I've been writing about the Bring Your Own Device (BYOD)/Consumer IT challenge for the past several months. Today, an action plan goes into effect. Here's the message we sent to employees:
"Information Systems will be conducting an aggressive campaign to ensure every mobile device is encrypted. This initiative applies to all staff and students. The program is mandatory and required for any mobile device used to access BIDMC-related systems, programs or documents, including email, clinical applications and administrative documents such as financial spreadsheets, grant information or staff lists.
Many of you participated in last month’s program regarding smart phone devices used to connect to the Exchange email system using ActiveSync. These devices now require password protection. Look for more information soon on new smartphone encryption and 'auto wipe' requirements.
Securing Laptops and iPads
The next stage of work is encrypting laptops, iPads and other tablet computers. It will proceed in two phases.
The first phase, beginning this week, focuses on institutionally owned laptops and iPad-type tablet computers. Other versions of tablet computers will be addressed in a later phase. Service depots will be set up in and around the main campus. The first location will be the Center for Life Sciences (CLS). This building was chosen because it has the largest population of laptops and iPads.
We appreciate the cooperation of staff of CLS especially because you are the first to undergo this new process. The CLS experience will guide IS planning for the entire medical center. We will coordinate our encryption program with Research Administration’s research equipment inventory project, eliminating redundant phone calls to investigators.
What You Need to Do
Prepare Your Device – Prior to dropping off the laptop or iPad at the service depot, delete unneeded applications and data. All valuable data and important files, email, applications and other documents stored on the device should be backed up to your network home directory. Do NOT back up the data to an Internet cloud service such as Apple’s iCloud, or DropBox. Storing protected health or personal information on these sites is against corporate security policy.
Schedule an Appointment - Information Systems will contact staff for which records show you have been issued an institutionally funded laptop or iPad.
Leave the Device - Encrypting a device may require several hours depending on the method used. For this reason, you will be expected to leave the device at the service depot. Every attempt will be made to complete the work within the same business day.
Pick Up the Device - Upon returning the device, depot staff will brief you on what work was done and your on-going responsibilities for maintaining the security of the device. You will be asked to start the device from a cold boot and verify it is in working order.
What IS Will Do
Intake – To qualify under HIPAA/HITECH 'safe harbor', full disk encryption is required. On arrival at the service depot, an initial assessment of the device’s configuration will be done to determine the most appropriate encryption method, e.g. software or hardware based. Some devices have encryption built in, but it needs to be activated. The method used will depend on the make, model and operating system version of the laptop or tablet computer.
Inspection - The service depot staff will scan the device for malware and vulnerabilities. They will check configuration settings to assure they comply with corporate security policy such as power-on password, inactivity timeouts, and, for iPads, auto wipe. If time permits, depot staff will apply operating system and third party software patches necessary to eliminate security vulnerabilities. If malware is detected, the device will be cleaned or re-imaged depending on the nature of the malware. The network address of the device will be recorded so I.S. knows it has been inspected when it appears on the data network. When practical, management (Microsoft SCCM for Windows or Casper for Macs) and anti-virus agents (McAfee EPO) will be installed to allow Information Systems staff to keep the device in good security hygiene throughout its life while in use at BIDMC.
Inventory the Device for Research – If your computer is one that still needs to be scanned as part of the bi-annual Research inventory required by federal law, a member of the Research Administration staff will scan the inventory tag while it is at the depot – or apply an inventory tag as needed. We are combining these efforts to make it more convenient for users.
Return - See #4 above.
What is Next?
The dates and locations for other service depot sites will be announced later this month as IS continues to secure laptops and iPads throughout the medical center.
The second phase will extend the program to other models of institutionally owned tablet computers as well as personally owned laptops and tablet computers that are used to access BIDMC-related data. This phase will begin in the fall after work on institutionally owned devices is completed. We will assist in encrypting and, time permitting, patching the devices. Once done, it will be the responsibility of the owner to maintain the encryption and healthy state of the device.
Information Systems will periodically check your mobile device to ensure the safeguards are still in place. Additionally, staff must attest, each time their password is renewed, that all mobile devices they use for hospital related business, including personal devices, are encrypted.
From this point forward, newly acquired laptop and tablet computers purchased from institutional funds cannot be used to access the BIDMC data network until their encryption status is verified by Information Systems.
Information Systems will monitor the network for rogue laptop and tablet devices that have not been screened for compliance. If a device is discovered that has not been screened, Internet access privileges will be blocked."
As I've told the press, it is no longer sufficient to rely on policy alone to secure personal mobile devices. Institutions must educate their staff, assist them with encryption, and in some cases purchase software/hardware for personal users to ensure compliance with Federal and State regulations. Over the next few months, I'll write several posts about our lessons learned supporting personal device security enhancements.
The July HIT Standards Committee Meeting
The July HIT Standards Committee focused on a discussion of maturity and adoptability criteria for standards, a review of recent testimony regarding best practices for electronic identity authentication of providers, an update from ONC on the certification program, and a continuing discussion of the future processes needed to support the S&I Framework.
Dixie Baker presented the Initial Report on Criteria to Assess Maturity of Standards and Specifications.
A robust discussion followed noting that interpretation of readiness is contextual. Sometimes it is reasonable for standards to include optionality. Sometimes it is beneficial to require pre-coordination between trading partners. Sometimes it is reasonable to encourage adoption of emerging but not widely tested standards. The excellent framework that Dixie presented will be tested with a sample standard - the HL7 Infobutton implementation guide for knowledge retrieval. At our next meeting, Dixie will report on lessons learned from this evaluation and any refinements she would suggest to the maturity/adoptability criteria.
Dixie also presented an overview of a recent hearing on trusted identification for providers. In a world filled with malware, screen scrapers and keystroke loggers, it is important to consider the vulnerability of username and password as authentication credentials. The Standards Committee agreed on the importance of accurately identifying and protecting endpoints in healthcare information exchange, however they noted that healthcare workflows require more complexity than just authenticating individual users. Sometimes organizational credentials (a practice) are needed since a message is routed to a place not a person. Sometimes delegation is needed when routing a message to the staff supporting a clinician. We also discussed the workflow impact of two factor authentication. Strong authentication is part of a multi-layered defense protecting privacy. Significant work will be required to develop a family of solutions supporting the requirements of healthcare.
Next, Carol Bean provided an update on the Permanent Certification program. The existing temporary Authorized Testing and Certification Bodies (ATCBs) will be replaced by permanent certification and testing organizations. The certification organizations are accredited by ANSI and authorized by ONC. The testing organizations are accredited by National Voluntary Laboratory Accreditation Program (NVLAP) , a division of NIST, and authorized by ONC. To date, 5 organizations have been accredited as certifiers, and 5 organizations have been accredited as testers. ONC plans to authorize these organizations in August, so the temporary program can be sunsetted soon.
Jodi Daniel provided an overview of the national progress on health IT. 110,000 clinicians have attested to meaningful use. Numerous initiatives including BlueButton, Decision Support (HealthE Decisions) and a Cancer patient engagement program have been launched. The trajectory is good.
Finally, Doug Fridsma presented an update on the S&I Framework projects.
We discussed the success criteria for S&I efforts to date. We agreed that projects should be aligned with policy goals. We noted that a formal priority setting process is important to allocate limited resources among many competing projects. HITSC hopes to advise that process, using such tools as the maturity and adoptability criteria for standards to assess the level of effort and cost needed to close standards gaps, enabling ONC to optimize the portfolio of S&I projects.
We'll continue to the S&I discussion at the next meeting. As the end of ARRA funding nears there is an opportunity to reconsider how best ONC, HITSC, and S&I can work together to guide the work on standards for the United States.
Dixie Baker presented the Initial Report on Criteria to Assess Maturity of Standards and Specifications.
A robust discussion followed noting that interpretation of readiness is contextual. Sometimes it is reasonable for standards to include optionality. Sometimes it is beneficial to require pre-coordination between trading partners. Sometimes it is reasonable to encourage adoption of emerging but not widely tested standards. The excellent framework that Dixie presented will be tested with a sample standard - the HL7 Infobutton implementation guide for knowledge retrieval. At our next meeting, Dixie will report on lessons learned from this evaluation and any refinements she would suggest to the maturity/adoptability criteria.
Dixie also presented an overview of a recent hearing on trusted identification for providers. In a world filled with malware, screen scrapers and keystroke loggers, it is important to consider the vulnerability of username and password as authentication credentials. The Standards Committee agreed on the importance of accurately identifying and protecting endpoints in healthcare information exchange, however they noted that healthcare workflows require more complexity than just authenticating individual users. Sometimes organizational credentials (a practice) are needed since a message is routed to a place not a person. Sometimes delegation is needed when routing a message to the staff supporting a clinician. We also discussed the workflow impact of two factor authentication. Strong authentication is part of a multi-layered defense protecting privacy. Significant work will be required to develop a family of solutions supporting the requirements of healthcare.
Next, Carol Bean provided an update on the Permanent Certification program. The existing temporary Authorized Testing and Certification Bodies (ATCBs) will be replaced by permanent certification and testing organizations. The certification organizations are accredited by ANSI and authorized by ONC. The testing organizations are accredited by National Voluntary Laboratory Accreditation Program (NVLAP) , a division of NIST, and authorized by ONC. To date, 5 organizations have been accredited as certifiers, and 5 organizations have been accredited as testers. ONC plans to authorize these organizations in August, so the temporary program can be sunsetted soon.
Jodi Daniel provided an overview of the national progress on health IT. 110,000 clinicians have attested to meaningful use. Numerous initiatives including BlueButton, Decision Support (HealthE Decisions) and a Cancer patient engagement program have been launched. The trajectory is good.
Finally, Doug Fridsma presented an update on the S&I Framework projects.
We discussed the success criteria for S&I efforts to date. We agreed that projects should be aligned with policy goals. We noted that a formal priority setting process is important to allocate limited resources among many competing projects. HITSC hopes to advise that process, using such tools as the maturity and adoptability criteria for standards to assess the level of effort and cost needed to close standards gaps, enabling ONC to optimize the portfolio of S&I projects.
We'll continue to the S&I discussion at the next meeting. As the end of ARRA funding nears there is an opportunity to reconsider how best ONC, HITSC, and S&I can work together to guide the work on standards for the United States.
Our Cancer Journey Week 30
Today Kathy visited her oncologist to discuss a 5 year course of anti-estrogen (tamoxifen) therapy. I've said before that Cancer is chronic disease and although the first phase of our journey ends on July 31 after 8 final radiation treatments, the vigilance for reoccurrence and the medications to minimize risk begins thereafter.
Tamoxifen, a competitive inhibitor for estrogen, makes great sense for Kathy because her breast cancer is estrogen receptor positive - estrogen makes it grow. She'll have to watch for endometrial cancer (The American Cancer Society lists tamoxifen as a known carcinogen, stating that it increases the risk of some types of uterine cancer even though it lowers the risk of breast cancer recurrence) and possible memory changes. She'll start taking Tamoxifen about 10 days after the end of radiation therapy.
We're preparing to celebrate the end of her treatment phase (chemotherapy, surgery, radiation) and the transition to maintenance and prevention on July 31. One small complication - having just turned 50, my first ever colonoscopy is scheduled for that day so the champagne may have to wait until August 1.
Starting in August, Kathy's life becomes much easier since she no longer has to commute daily for radiation therapy. Since Boston has two seasons - winter and road construction - the fatigue of the past 6 weeks has been significantly compounded by sitting in traffic every day for up to 3 hours.
August will be much more settled than the rest of the year thus far. Treatment will be done, my office schedule will be iighter, my daughter will be away, and our previous home will have closed escrow. What will we do with all that free time?
Our llama and alpacas will move to Unity Farm the week of August 20 (assuming all our fences are finished, our hay arrives, and the folks transporting the herd will be available).
We just learned that our llama is likely pregnant, so we'll have a mama llama. The llama gestation period is 11.5 months, so she'll likely have the cria (baby llama) next Summer. I welcome suggestions for names. The suggestions I've had thus far are Dolly Llama and Ding Dong (as in 'who put the Mom in Mama Llama Ding Dong?')
This weekend we'll visit the alpaca herd in Maine to learn about toenail trimming, vaccinations, and general health assessment. I may be an emergency physician but doing procedures on a 150 pound furry camelid will be a learning experience.
After July 31, Kathy will not have another medical appointment until January 29, 2013 when she has a screening mammogram and a followup with her breast surgeon.
Next week will be my last post about this part of the cancer journey. It has been an emotional, anxiety-filled time for both of us. We're looking forward to maintaining wellness instead of treating illness.
Tamoxifen, a competitive inhibitor for estrogen, makes great sense for Kathy because her breast cancer is estrogen receptor positive - estrogen makes it grow. She'll have to watch for endometrial cancer (The American Cancer Society lists tamoxifen as a known carcinogen, stating that it increases the risk of some types of uterine cancer even though it lowers the risk of breast cancer recurrence) and possible memory changes. She'll start taking Tamoxifen about 10 days after the end of radiation therapy.
We're preparing to celebrate the end of her treatment phase (chemotherapy, surgery, radiation) and the transition to maintenance and prevention on July 31. One small complication - having just turned 50, my first ever colonoscopy is scheduled for that day so the champagne may have to wait until August 1.
Starting in August, Kathy's life becomes much easier since she no longer has to commute daily for radiation therapy. Since Boston has two seasons - winter and road construction - the fatigue of the past 6 weeks has been significantly compounded by sitting in traffic every day for up to 3 hours.
August will be much more settled than the rest of the year thus far. Treatment will be done, my office schedule will be iighter, my daughter will be away, and our previous home will have closed escrow. What will we do with all that free time?
Our llama and alpacas will move to Unity Farm the week of August 20 (assuming all our fences are finished, our hay arrives, and the folks transporting the herd will be available).
We just learned that our llama is likely pregnant, so we'll have a mama llama. The llama gestation period is 11.5 months, so she'll likely have the cria (baby llama) next Summer. I welcome suggestions for names. The suggestions I've had thus far are Dolly Llama and Ding Dong (as in 'who put the Mom in Mama Llama Ding Dong?')
This weekend we'll visit the alpaca herd in Maine to learn about toenail trimming, vaccinations, and general health assessment. I may be an emergency physician but doing procedures on a 150 pound furry camelid will be a learning experience.
After July 31, Kathy will not have another medical appointment until January 29, 2013 when she has a screening mammogram and a followup with her breast surgeon.
Next week will be my last post about this part of the cancer journey. It has been an emotional, anxiety-filled time for both of us. We're looking forward to maintaining wellness instead of treating illness.
Hospital Disaster Planning
In my role as CIO and a Professor of Medicine, I'm asked many questions about the policies, processes, and procedures of healthcare. Here's one I was recently asked about Hospital Disaster planning. Meg Femino, BIDMC Director of Emergency Management, prepared the answer.
The question:
Your hospital has been placed on alert for receiving patients from a local explosion at a large factory. Reports from the scene are spotty in terms of numbers killed or injured, and you do not know how many patients you may be getting. News reports are calling for casualties in the 100s, but local fire responders are sending in conflicting reports. You need to know what your ED will be receiving, so you can determine whether to close surgery to elective cases and to go on ED bypass for regular patients. Rumors are swirling inside the hospital and the chain of command about how severe the incident is and what it will do to your ability to function. What thoughts do you have about how to learn what you need to know in order to structure the hospital's preparations and continue regular functioning at the same time? What resources can you tap in order to learn more accurately about the situation at the scene and what you can expect to come to your ED? How would you manage this situation to cause the minimum disruption to regular hospital functioning?
When faced initially with a disaster situation in a health care setting, what do you think your first five steps need to be? Why?
Meg's answer:
This can be a common scenario, early information is always scant, unconfirmed and conflicting. Due to the mechanism of injury (explosion), chances are traumatic injuries will be present. That is what we would base our initial response on until credible information came in. We would immediately implement the following strategies:
* Activate the Emergency Operations Plan and the Incident Command System
* We would report to EMS via our disaster radio how many red (emergent), yellow (urgent) and green (non urgent) patients we can take. This is only a guide for EMS to distribute patients equally if they can, in a large mass casualty, you get what you get.
* Clear as many patients out of the Emergency Department as we could- admitted patients upstairs immediately, discharge others and decision make on the rest
* Alert the trauma teams with numbers expected, injuries, time to ED and any other pertinent information available
* Alert the OR's to hold any currently open rooms, do not start any other cases until we have more information and begin to assemble trauma teams. We know from previous drills we can open 17 OR rooms with staffed teams in 2 hours if we have to, this would involve canceling all non-emergent surgeries.
* We would see how many staffed in-patient beds are available in house and prepare for early discharges if we needed to. I call this the purge to surge.
* Alert the blood bank of potential incoming trauma to prepare for high volume of blood use
* Open the command center and assemble incident command team and begin gleaning information.
How we get information and share information during a citywide event:
* The Boston Hospitals have a emergency manager on call 24/7 for events like this. We would immediately be in touch with him, he liaisons with other citywide agencies and shares this information with hospitals.
* The TV provides information and usually pictures of the scene so we can get a better idea of the scope
* The city utilizes WebEOC which is a software system all hospitals, public safety, public health, EMS and others are linked in to. This system would be active within 15 minutes. Informations is shared here across disciplines and is great for situational awareness. We can also share our situation with others, make resource requests and monitor others.
* Boston also has a medical intelligence center housed at Boston EMS, they would be pushing out information as it comes available. They would be asking our needs and monitoring the situation.
* We (hospital emergency managers) receive information messages from state agencies via the HHAN (Health and Homeland Alert Network), if they activate the state EOC etc.
* We also monitor the disaster radio in the ED, they will update us on how many more patients on scene, where they are going etc.
We flex our incident command team up or down as needed for response and tailor our response strategies to the needs of the event. As far as the five first steps I would say
1. Activation of the Emergency Operations Plan and notification Incident Command- this brings the team approach to the response
2. Preparing the hospital for patient surge
3. Gleaning information and sharing information to establish accurate situational awareness
4. Monitoring of resources- finding the balance with staffing and burn rates of supply. This allows you to continue treating and know when to ccall for more.
5. Stabilizing the event- treating those from the event to return the hospital to normal operations
The question:
Your hospital has been placed on alert for receiving patients from a local explosion at a large factory. Reports from the scene are spotty in terms of numbers killed or injured, and you do not know how many patients you may be getting. News reports are calling for casualties in the 100s, but local fire responders are sending in conflicting reports. You need to know what your ED will be receiving, so you can determine whether to close surgery to elective cases and to go on ED bypass for regular patients. Rumors are swirling inside the hospital and the chain of command about how severe the incident is and what it will do to your ability to function. What thoughts do you have about how to learn what you need to know in order to structure the hospital's preparations and continue regular functioning at the same time? What resources can you tap in order to learn more accurately about the situation at the scene and what you can expect to come to your ED? How would you manage this situation to cause the minimum disruption to regular hospital functioning?
When faced initially with a disaster situation in a health care setting, what do you think your first five steps need to be? Why?
Meg's answer:
This can be a common scenario, early information is always scant, unconfirmed and conflicting. Due to the mechanism of injury (explosion), chances are traumatic injuries will be present. That is what we would base our initial response on until credible information came in. We would immediately implement the following strategies:
* Activate the Emergency Operations Plan and the Incident Command System
* We would report to EMS via our disaster radio how many red (emergent), yellow (urgent) and green (non urgent) patients we can take. This is only a guide for EMS to distribute patients equally if they can, in a large mass casualty, you get what you get.
* Clear as many patients out of the Emergency Department as we could- admitted patients upstairs immediately, discharge others and decision make on the rest
* Alert the trauma teams with numbers expected, injuries, time to ED and any other pertinent information available
* Alert the OR's to hold any currently open rooms, do not start any other cases until we have more information and begin to assemble trauma teams. We know from previous drills we can open 17 OR rooms with staffed teams in 2 hours if we have to, this would involve canceling all non-emergent surgeries.
* We would see how many staffed in-patient beds are available in house and prepare for early discharges if we needed to. I call this the purge to surge.
* Alert the blood bank of potential incoming trauma to prepare for high volume of blood use
* Open the command center and assemble incident command team and begin gleaning information.
How we get information and share information during a citywide event:
* The Boston Hospitals have a emergency manager on call 24/7 for events like this. We would immediately be in touch with him, he liaisons with other citywide agencies and shares this information with hospitals.
* The TV provides information and usually pictures of the scene so we can get a better idea of the scope
* The city utilizes WebEOC which is a software system all hospitals, public safety, public health, EMS and others are linked in to. This system would be active within 15 minutes. Informations is shared here across disciplines and is great for situational awareness. We can also share our situation with others, make resource requests and monitor others.
* Boston also has a medical intelligence center housed at Boston EMS, they would be pushing out information as it comes available. They would be asking our needs and monitoring the situation.
* We (hospital emergency managers) receive information messages from state agencies via the HHAN (Health and Homeland Alert Network), if they activate the state EOC etc.
* We also monitor the disaster radio in the ED, they will update us on how many more patients on scene, where they are going etc.
We flex our incident command team up or down as needed for response and tailor our response strategies to the needs of the event. As far as the five first steps I would say
1. Activation of the Emergency Operations Plan and notification Incident Command- this brings the team approach to the response
2. Preparing the hospital for patient surge
3. Gleaning information and sharing information to establish accurate situational awareness
4. Monitoring of resources- finding the balance with staffing and burn rates of supply. This allows you to continue treating and know when to ccall for more.
5. Stabilizing the event- treating those from the event to return the hospital to normal operations
The Return on Investment of Administrative Simplification
Since 1997, the New England Healthcare Exchange Network (NEHEN), a non-profit run by stakeholder board members, has provided community-wide collaborative payer-provider administrative transaction exchange for a fixed subscription fee.
I was recently asked about the return on investment of administrative healthcare information exchange.
The answer is summarized in this presentation.
NEHEN members use the exchange for benefits, eligibility, referral authorization, claim status inquiry, and claims transactions. There are no transaction fees.
Creative ways in which members use NEHEN include:
*45 days following service, self-pay accounts are passed through NEHEN to re-check for changes in insurance coverage, resulting in assignment of a payer to 15-20% of self-pay accounts
*Bad debt accounts are checked via NEHEN before write-off, resulting in assignment of a payer to 3-4% of bad debt accounts
*The accuracy of demographics and payer information is checked during inpatient hospitalizations so any corrections can be made while the patient is still receiving services.
The end result over the past decade is that denial rates have dropped from 5.5% to 3.25% of submitted claims. Bad debt is running at 0.6% of net revenue compared to the pre-NEHEN rate of 1.2%. Administrative write-offs due to delayed billing are at 0.02% of net revenue
Since payers and providers collaboratively run NEHEN without a middleman, the cost of supporting 100 million transactions per year is very low. For a large academic medical center, the NEHEN annual subscription is approximately $250,000. If the same transactions were processed by an outsourced revenue cycle vendor (.20 transaction fee) the cost would be about $952,000. If the same transactions were sent via a clearinghouse (.12 transaction fee), the cost would be about $571,000.
Lower administrative costs for payers and providers, more timely reimbursement, and fewer write-offs have created a return on investment for NEHEN that has resulted in sustained NEHEN membership for 50+ hospitals, 5000+ physicians, and 4.5M+ health plan members.
The is a clear ROI for administrative transaction exchange and NEHEN will continue to be a convener of payers and providers for years to come.
I was recently asked about the return on investment of administrative healthcare information exchange.
The answer is summarized in this presentation.
NEHEN members use the exchange for benefits, eligibility, referral authorization, claim status inquiry, and claims transactions. There are no transaction fees.
Creative ways in which members use NEHEN include:
*45 days following service, self-pay accounts are passed through NEHEN to re-check for changes in insurance coverage, resulting in assignment of a payer to 15-20% of self-pay accounts
*Bad debt accounts are checked via NEHEN before write-off, resulting in assignment of a payer to 3-4% of bad debt accounts
*The accuracy of demographics and payer information is checked during inpatient hospitalizations so any corrections can be made while the patient is still receiving services.
The end result over the past decade is that denial rates have dropped from 5.5% to 3.25% of submitted claims. Bad debt is running at 0.6% of net revenue compared to the pre-NEHEN rate of 1.2%. Administrative write-offs due to delayed billing are at 0.02% of net revenue
Since payers and providers collaboratively run NEHEN without a middleman, the cost of supporting 100 million transactions per year is very low. For a large academic medical center, the NEHEN annual subscription is approximately $250,000. If the same transactions were processed by an outsourced revenue cycle vendor (.20 transaction fee) the cost would be about $952,000. If the same transactions were sent via a clearinghouse (.12 transaction fee), the cost would be about $571,000.
Lower administrative costs for payers and providers, more timely reimbursement, and fewer write-offs have created a return on investment for NEHEN that has resulted in sustained NEHEN membership for 50+ hospitals, 5000+ physicians, and 4.5M+ health plan members.
The is a clear ROI for administrative transaction exchange and NEHEN will continue to be a convener of payers and providers for years to come.
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