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  • Everyone connected with healthcare supports interoperability saying it improves care, reduces medical errors and lowers costs
  • But interoperability is a long way from reality and electronic patient records are only part of an answer
  • Could Blockchain a technology disrupting financial systems resolve interoperability in healthcare?
  • Blockchain is an open-source decentralized “accounting” platform that underpins crypto currencies
  • Blockchain does not require any central data hubs, which in healthcare have been shown to be easily breached
  • Blockchain technology creates a virtual digital ledger that could automatically record every interaction with patient data in a cryptographically verifiable manner
  • Some experts believe that Blockchain could improve diagnosis, enhance personalised therapies, and prevent highly prevalent devastating and costly diseases
  • Why aren’t healthcare leaders pursuing Blockchain with vigour?
 
Why Blockchain technology will not disrupt healthcare

Blockchain technology is disrupting financial systems by enhancing the reconciliation of global transactions and creating an immutable audit trail, which significantly enhances the ability to track information at lower costs, while protecting confidentiality. Could Blockchain do something similar for healthcare and resolve the challenges of interoperability by providing an inexpensive and enhanced means to immutably track, store, and protect a variety of patient data from multiple sources, while giving different levels of access to health professionals and the public?
 
Blockchain and crypto currencies

You might not have heard of Blockchain, but probably you have heard of bitcoin; an intangible or crypto currency, which was created in 2008 when a programmer called Satoshi Nakamoto (a pseudonym) described bitcoin’s design in a paper posted to a cryptography e-mail list. Then in early 2009 Nakamoto released Blockchain: an open source, global decentralized accounting ledger, which underpins bitcoin by executing and immutably recording transactions without the need of a middleman. Instead of a centrally managed database, copies of the cryptographic balance book are spread across a network and automatically updated as transactions take place. Bitcoin gave rise to other crypto-currencies. Crypto currencies only exist as transactions and balances recorded on a public ledger in the cloud, and verified by a distributed group of computers.
 
Broad support for interoperability
 
Just about everyone connected with healthcare - clinicians, providers, payers, patients and policy makers - support interoperability, suggesting data must flow rapidly, easily and flawlessly through healthcare ecosystems to reduce medical errors, improve diagnosis, enhance patient care, and lower costs. Despite such overwhelming support, interoperability is a long way from a reality. As a result, health providers spend too much time calling other providers about patient information, emailing images and records, and attempting to coordinate care efforts across disjointed and disconnected healthcare systems. This is a significant drain on valuable human resources, which could be more effectively spent with patients or used to remotely monitor patients’ conditions. Blockchain may provide a solution to challenges of interoperability in healthcare.
 
Electronic patient records do not resolve interoperability

A common misconception is that electronic patient records (EPR) resolve interoperability. They do not. EPRs were created to coordinate patient care inside healthcare settings by replacing paper records and filing cabinets. EPRs were not designed as open systems, which can easily collect, amalgamate and monitor a range of medical, genetic and personal information from multiple sources. To realize the full potential and promise of interoperability EPRs need to be easily accessible digitally, and in addition, have the capability to collect and manage remotely generated patient healthcare data as well as pharmacy and prescription information; family-health histories; genomic information and clinical-study data. To make this a reality existing data management conventions need to be significantly enhanced, and this is where Blockchain could help.

 

Blockchain will become a standard technology
 
Think of a bitcoin, or any other crypto currency, as a block capable of storing data. Each block can be subdivided countless times to create subsections. Thus, it is easy to see that a block may serve as a directory for a healthcare provider. Data recorded on a block can be public, but are encrypted and stored across a network. All data are immutable except for additions. Because of these and other capabilities, it seems reasonable to assume that Blockchain may become a standard technology over the next decade.
 
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The IoT and healthcare  

Future healthcare shock
Blockchain and healthcare

Because crypto currencies are unregulated and sometimes used for money laundering, they are perceived as “shadowy”. However, this should not be a reason for not considering Blockchain technology. 30 corporations, including J.P. Morgan and Microsoft, are uniting to develop decentralized computing networks based on Blockchain technology. Further crypto currencies are approaching the mainstream,  and within the financial sector, there is significant and growing interests in Blockchain technology to improve interoperability. Financial services and healthcare have similar interoperability challenges, but health providers appear reluctant to contemplate fundamental re-design of EPRs; despite the fact that there is a critical need for innovation as genomic data and personalized targeted therapies rise in significance and require advanced data management capabilities. Here are 2 brief examples, which describe how Blockchain is being used in financial services.
 
Blockchain’s use in financial services
 
In October 2017, the State Bank of India (SBI) announced its intention to implement Blockchain technology to improve the efficiency, transparency, security and confidentiality of its transactions while reducing costs. In November 2017, the SBI’s Blockchain partner, Primechain Technologies suggested that the key benefits of Blockchain for banks include, “Greatly improved security, reduced infrastructure cost, greater transparency, auditability and real-time automated settlements.”
 
Dubai, a global city in the United Arab Emirates, is preparing to introduce emCash as a crypto currency, and could become the world’s first Blockchain government by 2020. The changes Dubai is implementing eventually will lead to the end of traditional banking. Driving the transformation is Nasser Saidi, chief economists of the Dubai International Financial Centre, a former vice-governor of the Bank of Lebanon and a former economics and industry minister of that country. Saidi perceives the benefits of Blockchain to include the phasing out of costly traditional infrastructure services such as accounting and auditing.

 
Significant data challenges

Returning to healthcare, there are specific challenges facing interoperability, which include: (i) how to ensure patient records remain secure and are not lost or corrupted given that so many people are involved in the healthcare process for a single patient, and communication gaps and data-sharing issues are pervasive, and (ii) how can health providers effectively amalgamate and monitor genetic, clinical and personal data from a variety of sources, which are required to improve diagnosis, enhance treatments and reduce the burden of devastating and costly diseases. 
 
Vulnerability of patient data

Not only do EPRs fail to resolve these two basic challenges of interoperability they are vulnerable to cybercriminals. Recently there has been an epidemic of computer hackers stealing EPRs. In June 2016 a hacker claimed to have obtained more than 10m health records, and was alleged to be selling them on the dark web. Also in 2016 in the US there were hundreds of breaches involving millions of EPRs, which were reported to the Department of Health and Human Services. The hacking of 2 American health insurers alone, Anthem and Premera Blue Cross, affected some 90m EPRs.
 
In the UK, patient data and NHS England’s computers are no less secure. On 12 May 2017, a relatively unsophisticated ransomware called WannaCry, infected NHS computers and affected the health service’s ability to provide care to patients. In October 2017, the National Audit Office (NAO) published a report on the impact of WannaCry, which found that 19,500 medical appointments were cancelled, computers at 600 primary care offices were locked and five hospitals had to divert ambulances elsewhere. Amyas Morse, head of the NAO suggests that, “The NHS needs to get their act together to ensure the NHS is better protected against future attacks.”

 
Healthcare legacy systems
 
Despite the potential benefits of Blockchain to healthcare, providers have not worked out fully how to move on from their legacy systems and employ innovative digital technologies with sufficient vigour to effectively enhance the overall quality of care while reducing costs. Instead they tinker at the edges of technologies, and fail to learn from best practices in adjacent industries.  
 
“Doctors and the medical community are the biggest deterrent for change”
 
Devi Shetty, heart surgeon, founder, and Chairperson of Narayana Health articulates this failure“Doctors and the medical community are the biggest deterrent for the penetration of innovative IT systems in healthcare to improve patient care . . . IT has penetrated every industry in the world with the exception of healthcare. The only IT in patient care is software built into medical devices, which doctors can’t stop. Elsewhere there is a dearth of innovative IT systems to enhance care,” see video. Notwithstanding, Shetty believes that, “The future of healthcare is not going to be an extension of the past. The next big thing in healthcare is not going to be a new drug, a new medical device or a new operation. It is going to be IT.”
 
 
Google, Blockchain and healthcare
 
Previous HealthPad Commentaries have suggested that the failure of healthcare providers to fully embrace innovative technologies, especially those associated with patient data, has created an opportunity for giant technology companies to enter the healthcare sector, which shall dis-intermediate healthcare professionals.

In May 2017, Google announced that its AI-powered subsidiary, DeepMind Health, intends to develop the “Verifiable Data Audit”, which uses Blockchain technology to create a digital ledger, which automatically records every interaction with patient data in a cryptographically verifiable manner. This is expected to significantly reduce medical errors since any change or access to the patient data is visible, and both healthcare providers and patients would be able to securely track personal health records in real-time.

 
Takeaways

Blockchain is a new innovative and powerful technology that could play a significant role in overcoming the challenges of interoperability in healthcare, which would significantly help to enhance the quality of care, improve diagnosis, reduce costs and prevent devastating diseases. However, even if Blockchain were the perfect technological solution, which enabled interoperability, change would not happen in the short term. As Max Planck said, “A new scientific innovation does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.” While we wait for those who control our healthcare systems to die, billions of people will continue to suffer from preventable lifetime diseases, healthcare costs will escalate, healthcare systems will go bankrupt, and productivity in the general economy will fall.
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  • Over the next decade the combination of big data, analytics and the Internet of Things (IoT) will radically change healthcare
  • The social media revolution has raised peoples’ awareness of lifestyles and healthcare
  • The rise of smart watches and fitness sensors combined with IOT and Artificial Intelligence (AI) paves the way for preventative medicine becoming a key driver in the management of straining healthcare services and spending
  • Big data, analytics and the IoT is positioned to accelerate change away from output-orientated healthcare systems to value-based outcome-orientated systems
  • Patients and payers are increasingly aware of the opportunities and demanding change
  • The slowness for MedTech companies to change creates opportunities for newcomers to penetrate and grab share of healthcare markets
  • Regulation and requirements to undergo significant clinical studies to become standard of care will slow consumer and patient access to services
  
The IoT and healthcare
 
The Internet of Things (IoT) is positioned to radically transform healthcare. There are powerful social, demographic, technological, and economic drivers of this change. We describe some of these, and suggest that, within the next 10 years, there will be hundreds of millions of networked medical devices sharing data and knowhow, and this will drive a significant shift away from traditional healthcare systems focused on outputs to value-based systems dedicated to prevention and improving outcomes while lowering costs.
 

The IoT and its potential impact on healthcare
 
The IoT, which Cisco refers to as “the Internet of Everything” and GE as the “Industrial Internet” is also referred to as “machine-to-machine” (M2M) technologies, and as “smart sensors”. Whatever term is used, the IoT is an ever-expanding universe of devices embedded with microchips, sensors, and wireless communications capabilities, which enable them to collect, store, send and receive data. These smart devices and the data they collect are interconnected via the Internet, which significantly expands their potential uses and value. The IoT enables connectivity from anywhere to anywhere at any time, and facilitates the accumulation of big data and artificial intelligence (AI) to either complement or replace the human decision-maker. Over the next decade, anything that can be connected to the Internet probably will be. The Internet provides an almost ubiquitous, high-speed network, and cloud-based analytics, which, in nanoseconds, can read, analyse and act upon terabytes of aggregated medical data. Smart distributed services are positioned to become a powerful tool for health providers by optimizing medical results, preventing mistakes, relieving overburdened health professionals, improving patient outcomes, and lowering costs.
 
Two approaches to a common healthcare challenge

Let us illustrate the shift in healthcare referred to above by considering two different approaches to a shared healthcare challenge: that of providing people with personalized advice about maintaining and improving their wellbeing in order to ward-off lifestyle related illnesses, such as type 2 diabetes (T2DM). This is important because T2DM is a devastating lifestyle induced condition, which affects millions, costs billions, and in most cases can be prevented by lifestyle changes.
 
Approach 1

One approach is the world’s first nationwide diabetes prevention program, Healthier You, which was launched by NHS England, Public Health England and Diabetes UK in 2016. It is aimed at the 11m people in England thought to have pre-diabetes, which is where blood sugar levels are higher than normal, but not high enough for a diagnosis of T2DM. About 5-10% of people with pre-diabetes progress to "full-blown" T2DM in any given year. Healthier You is expected to be fully operational by 2020. Each year thereafter the program is expected to recruit 100,000 people at risk of T2DM. Personal lifestyle coaches will periodically monitor the blood sugar levels of these, and make recommendations about their diets and lifestyles. This is expected to prevent or slow the people with pre-diabetes progressing to full-blown T2DM.
 
Approach 2

The second approach is GymKit and Chatbox. The former is a new feature Apple is expected to add to its watch in late 2017, and the latter is a mobile app developed by Equinox, a New York-based health club chain, for its members.

Gymkit will enable the Apple watch to have seamless connectivity to the overwhelming majority of different kinds of cardiovascular equipment used in most fitness centres. Currently, there are a variety of smartphone apps, which allow gym users to connect to cardiovascular machines, but these are at best patchy. Gymkit is different, and will automatically adjust a user’s personalized needs to any cardiovascular machine without the user having to press a button. Itwill then wirelessly collect a range of data - if on a treadmill: speed, duration, incline, etc., - and combine these data with the user’s heart rate, age, gender, weight and body type to make health-related calculations and recommendations, and wirelessly transmit these to the user.

Chatbox does something similar. Ituses artificial intelligence (AI) to simulate the human voice, which talks to new health club members, encourages them to set personal goals, and sends them messages when they fall short. Further, Chatbox has sensors, which track users while they are in the gym, and suggests ways of improving and extending their personalized workouts. A survey, undertaken by Equinox of its members across 88 of its facilities reported that Chatbox users visited the fitness centres 40% more often than those without the app. This is significant because people who fail to form a habit of physical exercise tend to drop lifestyle goals.

The 2 approaches compared

Healthier You is unlikely to have more than a modest impact on the UK’s diabetes burden because the format it has adopted is like filling a swimming pool with a teaspoon. It would take over 100 years to recruit and counsel the 11m people with pre-diabetes, especially while the prevalence levels of pre-diabetes and T2DM in the UK are increasing.  Successfully changing the diets and lifestyles of large numbers of people requires an understanding of 21st century technologies. Ubiquitous healthcare technologies such as smartphone apps and wearable’s that support lifestyles abound, and have leveraged people's enhanced awareness of themselves and their health. Hence peoples’ large and rapidly growing demands for such devices to track their weight, blood pressure, daily exercise, diet etc. From apps to wearables, healthcare technology lets people feel in control of their health, while potentially providing health professionals with more patient data than ever before.  

The IoT and consumers

There are more than 165,000 healthcare apps currently on the market, there is a rapid growth in wearables, and smartphone penetration in the US and UK has surpassed 80% and 75% respectively. According to a 2017 US survey by Anthem Blue Cross, 70m people in the US use wearable health monitoring devices, 52% of smartphone users gather health information using mobile apps, and 93% of doctors believe mobile apps can improve health. 86% of doctors say wearables increase patient engagement with their own health, and 88% of doctors want patients to monitor their health. 51% of doctors use electronic access to clinical information from other doctors, and 91% of hospitals in the US have moved to electronic patient records (EPR).
 
Notwithstanding, these apps and wearables are rarely configured to aggregate, export and share the data they collect in order to improve outcomes and lower costs. This reduces their utility and value. However, the large and rapid growth of this market on the back of the social media revolution, and the impact it is having on shaping the attitudes and expectations of millions of consumers of healthcare, positions it well as a potential driver of significant change.

 A “minuscule fraction” of what is ultimately possible

According to Roger Kornberg, Professor of Structural Biology at Stanford University, the current capabilities of smart sensors like those used in Apple’sGymKit and Equinox’s Chatbox, “is only a minuscule fraction of what is ultimately possible . . . A sensor attached to a smartphone will enable it to answer any question that we may have about ourselves, and our environment,” says Kornberg. Smart sensors can provide you with a doctor in your pocket, which can be connected to a plethora of other devices that could collect, store, analyze and feedback terabytes of medical information in real time. Kornberg, who won the 2006 Nobel Prize for Chemistry, is excited about the disruptive effect, which smart sensors are having on traditional healthcare systems. This is because they can be connected to almost any medical device and human organ to, “monitor specimens . . . record in real time the health status of individuals,  . . . transmitelectronic signals wirelessly,  . . .  (and) provide responses to any treatment,” says Kornberg. 

Kornberg is engaged in developing sensors with the ability to detect and measure biological signals and data from humans, which can be wirelessly linked to smartphones to transmit the information for analysis, storage and further communication. Kornberg is convinced that, in the near term, we will be able to create a simple and affordable networked device that will, “detectan impending heart attack, in a precise and quantitative manner, before any symptoms”.
 


Potential of sensor technology



The excitement in the development of biosensors

 
Drivers of the IoT and market trends

Partly driving the IoT in healthcare and other industries are the: (i) general availability of affordable broadband Internet, (ii) almost ubiquitous smartphone penetration, (iii) increases in computer processing power, (iv) enhanced networking capabilities, (v) miniaturization, especially of computer chips and cameras, (vi) the digitalization of data, (vii) growth of big data repositories, and (viii) advances in AI and data mining.
 
Market trends suggest substantial growth in the total number of networked smart devices in use. By 2020, when the world’s population is expected to reach 7.6bn, it is projected that there will be between 19 and 50bn IoT-connected devices worldwide, more than 8bn broadband access points, more than 4m IoT jobs, and the number of installed IoT technologies will exceed that of personal computers by a factor of 10.
 
Crisis in primary care is a significant driver of change
 
In addition to these technological drivers, the simultaneous population aging and the shrinking pool of doctors also drives the IoT in healthcare. Increasing numbers of older people presenting with complex comorbidities significantly increases the large and rapidly growing demands on an over-stretched, shrinking population of doctors. This results in a crisis of care.
 
A 2015 Report from the Association of American Medical Colleges (AAMC) suggests that there is an 11 to 17% growth in total healthcare demand, of which a growing and aging population is a significant component. Further, the Report suggests that the US could lose 100,000 doctors by 2025, and that primary care physicians will account for 33% of that shortage.

There is a similar crisis in the UK, where trainee GPs are dwindling, young GPs are moving abroad, and experienced GPs are retiring early. According to data from the UK’s General Medical Council (GMC), between 2008 and 2014 an average of nearly 3,000 certificates were issued annually to enable British doctors to work abroad. Currently, there are hundreds of vacancies for GP trainees. Findings from a 2015 British Medical Association (BMA) poll of over 15,000 GPs, found that 34% of respondents plan to retire by 2020 because of high stress levels, unmanageable workloads, and too little time with patients.
 
Interestingly, Brexit is expected to compound the crisis of care in the UK. According to a 2017 General Medical Council survey of more than 2,000 doctors from the EU working in the UK, 60% said they were considering leaving the UK, and, of those, 91% said the UK’s decision to leave the EU was a factor in their considerations. 

 
Changing healthcare ecosystems

These trends help healthcare payers to employ IoT strategies in an attempt to replace traditional healthcare systems, which act when illnesses occur and report services rendered, with value-based healthcare systems focused on outcomes. US payers are leading this transformation. Some payers in the US have employed IoT strategies to convert a number of devices used in various therapeutic pathways into smart devices that collect, aggregate and process terabytes of healthcare data gathered from thousands of healthcare providers, and electronic patient records (EPRs) describing millions of treatments doctors have prescribed to people presenting similar symptoms and disease states. Cognitive computing systems analyse these data and instantaneously identify patterns that doctors cannot. Such systems, although proprietary, are positioned to help reduce the ongoing challenges of inaccurate, late, and delayed diagnoses, which each year cost the US economy some US$750bn and lead to between 40,000 and 80,000 patient deaths.
 
IBM Watson
 
IBM’s supercomputer, Watson is a well-known proprietary system that uses IoT strategies that include a network of smart sensors and databases to assist doctors in various aspects of diagnoses and treatment plans tailored to patients’ individual symptoms, genetics, and medical histories. Watson draws from 600,000 medical evidence reports, 1.5m EPRs, millions of clinical trials, and 2m pages of text from medical journals. A variant, IBM Watson for Oncology, has been designed specifically to help oncologists, and is currently in use at the Memorial Sloan-Kettering Cancer Center in New York. Also, it is being used in India where there is a shortage of oncologists. The Manipal Hospital Group, India’s third largest healthcare group, which manages about 5,000 beds, and provides comprehensive care to around 2m patients every year, is using Watson for Oncology to support diagnosis and treatment for more than 200,000 cancer patients each year across 16 of its hospitals.
 
In 2016 IBM, made a US$3bn investment designed to increase the alignment of its Watson super cognitive computing with the IoT, and allocated more than US$200m to its global Watson IoT headquarters in Munich. IBM will have over 1,000 Munich-based researchers, engineers, developers and business experts working closely with specific industries, including healthcare, to draw insights from billions of sensors embedded in medical devices, hospital beds, health clinics, wearables and apps in endeavors to develop IoT healthcare solutions.
 
Babylon
 
Using a similar IoT network of smart sensors and databases, Babylon, a UK-based subscription health service start-up, has launched a digital healthcare AI-based app, which offers patients video and text-based consultations with doctors, and is designed to improve medical diagnoses and treatments. Early in 2017, NHS England started a 6-month study to test the app’s efficacy by making it available to 1.2m London residents. The Babylon app is expected to be able to analyse, “hundreds of millions of combinations of symptoms” in real time, while taking into account individualized information of a patient’s genetics, environment, behavior, and biology. Current regulations do not allow the Babylon app to make formal diagnoses, so it is employed to assist doctors by recommending diagnoses and treatment options. Notwithstanding, Ali Parsa, Babylon’s founder and CEO says, "Our scientists have little doubt that our AI will soon diagnose and predict personal health better than doctors”.
 
Market forecasts

Market studies stress the vast and growing economic impact of the IoT on healthcare. Business Insider Intelligence (BII) suggested that the IoT has created nearly US$100bn additional revenue in medical devices alone. It forecasts that cost savings and productivity gains generated through the IoT and subsequent changes will create between US$1.1 and US$2.5trillion in value in the healthcare sector by 2025. In 2016, Grand View Research Inc. projected that the global IoT healthcare market will reach nearly US$410bn by 2022. A 2013 Report from the McKinsey Global Institute on Disruptive Technologies, suggests that the potential total economic impact of IoT will be between US$3 and US$6trillion per year by 2025, the largest of which will be felt in healthcare and manufacturing sectors. Although forecasts differ, there is general agreement that, over the next decade, the IoT is projected to provide substantial economic and healthcare benefits in the way of cost savings, improved outcomes, and efficiency improvements.
  
IoT and MedTech companies

We have briefly described the impact of the IoT on patients, healthcare payers and providers. But what about MedTech companies? They have the capabilities and knowhow to develop and integrate the IoT into their next generation devices. However, MedTech innovations tend to be small improvements to existing product offerings. Data, accumulated from numerous smart medical devices, are enhanced in value once they are merged, aggregated, analyzed and communicated. And herein lies the challenge of data security. Arguably the greater the connectivity between medical devices, the greater the security threat. In 2013 the FDA issued a safety communication regarding cyber security for medical devices and health providers, and recommended that MedTech companies determine appropriate safeguards to reduce the risk of device failure due to cyber-attacks. The cautious modus vivendi of most MedTech companies suggests that, in the near term, a significant proportion will not develop IoT strategies, and this creates a gap in the market.
 
The IoT and new and rising healthcare players

Taking advantage of this market gap is a relatively small group of data-orientated companies, which have started to employ IoT technologies to gain access to healthcare markets by developing specific product offerings, increasing collaborative R&D, and acquiring new data oriented start-ups. For instance, in addition to IBM and Apple mentioned above, Amazon is expected to enter the global pharmaceutical market, which is anticipated to reach over US$1 trillion by 2022. Microsoft has used IoT strategies to build its Microsoft Azure cloud platform to facilitate cloud-based delivery of multiple healthcare services. Google Genomics is using IoT strategies to assist the life science community organise the world’s genomic data and make it accessible by applying the same technologies that power Google Search to securely store petabytes of genomic information, which can be analysed, and shared by life science researchers throughout the world.

Takeaways
 
The powerful social, demographic, technological and economic drivers of healthcare change over the next decade suggest an increasing influence of IoT technologies in a sector not known for radical or innovative change. Research suggests that hundreds of millions of networked medical devices will proliferate globally within the next decade. The potential healthcare benefits to be derived from these are expected to be significant, especially through enhancing preventative and outcome-oriented healthcare while reducing costs. This has to be achieved in a highly regulated environment where concerns of data security are paramount. To reap the potential benefits of the IoT in healthcare, policymakers will have to reconcile the need for IoT regulation with the significant projected benefits of the IoT. Smart technologies require smart management and smart regulation.
 
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