Introduction to Primary Care

Introduction to Primary Care

Introduction to Primary Care Health Jennifer Lake, PharmD And Dr. Geordie Fallis South East Toronto Family Health Team And University of Toronto Objectives List the elements of primary health care. Describe common models of primary health care in Canada, especially family health teams and community

health centers in Ontario. List common reasons for primary care reform in Ontario/ Canada. Define Interprofessional Collaboration and how it plays an integral part in Ontarios Primary Health Care system. Discuss potential roles/ responsibilities of a primary care pharmacist & identify which can be done independently and which are done within a collaborative practice model. Definition Primary care: Primary health care:

Primary Care involves the diagnosis, treatment and follow-up for a specific disease or health problem provided by health practitioners, usually as the first point of entry into the health care system Primary Care Who is it provided by? Primary Care Focuses on provision of health services

A reactive system Primary Care Focuses on provision of health services A reactive system Deals mainly with prevention/treatment of illness Interventions focus on individuals NOT on communities or populations Primary Health Care an integral part both of the countrys

health system, of which it is the central function and main focus, and of the overall social and economic development of the community. .bringing health care as close as possible to where people live and work (WHO, 1978) Health Canada Definition Primary health care: an approach to health and a spectrum of services beyond the traditional health care system.

It includes all services that play a part in health, such as income, housing, education, and environment. Primary care: the element within primary health care that focuses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury. Primary Health Care Encompasses primary care AND the other determinants of health

Health Determinants 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

12. Income & Social Status Social Support Networks Education & Literacy Employment & Working Conditions Social Environments Physical Environments Biology & Genetic Endowment Personal Health Practices & Coping Skills Healthy Child Development Health Services Gender

Culture What we know National health care systems with strong primary care infrastructures have healthier populations, fewer healthrelated disparities and lower overall costs for health care* A discontinuity of primary care means patients will see more specialists, contributing to increased costs Systems that rely on primary care physicians rather than specialists as the main source of physician care have better health outcomes; improved equity, access and continuity; and lower costs *Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Millbank Q 2005:83:457-502.

So, if Primary Health Care is supposed to deal with all of this We need Primary Health Care Reform. Why do we need to reform primary health care in Ontario? 10% of Ontarians have no family physician Health Human Resources Trend data indicates that Ontario faces a significant reduction in its health human

resources workforce by 2010. Address the need to change the scopes and patterns of practice of health care providers to reflect changes in how health care services are delivered, particularly through new approaches to primary health care Why do we need to reform primary care in Ontario?

10% of Ontarians have no family physician Lengthy waiting times to see a family physician Access: General Population 2008 % of population with a regular source of care: Doctors office, clinic or practice - Canada 78% - Ontario 85% Walk-in clinic, CLSC or CHC - Canada 17% - Ontario 11%

Difficulty accessing routine or ongoing care: - Canada 13% - Ontario 15% (highest among provinces) Experiences with Primary Health Care in Canada, CIHI, July 2008; Sutherland and Leatherman Chartbook on Healthcare Quality in Canada, Ottawa, CHSRF (manuscript in preparation) Access: People with Chronic Illness Time waited for MD appointment when sick: same day - Canada 26%, Ontario 23% > 6 days - Canada 34%*, Ontario 28% Somewhat or very difficult to get care on nights and weekends:

Canada 56%, Ontario 54% Went to ER for a condition that could have been treated by regular doctor if available: Canada 23%*, Ontario 26% *Highest among Australia, Canada, France, Germany, Netherlands, New Zealand, UK, US Schoen et al., Health Affairs Web Exclusive 2008:w1-16; Commonwealth Fund 2008 International Health Policy Survey (custom data provided by the Ontario Health Quality Council) Why do we need to reform primary care in Ontario?

10% of Ontarians have no family physician Lengthy waiting times to see a family physician Inadequate outcomes for individuals with chronic disease Type 2 Diabetes ~ 9% of Ontarians have diabetes (approx. 900,000 people). It is estimated that: >50% of people are not at recommended blood glucose targets. ~50% of people have had their eyes and feet examined and this number has not improved in the last 3 years. <50% of people have bloodwork up to date.

Depressive symptoms are present in approximately 15% of patients with diabetes. Depressive disorders in adults are associated with poorer selfcare behavior, poorer glycemic control, health complications and other challenges. Health Council of Canada. A Health Outcomes Report - Why Health Care Renewal Matters: Lessons from Diabetes. March 2007. Ontario Health Quality Council. Quality Monitor 2010 Report on Ontarios Health System. Health Council of Canada. A Health Outcomes Report - Why Health Care Renewal Matters: Lessons from Diabetes. March 2007. Stand up to Diabetes. Ontario Ministry of Health and Long-Term Care. May 2010. Canadian Diabetes Association. 2008 Clinical Practice Guidelines.

Better Diabetes Health : Easy as 1, 2, 3 If youre living with diabetes, there are three tests that are important to managing your disease and maintaining your health : 1. A blood test that measures sugar control (called HbA1C) This test needs to be done at least every 6 months. 2. A blood test that measures your bad cholesterol (called LDL-C) This test needs to be done at least every 12 months. 3. A painless test that looks at the blood vessels in your eyes This test needs to be done at least every 24 months. If you or someone close to you has diabetes and are not sure whether you have had these three tests, talk to the doctor providing your diabetes care. To help ensure you receive these tests regularly, a Diabetes Testing Report with the

dates of when you last had these three tests will be sent from the Ministry of Health and Long-Term Care to your doctor or nurse practitioner in Nurse Practitioner-Led Clinics. People who receive these tests are better able to manage their diabetes and avoid complications. Watch your dates and get your tests regularly. In addition to these three key tests, it is important to monitor your blood pressure regularly and have your feet checked by your doctor at least once a year. Why do we need to reform primary care in Ontario? 10% of Ontarians have no family physician Lengthy waiting times to see a family physician Inadequate outcomes for individuals with

chronic disease Not preventing illness/ promoting health as we could Quality and Outcomes Preventive Care % people > 65 receiving influenza vaccination (2005): 66.5% % of women 50-69 with mammography (2003): 70.6% % of women 20-69 with cervical cancer screening (2003): 74.9% Anderson and Markovitch, Commonwealth Fund November 2008; Anderson, Frogner and Reinhardt, Health Affairs

2007;26(5):1481-9 Why do we need to reform primary care in Ontario? 10% of Ontarians have no family physician Lengthy waiting times to see a family physician Inadequate outcomes for individuals with chronic disease Not preventing illness/ promoting health as we could Need to improve provider satisfaction / retention Underuse of skilled team members

Use of skilled providers/ satisfaction Reports on health human resources have suggest teamwork may be an effective way of reducing staff shortages and stress and burnout among healthcare professionals Research has shown that teamwork can significantly reduce workloads; increase job satisfaction and retention Lichtenstein, R., Alexander, J., McCarthy, J., & Wells, R. (2004). Participation and influence in interdisciplinary treatment teams: Effects on job satisfaction and intention to quit. Journal of Health and Social Behavior, 45(3), 322-335

Teamwork before all the titles Geordie story Interprofessional Collaboration Interprofessional care is the provision of comprehensive health services to patients by multiple health caregivers who work collaboratively to deliver quality care within and across settings. Collaborative practice is defined as an interprofessional process for communication and decision-making that enables the knowledge and skills of care providers to synergistically influence

the client/patient care provided. Collaborative practice is linked to the concept of teamwork Team based care/ IPC Studies have shown that IPC can lead to: increased access to health care improved outcomes for people with chronic diseases less tension and conflict among caregivers better use of clinical resources easier recruitment of caregivers

lower rates of staff turnover Teams in Primary Care Newly emerging primary health care teams are envisioned as providing the most appropriate care, by the most appropriate providers in the most appropriate settings The structure and composition of organizations teams differ, depending on the needs of the population, the choices of the professionals involved, and the availability of

regional support teams. Canadian Family PhysicianOctober 2010 vol. 56 no. 10 e368-e374 Health Canada & Primary Care Each jurisdiction is undertaking its own approach but some common areas of focus have emerged: Creation of primary health care teams and organizations which are responsible for providing comprehensive services to their clients (including coordination with other levels of care); Creation or enhancement of telephone advice lines to provide 24-hour first-contact services; Improvements in the management of chronic diseases (which

account for 40-70% of health care system costs); Greater emphasis on health promotion and illness/injury prevention; Voluntary participation by providers and patients alike; Capacity-building in evaluation, so that system performance may be monitored; and Explicit focus on change management activities to support all of the above. Ontario Governments Current Health Care Priorities Reducing wait times with a particular focus on emergency departments

Improved care for people living with diabetes Delivering access to family healthcare for all Ontarians What has happened in Ontario to move towards this primary health care model? Models of Primary Health Care Primary care providers in Ontario work in a number of different models:

Family Health Teams Community Health Centres Family Health Networks Family Health Groups Comprehensive Care Model (CCM) Family Health Organization (FHO) Rural-Northern Physician Group Agreement (RNPGA) Date Program Announced Primary Care Model

2006 Family Health Organization (FHO) 2005 Comprehensive Care Model (CCM) 2004 Family Health Team (FHT)

2003 Family Health Group (FHG) 2002 Family Health Network (FHN) 1998 Primary Care Network (PCN)* 1998

1979 Northern Group Funding Plan (NGFP) Health Service Organization (HSO)* 1975 Community Health Centre (CHC) --- Fee-for-service (FFS)

2002 Romanow and Kirby Reports Fee-for-Service (FFS) Model Paying physicians for each separate service they provide May not provide a mechanism for paying physicians for providing preventative care Some suggest an obstacle to further development is the persistence of fee-for-service model Paying physicians for each separate service they provide

can create a perverse incentive to focus on the quantity of services provided rather than on the quality of services in order to maximize a physicians income. Fee-for-service model Many family physicians favor FFS because of its historical and well-recognized advantages: Work is clearly linked to payment.

Increasing workloads are rewarded with payment incentives. After-hours work is recognized with appropriate payment incentives. FFS offers the flexibility to increase or decrease workloads independently based on personal preference or other obligations such as the contribution of income to internal distribution within a group practice The potential disadvantages of FFS include: The risk that remuneration will be driven by workload income. Fees associated with solitary services and activities might not contribute to the overall care of the patient or the achievement of targeted population health outcomes. Some time-consuming services are inadequately remunerated, e.g.

chronic care management, counselling or interdisciplinary collaboration. There is usually a lack of dedicated remuneration for team-based activity. Community Health Centres (CHC) Integrate health and social services Nonprofit organizations that provide primary health care for individuals, families and communities Work with communities to strengthen their capacity to take responsibility for health and well being Each health centre is established and governed by a

communityelected board of directors Physicians are employed in CHCs and paid a salary; number of doctors varies (three doctors on average) Inter-disciplinary teams of physicians working with other professionals including nurse practitioners, dietitians and health educators ci_id=3002&la_id=1 Roster A population of patients who have signed agreements to receive care from a specific provider/ provider group

A requirement to "roster " or enroll patients, either formally or informally, in order to more clearly define the family physician's patient population The provider/ provider group provides a basket of services which are defined as essential/ comprehensive primary care services Capitation Capitation - Base payment rate is determined by the age and sex of rostered patients. (Age and sex alone predicts about 70% of the utilization of primary care services.) Capitation has the additional attraction to funders of ensuring some system equity in health service funding, so that funds are

disbursed on the basis of need rather than entirely on service utilization, especially in jurisdictions where access to defined services might be limited. Advantages Disadvantages Predictable income for family physicians Potential to choose patients that are easier to care for than others because of their demographics or other characteristics

Aligning patients with the most responsible family physician, thus encouraging continuity and comprehensiveness of care as well as appropriate screening and prevention activities Negation or loss of access bonuses for family physicians serving a rostered population, some of whose rostered members (patients) may seek health services outside of the roster Ability to hire other health professionals to provide capitated services

Capitation For every patient that is rostered, a specified $ amount for every male/ female in a specific age bracket The money is the same whether the patient is seen once or multiple times Incentives (Bonus) Incentives (sometimes called bonuses) are used for a variety of reasons, including: Achieving predetermined previously agreed targets, (e.g. the percentage of eligible patients) who have received certain preventative services

Pap smears, colorectal cancer screening, mammography, influenza immunizations or childhood immunizations Encouraging certain family practice services (obstetrical care or house calls) Ensuring the ongoing availability of primary healthcare for patients without access to family physicians, by encouraging existing family physicians to take on new patients, (e.g. provision of a "new patient " fee) Providing after-hours services Rural Northern Physician Group Agreement (RNPGA)

Serves rural and northern communities Complement of one to seven physicians. Physician or community governed Provide comprehensive primary health care services during regular & extended hours. Emergency services are provided 24/7 and patients have access to a nurse-staffed Telephone Health Advisory Service.

Additional healthcare providers if apply for Family Health Team funding (previous government funding available as well) Family Health Network (FHN) Minimum requirement of 5 doctors Compensation is a blended payment form: Capitation to a roster (Enrolled Patients) + Incentives + Fee-for-service paid for other services. Bonuses and incentives are paid for services such as preventive care, prenatal care and home visits for enrolled patients and for hospital visits obstetrical care and palliative care for all

patients. Have a nurse-staffed after hours telephone advisory service to provide primary care for their patients 24 hours a day, seven days a week. Family Health Group (FHG) Minimum requirement of 3 doctors Physicians are paid directly through Fee-forService (FFS) with additional comprehensive care incentives Family Health Groups offer regular office hours plus extra After Hours blocks of office time. FHG physicians are also on call to a ministry

funded Telephone Health Advisory Service (THAS) outside of regular office hours that takes phone calls from their enrolled patients. Comprehensive Care Model (CCM) Designed specifically for solo-practice physicians Fee-for-Service plus incentives These physicians offer comprehensive primary health care services to their enrolled patients Regular office hours plus one three hour block of after hours services per week

(evening or weekend). Family Health Organization (FHO) Harmonized Health Service Organization and Primary Care Network Agreements Capitation based on a defined basket of primary care services provided to enrolled patients Bonuses and premiums similar to FHN Bonuses and incentives for preventive care, prenatal care and home visits for enrolled patients and for hospital visits obstetrical care and palliative care for all patients. FHOs provide care during regular and extended office

hours (evenings/ weekends) Patients have access to a nurse staffed Telephone Health Advisory Service Through Institutional Substitution Program Grants, allied health professionals are part of some of the teams as well. Family Health Teams FHTs in Ontario Since April 2005, 170 teams have been created & will improve access to health care for more than 2.7 million Ontarians. FHTs in Ontario (solo or networked)

Physician governed Community governed Mixed governed In August 2010 - 30 more teams bringing the total number of Family Health Teams in Ontario to 200. Profile of FHTs Usually 3 - 25 family physicians Some large networked FHTs (up to 115 family physicians) Rostered populations Comprehensive care

Population-based care Governance of FHT defines funding model: Provider/ Mixed governance Capitation + Incentives Community governance Salaried Or capitation + incentives Supported by IT

Profile of FHTs Emphasize health promotion and illness prevention Based on chronic disease management Emphasize self-management Team based care Full range of administrative and clinical team members Linked with other community and health services transformation/fht/fht_guides.html


No set >5 >3 1 Roster patient No

Yes No Yes Yes Maybe Yes Yes Primary payment

FFS Cap or Salary Salary Cap +/- FFS FFS FFS

Cap Cap Incentive for preventative care No Yes Yes

Yes Yes Yes Yes Yes After hours care available (office)

No Yes Yes 3-5 x / wk 3-5x / 3h/ wk 3-5x / 1 5x / wk wk week

After hours No telephone access Yes Yes Yes Yes

No Yes Alternate HCPs involved No Yes Yes

Maybe No No Mayb Maybe e Focus on psychosocial/ at risk population

No Maybe Yes No No No No >3 17 Yes Maybe Primary health care reform Key feature of primary health care reform is

a shift to teams of providers Growing consensus that family physicians, nurses, and other professionals working as partners will result in better health, improved access to services, more efficient use of resources, and better satisfaction for both patients and providers. Team approach, along with telephone advice lines, facilitates access to primary health care services after-hours, reducing the need for costly emergency room visits. Technologies can support informationsharing among providers to improve coordination

The Shift Traditional Model Primary Health Care Treatment Health promotion Illness Health

Cure Prevention, care, cure Episodic care Continuous care Specific problems Comprehensive care

Individual practitioners Teams of practitioners Health sector alone Intersectoral collaboration Professional dominance Community participation Passive reception

Joint responsibility Dr. B. Starfield, Johns Hopkins University The future To address the challenges discussedthe primary health care system is evolving Pharmacists must evolve accordingly Primary Care Check-Up

So how is the Canadian primary care system doing when it comes to providing SAFE and EFFECTIVE medication management? Adverse Events: 14wks postdischarge Forster et al. CMAJ Feb 2004; 170(3): 345 Assessed 1017 random ER visits to VGH ER 68% of drug-related ER visits PREVENTABLE

12% of all visits caused by drugs 74.6% of drug-related visits of moderate severity Most common causes of drug-related visits: ADRs (39.3%) and non-adherence (27.9%) Preventable adverse drug events Are occurring in Canada It is important to consider new and innovative ways to identify, prevent or treat adverse events before a patient suffers a serious health issue Pharmacists practicing in primary care

settings are poised to impact outcomes in this way Pharmacists in Primary Health Care Lets consider where and how MOST pharmacists currently practice within the primary care / primary health care system Primary Care Roles

Community Pharmacists (Expanded roles) Medscheck Refill authorization Home Care or Pharmacists in the home Pharmacists in Ambulatory practices Pharmacists influencing prescribing RxFiles Academic Detailing

Pharmacists on Primary Healthcare Teams Family Health Teams, CHCs Primary Health Networks (SK, AB) Pharmacists prescribing (AB, MB, SK) MedsCheck Ontario Ministry of Meds Original MedsCheck program was launched on April 1, 2007. Patients taking > 3 medications for a chronic condition. One-on-one 30 minute annual

appointment with a pharmacist to review medications and help a patient better understand their medication therapy There is no cost to the patient. Medscheck Medscheck at home unable to get to community pharmacy in person because of physical and/or mental health condition and/or the distance Medscheck for diabetes - Newly diagnosed benefit from consultation with the pharmacist towards overall disease management (monitoring & education)

Medscheck for Long-term care - Quarterly medication reviews and an annual in-depth medication analysis. Promoting healthier patient outcomes and better residentfocused care Improving and optimizing drug therapy for residents Promoting interdisciplinary collaboration in patient care. Medscheck Community pharmacists bill OHIP for the services they provide Services are completed independently In some cases, suggestions/ plans for patient management must be done

collaboratively Changes to medication regimens including dose adjustments or changes Pharmaceutical Opinion Program Effective September 1, 2011, Stage 1 of expanded professional pharmacy service Pharmaceutical Opinion Program - in which a potential drug related problem is identified at the time of dispensing is The service is completed independently but some suggestions/ plans may require collaborative management

The pharmacy bills OHIP for the service Medication assessment Similar to the new Ontario government: Pharmaceutical opinion program, primary care pharmacists will do medication assessments. Assessments take 30 60 minutes and all medications/ therapies are reviewed for assessment & plan provided Pharmacists will be paid as part of their salaries in team environments. Limited number of consulting pharmacists

being paid out-of-pocket/ company J Am Pharm Assoc (Wash). 2002 Sep-Oct;42(5):735-42 Medication assessments for me Referrals come from other providers including MDs or patients self-refer Review is done in my office & my documentation goes into our EMR Some plans can be implemented immediately with the patient & others require me to discuss or review with MD If I think the patient needs to see someone else on the team, I make the referral at the time

Insert a medication assessment Refill regulations (Ontario) March 14, 2011, new regulations came into effect permitting pharmacists to refill existing prescriptions, with no additional refills, under specified conditions. Patient has been prescribed the drug for a chronic and long-term condition Patient has a stable history with that drug Reasonable efforts to contact the prescriber have been unsuccessful; and

Prescriber of the original prescription would likely have authorized the refill; Refill regulation Community pharmacists can bill OHIP for this service This can only be completed by pharmacists at an accredited pharmacy, so does not get billed by hospital or primary care pharmacists If a primary care pharmacist refills meds, it is done as part of their salaried role & by a medical directive/ delegation

Canadian Family PhysicianDecember Bill 179 (ONTARIO) December 15, 2009 Bill 179 received assention, OCP has the authority to draft regulations around the new scope of practice and authorized acts for pharmacists. Administer medications by injection or inhalation Perform a procedure below the dermis (lancing a finger or injection) Ordering laboratory tests for monitoring medications/ therapy

Bill 179 Supports expansion of roles into: Vaccination Currently in BC Injectable medication administration & education Currently in BC once certified Diabetes monitoring happening by medical directive in primary care teams across the country Laboratory monitoring happening in speciality clinics and primary care teams by medical directive currently Academic detailing "Academic detailing", or "educational outreach",

is the process of providing balanced, non-commercial, evidence based information/education for individual physicians in their offices. It is adopted from the pharmaceutical industry's practice of 'detailing' physicians about new drugs; however, with academic detailing, the sales agenda is removed. The concept was pioneered by Stephen Soumerai and Jerry Avorn in the USA. Academic detailing has been shown to be one of the most successful methods for influencing the prescribing practices of physicians.

RxFiles (Saskatchewan) An academic detailing program providing objective, comparative drug information to health professionals. Began in 1997 as a service to Saskatoon family physicians & expanded in 2000 to physicians throughout Saskatchewan. RxFiles Drug Comparison Charts book, beginning in 2001. This is an independent practice which impacts prescribing patterns but not specific patients.

Academic detailing is an independent practice which a pharmacist (or other) will present information to prescribers This service is funded by the government/ grants and the University. Pharmacists are salaried employees. Anticoagulation clinics Ambulatory clinics in hospitals (Sunnybrook Hospital) and pharmacist managed clinics in primary care (SETFHT, Toronto Western Hospital and Centre for Family Medicine Waterloo) In other provinces (Quebec) these can be run out of community pharmacies

Family practice providers manage majority of patients on warfarin (Coumadin) Anticoagulation clinics Clinics can be managed by a pharmacist by coordinating/ processing all labs that come in for patients or by using point-of-care technology to test the INR themselves LINK TO INR VIDEO Anticoagulation clinics

Payment for the pharmacist is through their salary from a hospital or family health team In Quebec, trained pharmacists (require additional course) can bill the government for this service This is done collaboratively through a medical directive/ delegation agreement with the collaborating providers Pain management/ clinics Pain management is an area receiving widespread press as a chronic disease not well managed

Pharmacists participate in speciality clinics or provide one-on-one counselling in a team environment Pharmacists are involved in teams in Hamilton, Guelph, Toronto and Saskatoon Pain Management/ Clinics Pain assessment & management always has to be collaborative due to the nature of medications used to treat pain Narcotics are federally legislated & as such, cannot be delegated/ directed by a physician for prescribing to another provider

These practices would be covered by the pharmacists salary. Pharmacists prescribing Alberta: Pharmacists who have been evaluated & granted additional prescribing privileges may initiate, modify, & extend (manage) drug therapy for acute & chronic conditions when

working interdependently or collaboratively Manitoba: :Passed the new Pharmaceutical Act (Bill 41) in December 2006, which would allow pharmacists to prescribe and administer drugs, order tests, and interpret patient-administered automated tests. (Regulations pending) Saskatchewan: Saskatchewan College of Pharmacists has submitted bylaw and regulation amendments to government for approval. They will allow interdependent pharmacist prescribing within collaborative practice environments. Level II Leverages advanced skills of some pharmacists within high functioning or more sophisticated interdisciplinary collaboration: oral contraception; lifestyle or health promotion; collaborative practice agreements; therapeutic substitution;

altering dosage and/or dosage regimen. Pharmacists prescribing This is done in a collaborative or interdependent environment Most pharmacists would be working within a team primary care or ambulatory clinic Pharmacists would prescribe and be paid as per their salary & not receiving additional billing/ incentive, as is seen in

physician prescribing. Considering the PHC movement in Ontario and Canada potential roles for pharmacists need creation / expanding? Over the next years we will see this happen! INSERT PHOTO FROM WORK The Care Team

The Patient Administrative/Clerical Team Care Navigator Chiropodist Family Doctor Family Medicine Residents Mental Health/Addictions Counsellor Nurse Practitioner Pharmacist Physician Assistant Registered Dietitian Registered Nurse Social Worker

Access to the right service by the right provider at the right time Special thanks to Kavita Mehta, Executive Director, South East Toronto Family Health Team Dr. John McDonald, Lead Physician, PrimaCare Community Family Health Team Derek Jorgenson, PharmD, University of Saskatchewan Who all contributed slides to this presentations


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