating back to the 1970s and approaching end of life conditions, Sunnybrook Health Sciences Centre faced the challenge of undertaking a project to upgrade the electrical substation, for their three million square foot campus and 16MW peak load, in its entirety. This presentation will discuss challenges faced by the project team, innovative substation design features and provisions for the development of a future campus microgrid.Sunnybrook Health Sciences Center is a full-service, 1359-bed hospital, located in Toronto, Ontario, home to a population of just over six million people. Sunnybrook is affiliated with the University of Toronto for academic health sciences, partnered with Veterans Affairs Canada and home to over 500 veterans. With an aggregate campus area of approximately three (3) million square feet at its main site, Sunnybrook is the largest regional trauma center in Canada and sees approximately 1.2 million patient visits each year. The hospital started seeing patients in 1946 and officially opened in 1948.

Sunnybrook receives its electrical service via two incoming 27.6kV utility circuits from Toronto Hydro and relies on its main outdoor electrical substation to distribute power around its campus, supporting a peak electrical demand load of approximately 16MW. With its existing electrical substation dating back to the 1970s and approaching end of life conditions, Sunnybrook faced the challenge of undertaking a project to replace their substation in its entirety. Project goals included: increasing substation capacity, providing resilient infrastructure to support future campus development, maximizing infrastructure renewal, minimizing operational costs/risks and improving operability. The challenges faced by the project team included: meeting project goals, creating a schedule to meet funding requirements, coordinating work with electrical utility upgrades/requirements, building within the footprint of the existing substation, and managing risk throughout the project. The project design commenced in 2015 and construction was completed in 2020. Final Commissioning took place in the midst of the Covid 19 pandemic, in April 2020.

Specific highlights will include: design features, equipment procurement, risk management, scheduling and construction aspects. The innovative design choice to use 38kV class gas-insulated switchgear, manufactured in Frankfurt, Germany, which offers a reduced footprint and maintenance requirements when compared to traditional air-insulated switchgear will be discussed in detail. We will review capacity upgrades for future site development, which included utility service upgrades (that had to be coordinated with our project), increasing substation capacity from 20MVA to 30MVA and associated civil upgrades. Risk management throughout the project will be discussed, both from a construction perspective, including off-site acceptance testing for equipment, and from a hospital perspective, including detailed shutdowns and procedures for transferring load.

We will also discuss a number of project features that improve operations and reliability in the hospital, such as a PLC-based automatic transfer system that allows the hospital to transfer load between incoming utility circuits and a network based monitoring/control system that integrates with Sunnybrook’s existing Email/SMS Text alarm messaging system. Additionally, we will review provisions that were included in the project to help Sunnybrook develop a future campus microgrid. Provisions will allow the newly constructed substation to interface with campus generation sources, including an 8MW diesel generator plant (which was completed in 2015), an 8MW combined heat and power plant (currently under construction) and a future energy storage project, which is in the feasibility stages. The presentation will endeavour to help facilities understand how to build an electrical substation for the future, when undertaking an electrical upgrade project of this nature.

Objectives At the end of this session, participants will be able to:
•  Identify innovative design features for the construction of an outdoor electrical substation and planning opportunities that can promote future operability.
•  Describe how a complicated electrical infrastructure renewal project can be undertaken.
•  List risk mitigation strategies to ensure critical hospital operations are not impacted.
•  Detail infrastructure that can support future campus development, including the development of an on-site microgrid
TRACK 3C HVAC Performance Optimization for Improved Health Outcomes
Speakers: Gordon Burrill, PEng., CCHFM, FASHE, CHFM, CHC, President, Teegor Consulting Inc.
Nick Stark, Vice President, H.H. Angus & Associates Ltd.
Overview: Efficient HVAC system operation must not only conserve energy and limit greenhouse gas emissions, but must be designed and operated primarily to contribute to patient and worker safety and occupant comfort. Established standard, CSA Z317.2 Special requirements for heating, ventilation, and air-conditioning (HVAC) systems in health care facilities has provided reliable guidance for HVAC systems in HCFs with the release of the updated 2020 edition, it is timely to provide an update of the changes.Canadian health care facilities (HCFs) are one of the most intensive users of energy and within these facilities, HVAC systems are the largest energy consumers. It is essential for these systems to be energy-efficient, well-maintained, and perform consistently. However, efficient HVAC system operation must not only conserve energy and limit greenhouse gas emissions, but must be designed and operated primarily to contribute to patient and worker safety and occupant comfort.

Proper design and operation of HVAC systems are essential for not only for the delivery of health care but also for the preservation of the healing environment. HVAC systems provide precise regulation of building temperature and humidity, room pressure and air movement, and air filtration/acceptable indoor air quality – all of which contribute to reducing the risk of airborne transmission of pathogens, enhancing infection control, and supporting positive clinical outcomes. It is to this extent that the operation of health care facilities is subject to increasing levels of scrutiny due to the sensitivities of the HCF environment, and the performance of the HVAC systems plays a vital role in delivering desired results.

Established standard, CSA Z317.2 Special requirements for heating, ventilation, and air-conditioning (HVAC) systems in health care facilities has provided reliable guidance for the planning, design, construction, commissioning, operation, and maintenance of HVAC systems in HCFs for several decades, and now with the release of the updated 2020 edition, it is timely to provide an update of the changes. The new edition clarifies planning and implementation for the new function of the space whether used for the same purpose or if there is to be a change of use. The Standard emphasizes the importance of involving the multi-disciplinary team (MDT) to conduct a risk assessment and review and document the associated infection control and patient safety risks before proceeding with any space or HVAC system changes.

This revised Standard provides expanded guidance on equipment provisions or redundancies for the facility to absorb; routine maintenance activities, nighttime/unoccupied space ventilation, and unexpected disturbances/outages while continuing to protect occupants, critical equipment, and the building infrastructure from catastrophic events and increasing climate change impacts.

Objectives: At the end of the session participants will be able to:
•  Understand how CSA Z317.2 and the suite of CSA Health Care Facility standards work cooperatively together.
•  Learn about the key changes in the fifth edition of CSA Z317.2 and the rationale for the updates.
•  Understand when HVAC systems should be upgraded based on the intended function of the space after the renovation.
•  Answer attendee questions on their issues and concerns with using CSA Z317.2.
1245-1315 Transition / Lunch Break
1315-1400 TRACK 4: Plenary Session
Construction Contracts – Need, Wants, and Pitfalls
Speaker: William J. Kenny, Q.C.
Overview: Every construction contract has terms that a Healthcare facility owner needs to have, terms that it wants to have but can evaluate and live without, and risks that need to be and can be allocated by contract. This session will review the needs, wants and pitfalls from the perspective of a Healthcare Facility Owner when planning for and negotiating a construction contract, and terms and contract arrangements to address available to address these concerns.
Objectives: At the end of this session, participants will be able to:
•  better understand contracts and legal rights thereunder
•  better understand contract clauses like “force majeure”
1400-1415 Transition / Break
1415-1500 TRACK 5: Concurrent Sessions 5A, 5B, 5C
TRACK 5A Patient Experience: How the Commissioning Process Ensures and Enhances the Patient Experience
Speakers: Craig Doerksen, CCHFM, CFM, CEM, MFM, P.Eng, Divisional Director, Facility Management, Shared Health: Health Sciences Centre Winnipeg, Winnipeg MB
Bill Algeo, CET LEED A.P., Building Technologist, Facilities Management Dept., Shared Health: Health Sciences Centre Winnipeg, Winnipeg MB
Overview: Commissioning a new healthcare facility or renovation project is not an event or a step in the process. Commissioning is an integral process to entire project delivery. Do we commission just the building systems? Do we somehow commission the entire building itself? When do we commission to ensure the patient experience? These issues aren’t addressed during the final days before occupancy or even during construction, but from the beginning of project through final occupancy moves.In Canada the patient experiences of our publicly funded and managed healthcare are paramount on the minds of politicians federally and provincially. With 40-50% of provincial budgets, and an overall 12% of our country’s Gross Domestic Product, healthcare experiences have toppled governments and promises of reform have swept others into power. While the care received is certainly a key component of the patient experience, the facility itself also plays a significant part.

How we manage, operate and maintain our healthcare facilities are key influencers. Patient satisfaction surveys often raise housekeeping and aesthetics as key influencers. What often isn’t though are the reliability elements of building systems. –
Commissioning a new healthcare facility or renovation project is not an event or a step in the process. Commissioning is an integral process to the entire project delivery. But is it just the building systems? Or do we somehow commission the entire building itself? Building systems are more than ever integrated, operate across technological platforms and are driving project budgets – capital, training and operational.

When do we commission a project to ensure the patient experience? These issues aren’t addressed during the final days before occupancy or even during construction, but from the beginning of project goal setting, through design and value engineering, construction and quality inspections, system demonstrations (often that time period pigeonholed for things to be “commissioned”), move in, occupancy and post occupancy.

With the CSA Z8000 to guide the design process, Z8001 provides guidance for commissioning, Z8002 for operations and maintenance and soon Z8003 which will assist with design research.

Patients experience a facility in every way. From the auditory experiences within the space, overhead paging speakers, plumbing lines hammering, the squeak of rubber floors to the whoosh of a clean HVAC system. Visually the design and way-finding experience is appreciated differently but have we considered those with vision impairments or dementia? The physical touch (somatosensory) experiences maybe aren’t intentional, however uneven or fine edge surfaces can occur by design default or product or installation fault. Pebbled, textured or porous surfaces aren’t always obvious in design but must be eliminated or minimized to ensure we reduce hospital acquired infection transmission. While we don’t plan olfactory (smell) or gustatory (taste) experiences, operationally there will be situations where smoke, chemicals and possible water contamination occur: have we designed to prevent these. There are other senses – not physically experienced but on a psychological level. The sense of safety and security. sense of comfort. sense of care. sense of timeliness. Some of these are designed in, others are byproducts of design.

Following on extensive experiences commissioning projects at Health Sciences Centre Winnipeg, examples of how the total commissioning process has improved the patient experience will be reviewed.

While clinical care has the most direct effect on the patient experience, a properly designed and completely commissioned building ensures that the building design and systems ensure the patient experience with the built environment.

The presenters have participated in new project developments representing 1.2 million square feet of new build (including 300 inpatient beds, 30+ operating theatres, 3 emergency departments) and multiple renovation projects over 25+ years. Over these past years the process has refined, however it has developed into a complete integrated commissioning process. This begins at the project concept design, through schematic design, construction, system performance and integrated testing and support through occupancy into operations.

How we experience something – our perception – is our reality. we communicate that perceived experience. We share that experience. That is our experience. That is what others others hear, that is what others will come to expect.

Objectives: At the end of the session participants will be able to:
•  Understand that commissioning is process involving entire project length
•  Develop the process scope for commissioning – which systems and elements
•  Discover how to implement a wide sweeping process to enhance the patient experience
•  Hear project examples of success (and challenges)
TRACK 5B Designing and Retrofitting Health Facilities for Accessibility
Speaker: Steve Dering, MSc, MIFSM, Grad IOSH, ICAC-BE, Chief Operations Officer, Direct Access, Cheshire, UK
Overview: Healthcare Managers face challenges in adapting buildings of various ages and purposes to meet the needs of disabled people. Disabled people can find it difficult to access their local emergency rooms, hospitals and health centres – inaccessible medical equipment, poor signage, internal steps, inadequate bathroom facilities and inaccessible parking areas create challenges for Health Managers to overcome in creating accessible facilities for all. This challenge has become more acute as a result of COVID-19 where people are encouraged not to touch – historically the key recommendation for wayfinding would be tactile signage.Disabled Canadians can find it difficult to access their local hospitals, emergency rooms and health centres – inaccessible medical equipment, poor signage, narrow doorways, internal steps, inadequate bathroom facilities, and inaccessible parking areas create challenges for Health Estate Managers to overcome in creating accessible facilities for all. The new Accessible Canada Act, passed by Parliament in June 2019, is a long-awaited legislation by disability advocates, but will it fulfil the numerous gaps that currently exist and what will it mean for accessible health care in Canada?

Disability is extremely diverse – the 2017 Canadian Survey on disability estimated one in five Canadians aged 15 or over has one or more disabilities that affects their daily life. This equates to 6.2m of the population. While some health conditions associated with disability results in poor health and extensive health care needs, others do not. However, all people with disabilities will have the same general health care needs as everyone else, and therefore need access to mainstream health care services. At the same time, health promotion and prevention activities seldom target people with disabilities. People with intellectual impairments and diabetes are less likely to have their weight checked. Adolescents and adults with disabilities are more likely to be excluded from diet and nutrition education programmes.

All healthcare facilities have obligations under the National Building Code of Canada and Building Codes in individual Provinces (such as the Province of British Columbia’s 2018 Building Code) to remove barriers to access. Reference can be made to various standards including the Canadian Standards Association B651 Accessible Design for the Built Environment, which can be used in lieu of the National Building Code. However, these codes only address basic access provisions such as accessible ingress/egress and disabled parking and washrooms, targeted largely at those with mobility impairments.

The new Accessible Canada Act, which has come into force, has yet to develop the standards and regulations. Even when this is achieved, they will only govern accessibility for parliament and Government of Canada departments, Canadian Forces and RCMP, and the federally regulated private sector. Although Health Canada is a federal institution, the current Canada Health Act does not address accessibility to medical facilities, hospitals, or doctors’ offices; that is covered under provincial legislation, that is, if the province has an accessibility or disability act. The provinces that have passed legislation have not yet mandated that assistive equipment is in place to ensure that not only those with disabilities but also pregnant women, those with injuries, or obesity can be examined with dignity.  The presentation therefore seeks to share an understanding of different provinces and their requirements to identify common themes that can go a long way to creating an accessible healthcare facility for service users.

Objectives: At the end of the session participants will be able to:
•  Identify barriers common to healthcare premises and action to mitigate impact.
•  Identify suitable management procedures or minor changes that increase accessibility
•  State where to find accessibility solutions.
TRACK 5C CSA Z8002.19 AHS’s Journey from Assessment to Implementation
Speaker: Paul Perschon, M.A Leadership B.BA , Alberta Health Services, Calgary AB
Overview: Alberta Health’s Facility Maintenance and Engineering CSA Z8002.19 journey from assessment to implementation. This session is focused on how Canada’s largest health authority is implementing this standard into the facilities operations across the province of Alberta. It will be focused on doing a deep dive into the work that the Facility Maintenance and Engineering (FM&E) Department did on the integration of the CSA Z8002 standard in the operations of facilities at Alberta Health Services.The purpose of the session is to help health authorities and hospitals learn from Alberta Health Service’s (AHS) journey of taking a very complex and broad standard CSA Z8002.19 (current), and implement it into the operations of hundreds of healthcare facilities across Alberta.

The session with work through the overall strategy from conception to execution of the project. The presentation will be broken into four sections which will provide a roadmap for other health authorities or hospitals who are interested in implementing this CSA standard into their operations:

  • Value of CSA Standard for Operations. AHS was merged from five health regions into the first and largest health authority in Canada. With this large amalgamation there were numerous systems and processes that were being used to manage their facilities. The Z8002.14 (past) standard provided an opportunity to improve standardization across the Province by using this document as reference to establish a consistent service delivery model.
  • Evaluation of Current State – Assessment vs. Audit – What’s the difference? AHS selected to use the CSA 8002-14 standard as a baseline, using an Organizational Excellence Assessment methodology rather than a compliance audit, since AHS had not, to date, tried to formally implement the standard. This method is focused on improvement, rather than compliance, and identified current strengths and opportunities for improvement in both the approach and deployment of the standard’s elements.
  • Engagement Strategy – How do you involve both front-line and management in such a large scale project? From the outset of this project, all levels of the Facilities Maintenance and Engineering function, from the Chief Program Office to front-line workers, were engaged in the strategy development and execution of the plan. Focus groups were conducted at all levels of the organization to gain input and insight, and a change management plan was deployed to ensure full awareness and engagement.
  • Operationalization of the Plan – Based on the findings of the baseline assessment, opportunities were prioritized within six areas of focus with integrated teams developing, testing, and implementing solutions.

a.  COMP (Coordinated Operations and Maintenance Program) – This team is developing a SharePoint platform to host, together with our e-Facilities application, all elements of the COMP in an easy to navigate package.

b. SOP’s – Developing a standard definition and format for SOP’s based on an understanding of the relationship between tasks, procedures and processes.

c. Inventory Management – Applying 5S principles to the management of parts and supplies to ensure that materials are managed and maintained at appropriate levels to be both cost effective and support critical equipment in a timely manner. Site level work will be consolidated into zone and provincial data bases to allow for site-to-site visibility and reduce duplication.

d. Training and Qualification – Development of a skills matrix to understand gaps between required training and the specific needs of Maintenance in healthcare environments to ensure that all tasks are performed by appropriately trained and qualified personnel.

e. Safety – Enhancing the use and compliance to safety standards (i.e. Field Level Risk Assessment, FLRA)

f. Contractor Management – Engaging with other areas of AHS to ensure that access to AHS facilities and start of work is controlled and that verification is complete on work conducted by contractors.

This has been a three-year project, with lots of progress and improvements to date, with more opportunities ahead. The success and continued improvements being realized are the result of the engagement and support of the facilities front-line, management, and senior leadership, as a province- wide facilities team working together to improve the delivery of patient care to all Albertans.

Objectives: At the end of the session participants will be able to:
•  Determine the value of CSA standard for operations.
•  Understand the Evaluation of current state – Assessment vs Audit – What’s the difference?
•  Understand Engagement Strategy – How to involve both frontline and management.
•  Evaluate the Operationalization of Plan – Areas of focus (COMP, SOPs’, Inventory Management, Training, and Safety). Challenges, benefits, and opportunities of work done to date.

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