scholarly journals Contribution of Free-Text Comments to the Burden of Documentation: Assessment and Analysis of Vital Sign Comments in Flowsheets

10.2196/22806 ◽  
2021 ◽  
Vol 23 (3) ◽  
pp. e22806
Author(s):  
Zhijun Yin ◽  
Yongtai Liu ◽  
Allison B McCoy ◽  
Bradley A Malin ◽  
Patricia R Sengstack
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Language Processing ◽  
Vital Sign ◽  
Medical Center ◽  
Free Text ◽  
Care Providers ◽  
Clinical Notes ◽  
Text Input ◽  
Medical Terms

Background Documentation burden is a common problem with modern electronic health record (EHR) systems. To reduce this burden, various recording methods (eg, voice recorders or motion sensors) have been proposed. However, these solutions are in an early prototype phase and are unlikely to transition into practice in the near future. A more pragmatic alternative is to directly modify the implementation of the existing functionalities of an EHR system. Objective This study aims to assess the nature of free-text comments entered into EHR flowsheets that supplement quantitative vital sign values and examine opportunities to simplify functionality and reduce documentation burden. Methods We evaluated 209,055 vital sign comments in flowsheets that were generated in the Epic EHR system at the Vanderbilt University Medical Center in 2018. We applied topic modeling, as well as the natural language processing Clinical Language Annotation, Modeling, and Processing software system, to extract generally discussed topics and detailed medical terms (expressed as probability distribution) to investigate the stories communicated in these comments. Results Our analysis showed that 63.33% (6053/9557) of the users who entered vital signs made at least one free-text comment in vital sign flowsheet entries. The user roles that were most likely to compose comments were registered nurse, technician, and licensed nurse. The most frequently identified topics were the notification of a result to health care providers (0.347), the context of a measurement (0.307), and an inability to obtain a vital sign (0.224). There were 4187 unique medical terms that were extracted from 46,029 (0.220) comments, including many symptom-related terms such as “pain,” “upset,” “dizziness,” “coughing,” “anxiety,” “distress,” and “fever” and drug-related terms such as “tylenol,” “anesthesia,” “cannula,” “oxygen,” “motrin,” “rituxan,” and “labetalol.” Conclusions Considering that flowsheet comments are generally not displayed or automatically pulled into any clinical notes, our findings suggest that the flowsheet comment functionality can be simplified (eg, via structured response fields instead of a text input dialog) to reduce health care provider effort. Moreover, rich and clinically important medical terms such as medications and symptoms should be explicitly recorded in clinical notes for better visibility.

scholarly journals Contribution of Free-Text Comments to the Burden of Documentation: Assessment and Analysis of Vital Sign Comments in Flowsheets (Preprint)

2020 ◽  
Author(s):  
Zhijun Yin ◽  
Yongtai Liu ◽  
Allison B McCoy ◽  
Bradley A Malin ◽  
Patricia R Sengstack
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Language Processing ◽  
Vital Sign ◽  
Medical Center ◽  
Free Text ◽  
Care Providers ◽  
Clinical Notes ◽  
Text Input ◽  
Medical Terms

BACKGROUND Documentation burden is a common problem with modern electronic health record (EHR) systems. To reduce this burden, various recording methods (eg, voice recorders or motion sensors) have been proposed. However, these solutions are in an early prototype phase and are unlikely to transition into practice in the near future. A more pragmatic alternative is to directly modify the implementation of the existing functionalities of an EHR system. OBJECTIVE This study aims to assess the nature of free-text comments entered into EHR flowsheets that supplement quantitative vital sign values and examine opportunities to simplify functionality and reduce documentation burden. METHODS We evaluated 209,055 vital sign comments in flowsheets that were generated in the Epic EHR system at the Vanderbilt University Medical Center in 2018. We applied topic modeling, as well as the natural language processing Clinical Language Annotation, Modeling, and Processing software system, to extract generally discussed topics and detailed medical terms (expressed as probability distribution) to investigate the stories communicated in these comments. RESULTS Our analysis showed that 63.33% (6053/9557) of the users who entered vital signs made at least one free-text comment in vital sign flowsheet entries. The user roles that were most likely to compose comments were registered nurse, technician, and licensed nurse. The most frequently identified topics were the notification of a result to health care providers (0.347), the context of a measurement (0.307), and an inability to obtain a vital sign (0.224). There were 4187 unique medical terms that were extracted from 46,029 (0.220) comments, including many symptom-related terms such as “pain,” “upset,” “dizziness,” “coughing,” “anxiety,” “distress,” and “fever” and drug-related terms such as “tylenol,” “anesthesia,” “cannula,” “oxygen,” “motrin,” “rituxan,” and “labetalol.” CONCLUSIONS Considering that flowsheet comments are generally not displayed or automatically pulled into any clinical notes, our findings suggest that the flowsheet comment functionality can be simplified (eg, via structured response fields instead of a text input dialog) to reduce health care provider effort. Moreover, rich and clinically important medical terms such as medications and symptoms should be explicitly recorded in clinical notes for better visibility.

Defining Legacy: The Perceptions of Pediatric Health Care Providers

2020 ◽  
Vol 59 (11) ◽  
pp. 1004-1010
Author(s):  
Jessika Boles ◽  
Maile Jones ◽  
Jenna Dunbar ◽  
Jessica Cook
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Family Relationships ◽  
Medical Center ◽  
Academic Medical Center ◽  
Free Text ◽  
Care Providers ◽  
Pediatric Health ◽  
Pediatric Health Care ◽  
Free Text Response

Legacy building interventions like plaster hand molds are offered in most children’s hospitals, yet little is known about how the concept of legacy is understood and described by pediatric health care providers. Therefore, this study explored pediatric health care providers’ perceptions of legacy at an academic medical center to ensure that future legacy interventions are evidence-informed and theoretically grounded. An electronic survey featuring three open-ended questions and two multiple-choice questions with an option for free text response was completed by 172 medical and psychosocial health care providers. Analysis yielded four themes: (1) legacy is intergenerational, enduring, and typically associated with end-of-life; (2) legacies articulate the impacts on others for which one is known and remembered; (3) legacies can be expressed through tangible items or intangible qualities; and (4) legacies are informed and generated by family relationships and work experiences. By understanding legacy as a personally and professionally contextualized experience, health care providers can better assess and meet the legacy needs of hospitalized pediatric patients and families.

scholarly journals Utility of Natural Language Processing for Clinical Quality Measures Reporting

2017 ◽  
Vol 9 (1) ◽  
Author(s):  
Dino P. Rumoro ◽  
Shital C. Shah ◽  
Gillian S. Gibbs ◽  
Marilyn M. Hallock ◽  
Gordon M. Trenholme ◽  
...  
Keyword(s):  
Health Care ◽  
Natural Language Processing ◽  
Natural Language ◽  
Language Processing ◽  
Medical Center ◽  
Academic Medical Center ◽  
Quality Measures ◽  
Surveillance Program ◽  
Free Text ◽  
Influenza Immunization

ObjectiveTo explain the utility of using an automated syndromic surveillanceprogram with advanced natural language processing (NLP) to improveclinical quality measures reporting for influenza immunization.IntroductionClinical quality measures (CQMs) are tools that help measure andtrack the quality of health care services. Measuring and reportingCQMs helps to ensure that our health care system is deliveringeffective, safe, efficient, patient-centered, equitable, and timely care.The CQM for influenza immunization measures the percentage ofpatients aged 6 months and older seen for a visit between October1 and March 31 who received (or reports previous receipt of) aninfluenza immunization. Centers for Disease Control and Preventionrecommends that everyone 6 months of age and older receive aninfluenza immunization every season, which can reduce influenza-related morbidity and mortality and hospitalizations.MethodsPatients at a large academic medical center who had a visit toan affiliated outpatient clinic during June 1 - 8, 2016 were initiallyidentified using their electronic medical record (EMR). The 2,543patients who were selected did not have documentation of influenzaimmunization in a discrete field of the EMR. All free text notes forthese patients between August 1, 2015 and March 31, 2016 wereretrieved and analyzed using the sophisticated NLP built withinGeographic Utilization of Artificial Intelligence in Real-Timefor Disease Identification and Alert Notification (GUARDIAN)– a syndromic surveillance program – to identify any mention ofinfluenza immunization. The goal was to identify additional cases thatmet the CQM measure for influenza immunization and to distinguishdocumented exceptions. The patients with influenza immunizationmentioned were further categorized by GUARDIAN NLP intoReceived, Recommended, Refused, Allergic, and Unavailable.If more than one category was applicable for a patient, they wereindependently counted in their respective categories. A descriptiveanalysis was conducted, along with manual review of a sample ofcases per each category.ResultsFor the 2,543 patients who did not have influenza immunizationdocumentation in a discrete field of the EMR, a total of 78,642 freetext notes were processed using GUARDIAN. Four hundred fiftythree (17.8%) patients had some mention of influenza immunizationwithin the notes, which could potentially be utilized to meet the CQMinfluenza immunization requirement. Twenty two percent (n=101)of patients mentioned already having received the immunizationwhile 34.7% (n=157) patients refused it during the study time frame.There were 27 patients with the mention of influenza immunization,who could not be differentiated into a specific category. The numberof patients placed into a single category of influenza immunizationwas 351 (77.5%), while 75 (16.6%) were classified into more thanone category. See Table 1.ConclusionsUsing GUARDIAN’s NLP can identify additional patients whomay meet the CQM measure for influenza immunization or whomay be exempt. This tool can be used to improve CQM reportingand improve overall influenza immunization coverage by using it toalert providers. Next steps involve further refinement of influenzaimmunization categories, automating the process of using the NLPto identify and report additional cases, as well as using the NLP forother CQMs.Table 1. Categorization of influenza immunization documentation within freetext notes of 453 patients using NLP

scholarly journals Effectiveness of an Electronic Communication Tool on Transitions in Care From the Intensive Care Unit: Protocol for a Cluster-Specific Pre-Post Trial (Preprint)

2020 ◽  
Author(s):  
Jeanna Parsons Leigh ◽  
Rebecca Brundin-Mather ◽  
Liam Whalen-Browne ◽  
Devika Kashyap ◽  
Khara Sauro ◽  
...  
Keyword(s):  
Health Care ◽  
Intensive Care ◽  
Health Care Providers ◽  
Primary Outcome ◽  
Audit And Feedback ◽  
Free Text ◽  
Care Providers ◽  
Transitions In Care ◽  
Post Trial ◽  
The Impact

BACKGROUND Transitions in care are vulnerable periods in health care that can expose patients to preventable errors due to incomplete or delayed communication between health care providers. Transitioning critically ill patients from intensive care units (ICUs) to other patient care units (PCUs) is particularly risky, due to the high acuity of the patients and the diversity of health care providers involved in their care. Instituting structured documentation to standardize written communication between health care providers during transitions has been identified as a promising means to reduce communication breakdowns. We developed an evidence-informed, computer-enabled, ICU-specific structured tool—an electronic transfer (e-transfer) tool—to facilitate and standardize the composition of written transfer summaries in the ICUs of one Canadian city. The tool consisted of 10 primary sections with a user interface combination of structured, automated, and free-text fields. OBJECTIVE Our overarching goal is to evaluate whether implementation of our e-transfer tool will improve the completeness and timeliness of transfer summaries and streamline communications between health care providers during high-risk transitions. METHODS This study is a cluster-specific pre-post trial, with randomized and staggered implementation of the e-transfer tool in four hospitals in Calgary, Alberta. Hospitals (ie, clusters) were allocated randomly to cross over every 2 months from control (ie, dictation only) to intervention (ie, e-transfer tool). Implementation at each site was facilitated with user education, point-of-care support, and audit and feedback. We will compare transfer summaries randomly sampled over 6 months postimplementation to summaries randomly sampled over 6 months preimplementation. The primary outcome will be a binary composite measure of the timeliness and completeness of transfer summaries. Secondary measures will include overall completeness, timeliness, and provider ratings of transfer summaries; hospital and ICU lengths of stay; and post-ICU patient outcomes, including ICU readmission, adverse events, cardiac arrest, rapid response team activation, and mortality. We will use descriptive statistics (ie, medians and means) to describe demographic characteristics. The primary outcome will be compared within each hospital pre- and postimplementation using separate logistic regression models for each hospital, with adjustment for patient characteristics. RESULTS Participating hospitals were cluster randomized to the intervention between July 2018 and January 2019. Preliminary extraction of ICU patient admission lists was completed in September 2019. We anticipate that evaluation data collection will be completed by early 2021, with first results ready for publication in spring or summer 2021. CONCLUSIONS This study will report the impact of implementing an evidence-informed, computer-enabled, ICU-specific structured transfer tool on communication and preventable medical errors among patients transferred from the ICU to other hospital care units. CLINICALTRIAL ClinicalTrials.gov NCT03590002; https://www.clinicaltrials.gov/ct2/show/NCT03590002 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/18675

scholarly journals P129: Safer transitions in the care of the elderly: identification of essential information in transitional care

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S110-S111
Author(s):  
S. Trivedi ◽  
S. Beckett ◽  
A. Dick ◽  
R. Hartmann ◽  
C. Roberts ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Transitional Care ◽  
Transitions Of Care ◽  
Free Text ◽  
Care Providers ◽  
Cross Sectional ◽  
Term Care ◽  
Essential Information ◽  
Patient Advocates

Introduction: When presenting to the Emergency Department (ED), the care of elderly patients residing in Long Term Care (LTC) can be complicated by threats to patient safety created by ineffective transitions of care. Though standardized inpatient handover tools exist, there has yet to be a universal tool adopted for transfers to the ED. In this study, we surveyed relevant stakeholders and identified what information is essential in the transitions of care for this vulnerable population. Methods: We performed a descriptive, cross sectional electronic survey that was distributed to physicians and nurses in ED and LTC settings, paramedics, and patient advocates in two Canadian cities. The survey was kept open for a one month period with weekly formal reminders sent. Questions were generated after performing a literature review which sought to assess the current landscape of transitional care in this population. These were either multiple choice or free text entry questions aimed at identifying what information is essential in transitional periods. Results: A total of 191 health care providers (HCP) and 22 patient advocates (PA) responded to the survey. Within the HCPs, 38% were paramedics, 38% worked in the ED, and 24% were in LTC. In this group, only 41% of respondents were aware of existing handover protocols. Of the proposed informational items in transitional care, 100% of the respondents within both groups indicated that items including reason for transfer and advanced care directives were essential. Other areas identified as necessary were past medical history and baseline functional status. Furthermore, the majority of PAs identified that items such as primary language, bowel and bladder incontinence and spiritual beliefs should be included. Conclusion: This survey demonstrated that there is a need for an improved handover culture to be established when caring for LTC patients in the ED. Education needs to be provided surrounding existing protocols to ensure that health care providers are aware of their existence. Furthermore, we identified what information is essential to transitional care of these patients according to HCPs and PAs. These findings will be used to generate a simple, one page handover form. The next iteration of this project will pilot this handover form in an attempt to create safer transitions to the ED in this at-risk population.

scholarly journals Evaluation of Human Papillomavirus Vaccination After Pharmacist-Led Intervention: A Pilot Project in an Ambulatory Clinic at a Large Academic Urban Medical Center

2020 ◽  
Vol 135 (3) ◽  
pp. 313-321
Author(s):  
Julianna Cebollero ◽  
Suzanne M. Walton ◽  
Laurie Cavendish ◽  
Kristi Quairoli ◽  
Carrie Cwiak ◽  
...  
Keyword(s):  
Health Care ◽  
Human Papillomavirus ◽  
Health Care Providers ◽  
Medical Center ◽  
Vaccine Dose ◽  
Pilot Project ◽  
Care Providers ◽  
Post Intervention ◽  
Intervention Phase ◽  
Active Intervention

Objectives Despite the safety and efficacy of the human papillomavirus (HPV) vaccine, many persons are still not receiving it. The purpose of this pilot project was to evaluate the number of first doses of the 9-valent HPV (9vHPV) vaccination administered after a pharmacist-led intervention in the Adult Family Planning Clinic at Grady Health System (GHS), a large academic urban medical center in Atlanta, Georgia. Methods The pilot project had 3 phases: pre-intervention (November 15, 2016, through March 31, 2017), active intervention (November 15, 2017, through December 29, 2017), and post-intervention (December 30, 2017, through March 31, 2018). The pre-intervention phase was used as a historical control. The active intervention phase consisted of pharmacist interventions in the clinic and patient and health care provider education. The post-intervention phase evaluated the durability of pharmacist-led interventions performed and education provided during the active phase. Results Eighty-nine first-dose 9vHPV vaccines (of the 3-dose series) were administered to young adults aged 18-26 during the project period (November 15, 2017, through March 31, 2018); none were administered during the pre-intervention phase. Of 89 patients who received a first 9vHPV vaccine dose, 20 patients also received a second 9vHPV vaccine dose. During the project period, 166 doses of 9vHPV vaccine (first, second, or third doses) were administered. Conclusion This pharmacist-led intervention led to an increase in the number of young adult patients receiving their first dose of the 9vHPV vaccination series. With the support of other health care providers, pharmacist-led initiatives can expand vaccine-related health literacy and facilitate access to immunization services.

scholarly journals A Theoretical Twist on the Transparency of Open Notes: Qualitative Analysis of Health Care Professionals’ Free-Text Answers

10.2196/14347 ◽  
2019 ◽  
Vol 21 (9) ◽  
pp. e14347
Author(s):  
Gudbjörg Erlingsdóttir ◽  
Lena Petersson ◽  
Karin Jonnergård
Keyword(s):  
Health Care ◽  
Real Time ◽  
Health Care Providers ◽  
Actual Practice ◽  
Free Text ◽  
Care Organization ◽  
Care Providers ◽  
Medical Specialties ◽  
Positive Effects ◽  
Trade Offs

Background The New Public Management movement strove for transparency so that policy makers and citizens could gain insight into the work and performance of health care. As the use of the electronic health record (EHR) started to diffuse, a foundation was laid for enhanced transparency within and between health care organizations. Now we appear to be experiencing a new kind of transparency in the health care sector. Many health care providers offer their patients online access to their EHRs (here referred to as Open Notes). The Open Notes system enables and strives for transparency between the health care organization and the patient. Hence, this study investigates health care professional (HCP) perceptions of Open Notes and deepens the understanding of the transparency that Open Notes implies. Objective Based on two survey studies of HCP perceptions of Open Notes, this paper aims to deepen the academic writing on the type of transparency that is connected to Open Notes. Methods HCPs in adult psychiatry in Region Skåne, Sweden, were surveyed before and after implementation of Open Notes. The empirical material presented consists of 1554 free-text answers from two Web surveys. A qualitative content analysis was performed. Results The theoretically informed analysis pivots around the following factors connected to transparency: effectiveness; trust; accountability; autonomy and control; confidentiality, privacy, and anonymity; fairness; and legitimacy. The results show that free-text answers can be sorted under these factors as trade-offs with transparency. According to HCPs, trade-offs affect their work, their relationship with patients, and not least, their work tool, the EHR. However, since many HCPs also state that they have not met many patients, and in some cases none, who have read their EHRs, these effects seem to be more connected to the possibility (or threat) of transparency than to the actual effectuated transparency. Conclusions The implementation (or reform) of Open Notes is policy driven while demanding real-time transparency on behalf of citizens/patients and not the authorities, which makes this particular form of transparency quite unique and interesting. We have chosen to call it governed individual real-time transparency. The effects of Open Notes may vary between different medical specialties relative to their sensitivity to both total and real-time transparency. When HCPs react by changing their ways of writing notes, Open Notes can affect the efficiency of the work of HCPs and the service itself in a negative manner. HCP reactions are aimed primarily at protecting patients and their relatives as well as their own relationship with the patients and secondly at protecting themselves. Thus, governed individual real-time transparency that provides full transparency of an actual practice in health care may have the intended positive effects but can also result in negative trade-offs between transparency and efficiency of the actual practice. This may imply that full transparency is not always most desirable but that other options can be considered on a scale between none and full transparency.

scholarly journals Is MRI Overutilized for Evaluation of Knee Pain in Veterans?

2021 ◽  
Author(s):  
Scott Koenig ◽  
George Morcos ◽  
Rohan Gopinath ◽  
Kenneth Wang ◽  
Frank Henn ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Imaging Modality ◽  
Medical Center ◽  
Retrospective Chart Review ◽  
Care Providers ◽  
Mri Imaging ◽  
Knee Arthritis ◽  
Diagnostic Strategies ◽  
Mri Scans

AbstractMRI is an essential diagnostic imaging modality for many knee conditions; however, it is not indicated in the setting of advanced knee arthritis. Inappropriate MRI imaging adds to health care costs and may delay definitive management for many patients. The primary purpose of this study was to ascertain the frequency of inappropriate MRI scans performed at one Veterans' Administration Medical Center (VAMC). We performed a retrospective chart review of all knee MRIs ordered over a 6-month period. Inappropriate MRI was defined as MRI performed prior to radiographs (XRs), or in the presence of XRs demonstrating severe osteoarthritis, without leading to a nonarthroplasty procedure of the knee. Of the 304 cases reviewed, 36.8% (112) of the MRIs were deemed inappropriate, 33 were ordered by orthopedists, and 79 were ordered by other health care providers. Of the 33 ordered by orthopedists, 25 were ordered by retired/nonsurgical orthopedists. Obtaining an MRI delayed care by an average of 29.2 days. Of the 252 cases that had XR prior to MRI, none included all four views in the standard knee XR series and only four had weightbearing images. Over a third of knee MRIs performed at this VAMC were inappropriate and delayed care. Additionally, no XRs in our study contained all the necessary views to properly assess knee arthritis. These concerning findings signify a potential opportunity for education in diagnostic strategies, to better patient care and resource utilization in the VAMC.

scholarly journals Introduction of Ultrasound Simulation in Medical Education: Exploratory Study (Preprint)

2019 ◽  
Author(s):  
Selim Hani ◽  
Gihad Chalouhi ◽  
Zavi Lakissian ◽  
Rana Sharara-Chami
Keyword(s):  
Health Care ◽  
Medical Students ◽  
Health Care Providers ◽  
Health Care Professionals ◽  
Medical Center ◽  
Practical Experience ◽  
Diagnostic Tools ◽  
Care Providers ◽  
American University ◽  
Ultrasound Simulation

BACKGROUND Ultrasound is ubiquitous across all disciplines of medicine; it is one of the most commonly used noninvasive, painless diagnostic tools. However, not many are educated and trained well enough in its use. Ultrasound requires not only theoretical knowledge but also extensive practical experience. The simulated setting offers the safest environment for health care professionals to learn and practice using ultrasound. OBJECTIVE This study aimed to (1) assess health care professionals’ need for and enthusiasm toward practicing using ultrasound via simulation and (2) gauge their perception and acceptance of simulation as an integral element of ultrasound education in medical curricula. METHODS A day-long intervention was organized at the American University of Beirut Medical Center (AUBMC) to provide a free-of-charge interactive ultrasound simulation workshop—using CAE Vimedix high-fidelity simulator—for health care providers, including physicians, nurses, ultrasound technicians, residents, and medical students. Following the intervention, attendees completed an evaluation, which included 4 demographic questions and 16 close-ended questions based on a Likert scale agree-neutral-disagree. The results presented are based on this evaluation form. RESULTS A total of 41 participants attended the workshop (46% [19/41] physicians, 30% [12/41] residents, 19% [8/41] sonographers, and 5% [2/41] medical students), mostly from AUBMC (88%, 36/41), with an average experience of 2.27 (SD 3.45) years and 30 (SD 46) scans per attendee. Moreover, 15 out of 41 (36%) participants were from obstetrics and gynecology, 11 (27%) from internal medicine, 4 (10%) from pediatrics, 4 (10%) from emergency medicine, 2 (5%) from surgery and family medicine, and 5 (12%) were technicians. The majority of participants agreed that ultrasound provided a realistic setting (98%, 40/41) and that it allowed for training and identification of pathologies (88%, 36/41). Furthermore, 100% (41/41) of the participants agreed that it should be part of the curriculum either in medical school or residency, and most of the participants approved it for training (98%, 40/41) and teaching (98%, 40/41). CONCLUSIONS All attendees were satisfied with the intervention. There was a positive perception toward the use of simulation for training and teaching medical students and residents in using ultrasound, and there was a definite need and enthusiasm for its integration into curricula. Simulation offers an avenue not only for teaching but also for practicing the ultrasound technology by both medical students and health care providers.

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