Ease the Workflows in Healthcare with Informatics
Episode

Guillermo Sanz-Berney, Physician Informaticist, and Consultant

Ease the Workflows in Healthcare with Informatics

Be your geeky self and show your passion for informatics!

 

In this Future of Global Informatics episode, TJ Southern interviews Guillermo Sanz-Berney, a physician informaticist, about his passion for his profession, the issues QiiQ Health targets, and the work that needs to be done to bring even more awareness and opportunities to the field. Healthcare is skeptical about changing the status quo, but being able to collect granular data from patients can improve health outcomes and caregivers’ workflows. He explains how QiiQ Health is trying to digitize tasks, like data collection, and take them to a mobile interface to help emergency room workflows; This is a solution to a problem that so many informaticists are tackling across the industry. Throughout this conversation, Guillermo and TJ discuss other opportunities for using the information in healthcare and why it’s essential to spread awareness of the role of informaticists to get the most out of the vast data pools available.

 

Tune in to listen to Guillermo’s take on the current state of clinical informatics and some tips to navigate it successfully!

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Ease the Workflows in Healthcare with Informatics

About Guillermo Sanz-Berney:

Guillermo is a Latino, a son of immigrants (Chilean), gay, and left-handed (a Tera minority?). He hates to admit it, but he has 20+ years of working in the healthcare and health-tech space. He’s currently working on a startup that has a mission to ease the workflow of ER physicians by giving them back the gift of time. This will be done by minimizing the amount of time moving between terminals to do admin tasks and also free hands and eyes with mobile solutions so she can have a more satisfying interaction with their patient. This role gives him time to nurture and keep alive his love for medicine, writing, and technology. Some of the things that catch his interest in informatics are the manipulation of terminologies and vocabularies (clinical and non-clinical), global medicine, longitudinal health records, and HIESs (local, regional, national, and international). He’s also very motivated in the use of technology to gap the access to healthcare for those who are not versed in American culture and/or English (himself being native bilingual). He just started a few weeks ago, together with his friend and colleague Dr. Thanos Melisiotis, a podcast called QiiQ Conversations. One interesting side journey for him was being part of the founding editing team of the now-defunct Medpedia.com, a wiki-like website curated by clinical professionals.

 

Future of Global Informatics_Episode 19_Guillermo Sanz-Berney: Audio automatically transcribed by Sonix

Future of Global Informatics_Episode 19_Guillermo Sanz-Berney: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

TJ Southern:
Hey, y’all! Welcome to the Outcomes Rocket Network – The Future of Global Informatics Podcast, where we discuss global informatics through conversations with industry leaders and innovators so that you can understand what it is, what it does, and how it shapes the healthcare of our future. I am your host, TJ Southern.

TJ Southern:
Hey, y’all! Hey, y’all! Good day! Good day! And welcome to another episode of the Future of Global Informatics. It’s your girl, TJ Southern, and today we have Guillermo. Now, let me tell you all this, this episode is going to be funny, it’s going to be cool, crazy, funny, everything. Because I have, I’m just excited. I’m just excited. I won’t actually overtalk him. I will let him introduce himself to you guys, tell you guys who he is and what he is, what he’s about. All right, Guillermo, tell the people about yourself. Tell them about who you are.

Guillermo Sanz-Berney:
Thank you, thank you for that amazing introduction. I hope I can live up to that hype. Hi, everybody, my name is Guillermo. As you heard before, I’m physician, informatician, nephrologist by training, and informaticist by geek calling. And yeah, the geek runs along with me, my midi-chlorians are very high. And as you might say, you might hear from my accent. I am an Chilean-American, by way of New Jersey, so you’ll listen to this kind of weird Jersey-Chilean Latin accent. So please don’t let that discourage you, I do know what I’m talking about. I’ve lived in two countries. I was, as I said, I was born in Jersey. I lived in Chile for a long time, when my mom moved back to Chile, and I lived in two countries for a long time. So I am a bicultural kind of person, bilingual, and so I’ve learned a lot about life in two different, two different countries, two different cultures. And I finished, I started my medical education in Santiago, in Chile, in Universidad de Chile, and I finished it in San Diego, UC San Diego. And that’s where I actually started realizing that I, I always knew I loved anything to do with electronic computers, technology, innovation, etc. But up until that point I realized, I mean, I thought that I had to choose between those two passions back in the day, but at some point, I started realizing that I was doing a lot of the stuff that nobody wanted to do, like data management, even things like, like regulatory stuff that my fellowship years, you know, doing IRB consent forms, data management, learning about databases that I was there and they were still using Windows 3.11. I’m aging myself, and they were still doing stuff on Excel spreadsheets. Like, there has to be a better way. I, you can have five undergrads doing data, and so that’s how I started to get interested. And eventually, my mentor at UC San Diego told me about these new programs, that, I’m in the West Coast, so, but it’s like informatics moved from the East Coast to the West Coast. There were some programs in New York, and I went there and interviewed, but there was still a little bit more the bioinformatics kind of things, which was not what I was looking for. But eventually, there was a master’s in San Diego and I took the plunge, went back to school, and the rest is history, we could talk about it.

TJ Southern:
So you are a physician by trade, right? Yes, and this is the cool thing that I love, guys, because now we are starting to have a generation of physicians that actually love informatics. So when I started in this game, you know, all of my years ago, it was like pulling teeth to get physicians to come on this side for informatics. And the fact that I have had and I’ve been able to have the privilege of interviewing so many of them that are, you know, data science geeks or data geeks, just like Guillermo said it, it’s such a joy, it’s such a pleasure to be able to start to see the interdisciplinary workings, you know, coming together because really, truthfully, the data science wrangling, the wrangling of the healthcare information, it is the same or it needs to be the same interdisciplinary work that we did on the floor. So we’re just taking that same model and using it over on the informatics side. So don’t get it twisted, y’all. Physicians don’t get it twisted, nurses don’t get it twisted, pharmacists, y’all don’t get it twisted. We still need y’all over here the same way that we needed y’all over there on that side. So that’s my PSA, now that I got that out of the way, so, Guillermo, what inspires your work over in informatics? I know we heard that you said that you’re geeky, you love technology, you’ve always loved everything you know in that arena. But I actually want to take that question a little bit deeper for you, because the one thing that I love is the fact that we have someone on the cast that is bicultural, multicultural, right? So you’ve seen a lot. You’ve done a lot. You know, what really inspired your work in this industry?

Guillermo Sanz-Berney:
Well, I mean, I always bring that up about my upbringing, because I think that, I’m sure that, I don’t think, I’m sure that it has molded me on who I am today as a person and as a professional. And I think that when you look at the world from the outside box into a system that has actually been, even though people maybe have a different conception, but we work in a world, healthcare, that is, can be a little bit very conservative in certain aspects in the sense that they don’t want to change the way things are done because they have worked for them forever. And little things that when you’re creating like data entry like, when I was doing my research, like little things about how you, like for me, how it affects me, like how you, how you ask for race or ethnicity, how you ask for gender, how do you ask for even things about how many, your obstetric history, all those little things that people say, you know what you are, you’re limiting yourself in the information you can get just by speaking to what? Because that’s how these forms were created 25 years ago and we’re printing them again. You have this technology that gives you the ability to change that information, how you’re capturing to benefit your own outcomes, you know, and how you want to, how if this person is a specific race, ethnicity, gender, or obstetric history, you’re going to change, you don’t want to find out a little bit too late that you could have gotten this information that would affected how you treat it or the outcomes of this treatment. And so that’s how I focus, how I got a little bit interested in how, I’m not going to be able to change textbooks, in like, in five years, probably when I thought about it, well, I’m not going to be able to change these federal NIH funding forms. But I can say to the way that we have the data. So at some point, we can push the federal government, for example, say, you know what, I do have more granular data and this is how it works. So that’s a little bit how motivated me, when I first started, as how to be more granular and be more specific in the data that we’re, we’re consuming and then how we’re presenting that data so we can get a better turnaround of information from people who make decisions in this country.

TJ Southern:
And let me tell you, that is so important. It is so important, especially now since we are coming up on things like social determinants of health, right? A lot of times people don’t understand that it is truly that granular data that you get from the patient, right, that helps us really, really care for our patient populations, guys. We have to collect the correct data in order to care correctly. So I remember when I was in school, my master’s program, there was something called garbage in, garbage out, right? It’s the same concept. It’s the same concept, y’all, for all my informaticists that are out here working in the field, shout out to y’all. Make sure we get the right information in the chart. That’s, just playing the sample. Okay, so now what are you doing now? What organization do you work for now, and what is it that you guys are doing with analytics to improve outcomes?

Guillermo Sanz-Berney:
So wow, I’ve had this very interesting journey. So right now, well, a lot of my life changed after, during and after COVID. My little life plan had a little bit of a change, and personally, that I wanted to do to highlight other aspects of my life instead of profession. But right now, I am doing two things mainly. One is I moved back to San Diego. I was living in Montreal, I was in Montreal when the pandemic hit. So I was doing oncology informatics, but I lived in San Diego for 14 years before I moved to New York, and then I moved to Montreal, and then I moved back to San Diego because, as I said, COVID, I want to be close to my family, you know this is, my family’s first. And so, but before I moved back, I got involved, like many of us got to do a lot of social networking during the pandemic. And it was this new application called Clubhouse that was coming out almost a year and a half ago, which is mainly like voice kind of social work. And I met a lot of people who are not networking and I met these entrepreneur co-founders of a company called QiiQ Health. And the interesting thing about this QiiQ Health is, first of all, I wanted to work in, my family has a lot of entrepreneurs. I was always risk-averse. I’m always the person who wants to work in a place that I know what’s going to happen at the end of the month.

TJ Southern:
I get it, I get it.

Guillermo Sanz-Berney:
I thought, you know what? I need to learn to live because I’ve always worked at universities and health systems, and so everything is like big and blow, and there is not, there’s more job security, but there’s less innovation. And also, so I met these people and I thought, you know what, this is interesting. This is a company that’s trying to digitize a little bit the emergency room workflow. There’s a lot of things that happen in emergency medicine, or in the ER, which can be expedited. You know, there’s a lot of back and forth to the workstation, the back, I mean, people can maybe watch these shows on TV, but it’s actually worse when you see on TV that you cannot look at the patient in the ER, You have to go back and then you can … history and the physical impact. And so there’s a lot of documentation, like there’s a huge percentage, almost a third or more with physicians and nurses who are spending time in documentation, either ordering orders or intake. I mean, just the whole series of buttons you have to put just to get somebody admitted, that you lose, I mean, we know that that workflow in an ER is, as an internal medicine person myself, I am the person who likes to take these long stories and learn and go back to the book, that’s not the workflow that you want in the ER. You know, you don’t have the time to do that. So you do want to have, we want to try to, to make a little bit more mobile, the workflow, in the sense that you could have a voice recognition application, that you can actually do the intake or the HNP or the ordering or even the labs, etc. that would free up your mind, your hands, and also can be more interactive with the patient. And that is, I mean, there’s a lot of things that, because anybody who’s worked in healthcare knows that the big EMRs, they’re not made, they’re not specifically made, and their modules are not specifically made for specific workflows. There’s a big catch-all for everybody. And the people who make decisions about what EMR are you going to use have other goals? You know, they have other goals which are goals that need to be met, but they’re not the goals of the person who is in the front line with the patient. And so the idea is to try to target this, and to a more streamline, in this case specifically to the emergency room. So one of the co-founders is an ED physician, and so we’re trying to get this, first, we’re trying to get somehow, to merge a little about what a scribe would do and also a little bit about how you can view documentation away from the terminal, even though there are studies who say that clinical people don’t dislike that much, the workstation, because for them it’s kind of a little bit of a watercooler. So that’s like the only time where you can actually talk about what show you saw last night or whatever, whatnot, it’s like, yeah. So, but having said that, there is also, there is, especially when we saw the overburdening of the systems during the COVID in which, you know, people were in the hallways and, you know. Actually, did study saying there’s actually a decrease in satisfaction about using EMR during COVID because, you know, as I said, you have a lot of clicks you have to do and dropdown menus that you can just write a paper and say, you know, okay, patient has this and that. But that’s what I’m doing right now. And also I do some, I do freelance stuff. So, people who need a nerd who knows medicine, they get in touch with me and I help them out and stuff like that.

TJ Southern:
Let me tell you, that’s actually pretty cool because that, so the emergency room and women’s health triage, those are always like the two pain points for EMRs and workflows because, you know, the ER, you know, you just want to treat them as fast as you can. And not being able to have that touch, you know, because you’re trying to get all this information in, in the short window, to either treat them medically or ship them off, that is really, truly always been a pain point for a lot of organizations. So, yeah, that’s pretty cool that your organization is the one work to make that whole transition more mobile. The question that I have for you is, because you’ve been in this industry for quite some time and you’ve seen a lot of things, from your start to now, have you seen the opportunities just explode? Like what type of opportunities do you think are available? And I’m just going to talk about in your discipline, physician, what type of opportunities do you think are available in the future?

Guillermo Sanz-Berney:
No, yeah, I mean, it has, I mean, the whole landscape of clinical informatics has changed and exploded in the last 12 years. I mean, it’s I mean, it’s like, just like, again, aging myself, you know, like 20 years ago, you know, you just, like, who would’ve thought that you would have all this kind of information at the tip of your hands so readily available. And even though I’m always been an early adopter, I’m always, I look back and I watch these movies from the early 2000s and I’m like, wow, I remember we still had flip phones and all that kind of stuff, you know? And it’s like, how do you check your Facebook on those phones? You couldn’t, you didn’t have it. You didn’t have Facebook, first of all.

TJ Southern:
Let me tell you that that is so true. You know, I go back to my early days, I always tell people I’m going to date myself too. When I started in nursing, I was one of those that was like kind of in between, where we still had the charts at the desk where the provider would come by and put that little flag in the chart to let us know that he changed the orders. And my first experience with EMRs, we had a DOS system. I can’t even remember the system that we used. I worked at Community Health, shout out to Community Health for being my training ground, my breeding ground for women’s health. And, you know, sometimes I sit and think, how do we even survive, you know, writing those soap notes? Writing, oh my God, how did I ever survive? Like, all the time that it took, so, yeah, yeah. I totally understand.

Guillermo Sanz-Berney:
I mean, I reminisce about, we were talking with Santos, which is, he’s one of the co-founders of the company, and we were talking the other day and we were reminiscing, quote-unquote, about how in the future we will have a lot, I mean, there’s an effort now, everybody knows there’s HIEs when there’s health information exchange, there are …, which are bigger regional health exchange, and there’s a federal, I forgot the acronym again, but there’s a federal initiative now which Epic signed up about a federal kind of a health information exchange. So we’re talking about how that will benefit, having all that information, people are very mobile right now, they move around, so you have all that information. And we were talking about how we remember our medical, med student days, but we had to go down to archives and get these huge tomes of medical records to create for the intern, or the resident, these minuscule kind of, you know, a little bit of a compendium of the whole chart. And I said, you know what? A lot of my medicine, I learned it that way, you know, because I had to go and dig up and go interpret these and put them down. So, I mean, obviously somebody, a med student now, looks at me, … I was going to slap me, they say, what? You don’t have like to go to the archives and can do that now.

TJ Southern:
They say they ain’t going down to the basement.

Guillermo Sanz-Berney:
I’m like, you’re like, oh, okay, here’s, especially the elderly patient, I’m like, Oh my God, yeah. So, yeah, I mean, there’s so much. And the thing is that there’s so much information available right now for patient care, but we’re just scratching the surface. I mean we’re not using, we’re not using it.

TJ Southern:
Oh, my God, that is so true. Let me tell you, I spoke with another, I spoke with a data science resource yesterday, interviewing them. And the biggest thing that he said, the same thing, he said, we have so many data points, it’s unreal. He said, but we are not using them, we’re not using them.

Guillermo Sanz-Berney:
I mean, first of all, because people don’t know what, how to use them too. I don’t know if they’re scared of finding what they’re going to find there. And I mean, imagine if we could, the amount of data we would have, for example, if somebody gets an infection and even though we have standards and gold standard for … medicine, it’s very generalized. I mean, someone who gets a staph infection at Hospital X, might not respond the same way in Hospital Y, so why don’t we just have that information? We get all the blood cultures, or whatever culture we have from a year and we realize, you know, these patients here in this hospital do not respond to the first line … The amount of money and time and life that we would save, not having that information available is a matter of one thing of, if one is to invest that, especially a lot of informaticians, physicians, they can’t even dedicate themselves 100%. A lot of these jobs are CMIOs, are half-time, you have to do clinic. I mean, I’m not saying that you, if you want to do it, do it, but at some point you need to, this is something that you need, you can do and should be able to do if you want to do full time.

TJ Southern:
Yes, yes, let me tell you, I had another physician on here, you know, a couple of months ago, and she said the same thing. She said, you know, a lot of us want to do it. She said, but we’re stuck in clinic or we still have, you know, measures that we have to meet as far as how many patients that we’re seeing and things like that. So we can’t really chair or champion, you know, the EMRs. And she said some of us actually want to really be involved like we really want to see and push the system to the limits and see how we can use it to benefit our patients. So you bring up an amazing point because, yes, the physicians are still, you know, wrangled in that where they can’t really perform in the manner that they want to perform because they still have obligations on the other side. So I pray that we have CEOs and CIOs on here, and you guys understand the gravity or the criticalness of actually taking your physicians out of practice to use them to actually champion your EMRs, or, and we’re just saying EMRs as an example, I’m talking about having physicians champion to make sure that we have all technologies integrated for patient care. That is what’s going to help better patient outcomes. You heard it here first, guys. You’ve heard it here first.

Guillermo Sanz-Berney:
And I second it.

TJ Southern:
So my question is, okay, so we know that we can take the physicians, you know, to help the physicians transition into these roles full time, but let me tell you the golden nugget here, the golden key. The golden key is a lot of healthcare professionals that are in healthcare don’t really know about informatics. They don’t.

Guillermo Sanz-Berney:
Yeah, I don’t want to get in trouble. Yeah, you’re right.

TJ Southern:
So the question is, how do we bring awareness to the role? How do we bring awareness to the discipline?

Guillermo Sanz-Berney:
That’s very, I mean, it’s very interesting because I think that it is something that we have discussed with … and colleagues. It’s, because we have a debate between regulation and laws, etc, the versus, you know, let the technology be embraced organically. And I’m a little bit more towards, people need a little bit of a nudge to do things. I cannot trust the good nature of people to be, maybe a little bit too cynical, but I’m a Miranda, if you ever ask, you watch Sex in the City, I’m a Miranda, I’m very cynical. And so, I mean, I think that because of the Affordable Care Act and because of a meaningful use and high tech, you know that, that’s the reason why physicians who are very reluctant to start using electronic medical records or any kind of these, kind of, because they have their way, this is how I annotate, I have my little abbreviations. I mean, I understand, it’s very hard to gear from what you have. But, you know, once you see the benefits, you realize, you know what, I was stubborn or whatnot, and, but even though I do believe a little bit of regulation and a little bit of a nudge, I also think that things should be a little bit of, not like from this day and on, you cannot, you should be a little bit gradual but not too gradual. That’s why, you know, I remember when we were still trying to get ICD 10 and it was like, okay, almost this year, next year.

TJ Southern:
Oh my God, it took forever.

Guillermo Sanz-Berney:
You just have to say, now, because if you just say, if they know you’re going to postpone it every year, you know.

TJ Southern:
And I think it was postponed for like two years and I’m like, look, y’all, get it together. Europe is already here, why does it take us five years?

Guillermo Sanz-Berney:
I mean, it’s just like, it’s human nature. We just, so that’s all, I think that with a little bit of regulation and also a little bit of making it visible. Don’t make it, I know we dabble in acronyms, we rebel in a little bit of techno-jargon, but we need to tone it, just like tone it down. Just like when we have to tone it down, when we speak to patients and not talk about different kind of vernacular, we start talking to make it more accessible so they understand that this is not a technology for the sake of being hip. It’s a technology that’s there because it’s been shown or proven or we’re going to show and prove to you that it’s going to expedite your life and it’s going to expedite life and make better life for your patients.

TJ Southern:
I love that. I absolutely love that. That is, because it’s correct, that’s why I love it. Because you are absolutely right. You can’t like, you can show a little bit of grace, but when the feet start dragging, it’s time to just take the sippy cup and say.

Guillermo Sanz-Berney:
I mean, yeah, sorry, sorry, not sorry, not sorry, but sorry, not sorry, but it’s just like, you know, I gave you a year and a half or two years and you’re still, you know, doing this thing that has been shown that you could, you know, it’s not. And you know what? Sometimes, and I do hear people, and I can understand their point of view. Some people think that, oh, you just going to do this so you can squeeze more patients so you can make more revenue. It’s not about that. It really is not about that. It’s about you know, it’s like what you’re doing right now is, the way you’re doing it, you could do so much better, you know? It’s like, and I know that sometimes it sounds like it’s not, it’s a little bit convoluted, but, you know, it’s about gaining the trust. If you are, any work in any health system or any company as a CMIO or the CIO at the informaticist or whatever role, you just need to be very transparent in what you do, how you got there, and why are you doing it? Don’t be secret and just go there, and you have to, how you say that? Evangelize informatics. You have to talk about the things that you’re passionate and if you’re passionate by it, like I think you both and myself are, you know, you know, it’s good to show. And for us, lessons that we need to learn and we need to be patient. I can be impatient. I know I’ve been using because I’m an early adopter, I got the latest apps, I got the beta and the alpha … You just need to be also patient and say, okay, we can wait a little bit more for this version, but let’s do this.

TJ Southern:
I love it, I love it. Y’all heard it from Guillermo. He said, be transparent, be transparent, get user buy-in, right, before y’all come in tearing up stuff, trying to put new stuff in. Get user buy-in, be transparent, be a pied piper. That’s why we have this podcast.

Guillermo Sanz-Berney:
Exactly.

TJ Southern:
Because I’m a pied piper. I’m an evangelist for informatics. Y’all heard it here first.

Guillermo Sanz-Berney:
Yeah, you can wait for it, first, we’re going to have a little of an acappella group. I’m going to start a little acapella group for clinical informatics.

TJ Southern:
So, Guillermo, what are your final words or your parting words of wisdom that you would like to leave for our listeners?

Guillermo Sanz-Berney:
Well, I mean, I’m not that full of myself I think I could instill wisdom, but I can instill experience. I think that what, the greatest thing that I could give to anybody who is listening who is starting, who is already in this career, or who’s thinking about it, it’s just, don’t assume anything about when you hear about these words of informatics or clinical informatics or health informatics or pharmacoinformatics, any, there’s a lot of informatics that’s in healthcare. It’s just, do your research. Listen to podcasts like this, read, and find out because it is something that’s very beautiful. It is not detached from the patient, but oh, I want to see patients. You do get to see patients. Maybe you don’t touch the patients, but you do get to see patients and you do get to make a mark and you do get to better the outcomes and healthcare of the city, the county, the state, the country, the world that we live in. That’s another thing that’s very interesting about informatics, you don’t have barriers. You can actually do projects that are in other countries, that you could do things in Africa, in South America, in Asia, and collaborate and do global health if you are interested in global health informatics. So I’m just saying, you know, don’t … that deep inside of you, just let it flourish and grow and do it, and communicate and network, and you’ll see that the very interesting and fascinating task to take.

TJ Southern:
I absolutely love it. I pray. Y’all know, I didn’t say my favorite verse, so I’m going to say it now. I pray that y’all had your pen and your paper at the top of this call because Guillermo confirmed A, you need to network, B, it’s okay to be your geeky self. It’s all right, let it flourish. And C, be transparent. Oh, my God, thank you, this is such a pleasure and an honor to have you all here. I told y’all it was going to be fun, lots of laughs.

TJ Southern:
Hey, y’all! Thanks for joining us today for another episode of the Outcomes Rocket Network – The Future of Global Informatics Podcast. If your organization is looking for informatics talent, go to www.Beryllus.net. That is www. B E R Y L L U S .net, and we can assist you in finding some of the best nursing informatics talent this continent has to offer. We’ll talk to you later! Have a great day! See ya!

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Things You’ll Learn:

  • Almost a third of physicians and nurses in the ER spend substantial time in documentation, either in data intake or in orders.
  • The big EMR systems are not made for specific workflows like the Emergency Room or Women’s Health Triage.
  • There is a lot of information available for patient care, but most of it has yet to be used.
  • Two ways of making clinical informatics more visible are through regulations and by simplifying the vernacular for communication.
  • If you are considering entering clinical informatics, research the profession. 
  • Informaticists might not directly treat patients, but they get to see them and affect their health outcomes. 
  • When working in informatics, there are no barriers regarding where or in what field you can work.

Resources:

  • Connect with and follow Gullermo Sanz-Berney on LinkedIn.
  • For more information on topics related to informatics or on finding talented informaticists for your organization, please visit the Beryllus Website