The Toyota Effect: Improving Healthcare Delivery

UnknownWhen you think of Toyota auto manufacturing, you might not think of healthcare. But in the new short film series, The Toyota Effect, one of these short films does. And the results are impressive.

The first film, Saving Sight, by academy award-nominee Keif Davidson, features the intervention of the Toyota Production System (TPS) with the struggling Harbor-UCLA Medical Center’s eye clinic, which treats the underserved patient community in Southern California. In a moving story, a patient, Liseth, is featured. She is nearly blind and in need of immediate eye surgery. However, she is on a wait list for  surgery along with hundreds of other patients who are forced to wait months for treatment. Many go blind in the process.

Harbor-UCLA Medical Center reached out to Toyota for help. They didn’t know what was wrong with their operations but understood that working in chaos had stretched their hospital staff beyond capacity.

With the help of Toyota, Harbor-UCLA was able to streamline the efficiency of their operating system and enlist the support of hospital employees as problem solvers. With simple steps such as color-coding their system, they are now treating patients with urgent needs more quickly. Liseth had her eye surgery and has recovered her sight. The hospital’s wait list has now been eliminated.

The second film of The Toyota Effect, entitled 116 Innovators by award-winning director Steve James, is about the Chicago company, ACE Metal Crafts, a U.S. steel manufacturing company that grew so quickly that its capacity was completely outpaced by growth. The CEO of the company, Jean Pitzo, reached out to Toyota for help. With the assistance of TPS, chaos was quickly replaced by employees working in collaboration. Production time was shortened by several weeks. ACE Metal Crafts was able to satisfy more customers and become more competative in the marketplace.

In the film, Pitzo explained that TPS taught her that the leaders of a company disrespect their employees when the system isn’t flowing efficiently. In partnership with TPS, Pitzo and her staff streamlined the operations, thereby increasing employee satisfaction and motivation.

Imagine if Toyota Production System were to partner with our major hospitals in the U.S. to streamline their operations and to help their doctors and nurses feel more valued and respected.

Initially, clinicians and hospital administrators might be apprehensive about TPS intervening. They might be hesitant to welcome a large company to come in and identify problems and offer solutions. But if you consider the 210,000-440,000 people who die from preventable medical errors every year, maybe it’s time they consider some outside help.

Staff from TPS reports a commitment to zero job loss for employees of organizations they work with. They claim to focus on people, on supporting them in their jobs. As a result, employees experience increased personal investment in their work.

According to a 2011 American Nurses Association survey, three out of four nurses reported feeling stressed and burned out. The ANA attributed problems of fatigue and burnout to a chronic nursing shortage.

46 percent of physicians reported feeling burnout, according to a Medscape Physician Lifestyle report.

Imagine if TPS were to work with hospitals with the highest rates of burnout among their clinicians and employ their successful strategies. Isn’t it possible that we’d have fewer preventable medical errors? If employees were trained to work together in teams, to collaborate with one another, and even to contribute ideas to solve problems, isn’t it possible that quality of care and patient safety would be greatly improved?

According to the World Health Organization, effective teamwork in healthcare can have an immediate and positive impact on patient safety.

Because TPS is a process-oriented approach, it can be applied to any hospital or healthcare organization. This approach involves taking an objective view of the internal process of an organization, analyzing workflow, and implementing small steps to fix deep, underlying problems.

Preventable medical errors are tragic examples of our dysfunctional healthcare system. The U.S. healthcare system is rated 37th in the world, and that’s behind Costa Rica and Slovenia. Healthcare spending hit 3.1 trillion in 2014. According to the CommonWealth Fund, U.S. healthcare is the most expensive in the world and yet underperforms relative to other countries on most dimensions of performance.

Maybe it’s time we look to Toyota Production System and ask for help with developing a “lean” healthcare system in the U.S.

To view The Toyota Effect short films see here.

I welcome your comments.


Diagnostic Errors: new IOM report emphasizes patients’ collaboration with doctors

If you weren’t aware of the prevalence and severity of diagnostic errors, (misdiagnosis, missed diagnosis, delayed diagnosis) you might be now.

The Institute of Medicine (IOM ) released a new report called, Improving Diagnosis in Health Care. The report cited that most people will experience one or more diagnostic errors over their lifetimes. It also revealed that diagnostic errors contribute to 10 percent of patient deaths and account for up to 17 percent of hospital adverse events. But because of a scarcity of reporting and research on diagnostic errors, those numbers might be very conservative.

According to Mark Graber, MD, president of The Society to Improve Diagnosis in Medicine, diagnosis is wrong 10-15 percent of the time.

It happened to me. 10 times to be exact. During a 16-month long, severe chronic pain condition, I received 10 misdiagnoses from 11 physicians with different specializations. Along with the 10 misdiagnoses came 15 procedures and tests. Luckily, I found my own diagnosis in a New York Times article, In Women, Hernias May Be Hidden Agony

The surgeon and hernia specialist featured in the article, Shirin Towfigh, MD, diagnosed me correctly. She performed 3-hour surgery to repair a muscle tear in my C-section site and an inguinal hernia with a nerve pinched in the hole. I’ve been pain free for over 4 years and I am very grateful to her.

Some aren’t so lucky. Take Rory Staunton who was misdiagnosed in the ER with an upset stomach and dehydration. He died from severe septic shock brought on by a bacterial infection. There are countless others whose cancer or heart attacks were completely missed or misdiagnosed as innocuous ailments.

Arriving at a diagnosis can be an allusive process, not always easily uncovered through physical exams or tests. What contributes to misdiagnoses or missed diagnoses? See the Society to Improve Diagnosis website for causes.

The IOM report produced a number of recommendations for clinicians and insurers to improve diagnosis. It also emphasized patient and family collaboration with doctors. Since patients and their loved ones are such an important part of the diagnostic process, it’s essential that you know what you can do to help improve your chances of receiving an accurate diagnosis.

Here is where you come in.

As a patient, you are in partnership with your doctor. To be an effective team player you need to be an active participant in your care, not simply a passive recipient. If you aren’t feeling well enough to be proactive and form a mutual collaboration with your doctor, ask a loved one to assist. For more information on how to do this, please see my book, The Take-Charge Patient.

Free Patient’s Toolkit see here You do not have to input any personal information for the free download.

Tips to Help Ensure an Accurate Diagnosis

Symptom Diary

  • Before you see your doctor, create a symptom diary. Document your symptoms in a notebook, on your smart phone or other electronic device. Answer these questions:
  • What are your symptoms?
  • Where are they located?
  • What makes your symptoms worse or better, such as exercise or eating a meal?
  • Time of day your symptoms are better or worse?
  • What you have tried to alleviate your symptoms? Did they help or not?
  • If pain accompanies your symptoms or pain is the symptom, track it. On a scale of 1-10, 10 being the worst, document it every day.
  • Bring your symptom diary with you to see your doctor and enter into a dialogue with him/her.

List of Questions Before You See Your Doctor

Create a list of questions before you see your doctor. This allows you to think about what you need to focus on. Document the answers and pieces of the conversation you believe are important.

You Are Given a New Diagnosis

If you are given a new diagnosis from your doctor, consider asking these questions:

  • What is my diagnosis and what does it mean?
  • Are there any other possible diagnoses for my symptoms?
  • How did you arrive at this diagnosis? I.e.: test results, physical exam, radiology report, etc.
  • What is my treatment plan?
  • When do I follow up with you about my treatment plan?

If You Suspect a Misdiagnosis

If your treatment is not helping your symptoms, discuss it with your doctor. It’s possible that there is an alternative treatment that might work better for you.

  • Ask your doctor if it’s possible that you might have a different diagnosis.
  • Work with your doctor.

Ask That Tests Be Repeated or Read by a Different Clinician

Tests can be wrong or they can be read incorrectly. Ask that tests be done a second time or read by another doctor. Many doctors read reports given to them by radiologists regarding any imaging studies you’ve had. Ask that your doctor or another doctor read those tests.

Get Copies of your Medical Records

Obtain copies of your pertinent tests such as MRI, CT scan, X-ray, blood test results, surgery/op report. You should have all of these anyway in a health file at home, but if you don’t, simply make the request. You might have to sign a form or pay a small fee. Bring your own copies of tests to each new doctor you see.

Get a A Second Opinion

Patients are sometimes afraid to get second opinions. Please don’t be. It is your right and should not offend any medical professional.

  • Ask a doctor you respect and have confidence in to recommend a specialist.
  • Ask an RN or other healthcare professional for a recommendation.
  • Ask/email your loved ones, colleagues and any physicians you know for a respected physician to see for a second opinion. You will see some of the same names recommended.

Every Time You See a New Doctor

Bring all the items listed above with you to each and every medical appointment with a new doctor. Take notes while you’re there.

Bring a Loved One with You

It’s not easy for anyone to hear, much less remember correctly, what a doctor says. Especially if you aren’t feeling well. Bring a loved one with you to each appointment with a doctor. Ask that person to take notes. You can review the information with that person at a later time.

Research a Diagnosis

If you are informed about your diagnosis, you will be better prepared to ask questions. To research a diagnosis go to credible websites such as:

  • medical school websites.
  • medical society or academy websites.
  • disease organization websites.
  • government websites.

Googling symptoms and diagnoses can easily lead you to inaccurate information and scary stories.

My Patient’s Toolkit is here. Free download. You don’t have to input your email address or contact information. It is free to you to use at your leisure.

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By |October 7th, 2015|Categories: Current Health Topics|0 Comments

Patients Secretly Record Visits With Their Doctors

Recently, I accompanied my husband to an office visit with his orthopedic surgeon. Jamie had been experiencing set backs in his recovery from major surgery. I went with him because it can be pretty hard to distill medical information on the spot, much less remember it. I wanted to document what the surgeon said so I could research it later. The more information Jamie had, the more of an informed choice he could make about his treatment options. My husband was in pain, something that interferes with recall even in the best of situations. I hoped that if I were with him, it might also help him feel more at ease.

Since I suspected this office visit might contain some complicated and possibly stressful information, I considered recording what the surgeon said by using an app on my iPhone. I envisioned asking the doctor’s permission to record the conversation and decided against it because he might not have responded well to that idea. Some physicians and other providers react with suspicion and a defensive medicine posture when asked by patients to record what they’ve said.

My husband’s surgeon had a reputation for highly successful surgeries but not the greatest bedside manner. He’d always been pleasant with us, but since my husband’s recovery had been compromised with episodes of pain, I decided that an audio device could have instigated alarm. That would have interfered with the doctor’s focus on Jamie. With only 7-10 minutes, we had to make the most of this office visit. I wanted my husband out of pain.

In place of an audio recording, I took notes instead.

Healthcare professionals are well aware that patients experience anxiety in their exam rooms. It’s called white coat syndrome or white coat hypertension. Anxiety interferes with cognitive function, especially memory, making it difficult not only to process medical information, but to remember it. Besides, medical information can be complex. It’s hard to understand, especially in a foreign and uncomfortable medical environment such as a doctor’s office.

40-80 percent of medical information conveyed by healthcare practitioners is forgotten immediately by patients. Half of information retained by patients is incorrect. That’s such a small percentage that you’d think doctors would be handing out their own recordings to patients for every office or hospital visit. It might actually help with discharge planning from hospitals.

In theory, it should be perfectly acceptable for patients to record conversations with their medical providers. It’s a known fact that physicians are plagued by lack of follow through with treatment advice. What might be interfering with treatment adherence for patients is overwhelm or information overload. Others might be challenged with hearing impairment or low health literacy levels.

How many times have you visited a doctor and left the office only to forget some of what the doctor explained and told you to do next? I know I have.

But recording brings up fear of medical malpractice lawsuits for some physicians, even if permission is requested ahead of time. According to American Medical News, recording of the visit between doctor and patient could “exacerbate physicians’ temptation to practice defensive medicine.”

It’s hard for me to imagine that patients wouldn’t ask permission to record what their doctors tell them. But according to the KPCC article, When is it OK to record your doctor’s orders? patients are in fact secretly recording conversations with their doctors without asking permission first.

Talk about a blow to the patient-provider relationship.

Why not just ask a physician or other provider if it’s okay to record the conversation? All you have to do is explain that it’s hard to digest medical information as well as remember treatment instructions and you want to refer to the information so you get it right. Why record in secret?

To secretly record an office visit is a violation of trust. In California, the law specifies that both parties have to be aware that a recording is in place. Doctors are already afraid of being sued. Why would any patient surreptitiously tamper with the relationship with his/her doctor, something that is considered the cornerstone of quality care? Just ask the question. If permission to record is denied, you can either take notes or find another doctor.

In my most recent book, The Take-Charge Patient, I emphasize the importance of documenting the information your doctor gives you because it’s just too easy to misunderstand, forget, or walk out of the office without all your questions answered. It’s helpful if a doctor or other provider has a patient portal with access to notes and records, but that doesn’t take the place of your own documentation.

Tips to Remember What the Doctor Tells You

  • Prepare questions for your doctor ahead of time. This allows you to think about what you want out of the office visit.
  • Document the answers in a notebook, on your smart phone or other device. You will be able to reference instructions and explanations later when you are in a more relaxed environment.
  • Bring a loved one with you to take notes for you.
  • Some physicians and other providers offer a summary of your office visit. Ask if your provider offers this. But in addition, take your own notes.
  • Ask for a copy of tests performed by the doctor or imaging center at the time of service.


There are many more tips for patients’ visits with medical providers. I offer a free and no obligation Patient Toolkit on my website


By |October 7th, 2015|Categories: Current Health Topics|Tags: , , |0 Comments

Rapid Increase of Cyber Attacks on Patients’ Medical Records: 8 tips to protect your data

Your personal health information in your medical records might be scattered across a few doctor’s offices, a clinic or two, or even a hospital. Your health insurer certainly stores some important personal information about you. If you’re like me, you’ve changed health insurers a couple of times since the advent of the Affordable Care Act. This means that more than one health insurance company has your social security number, home address, phone number, email address, name of employer, list of diagnoses and possible medications. Just enough for a cyber criminal to snap it up in a few seconds and then monetize and sell your private information on the black market.

I don’t hear many talking about this. Few seem to be concerned even though major news media have been sounding the alarm for a couple of years.

Maybe it’s time to listen up.

There has been a sharp increase in cyber attacks and security breaches in healthcare organizations, exposing millions of patients and their medical records. According to a new Ponemon Institute study in May of 2015  criminal attacks on hospitals, clinics, healthcare providers and health insurers are up 125 percent since 2010. The study also revealed that most healthcare organizations are still unprepared to protect patient data. Nearly 90 percent of healthcare providers were breached in the last two years.

Why would cyber hackers want information in your medical records?

Cyber criminals are after your medical records because your personal information is all in one place and unlike credit card numbers, cannot be easily changed. Poached from your medical records are social security numbers, birthdates, medical IDs, addresses, and personal health information. This is a gold mine for criminals who retrieve your information and use it for their benefit, and at your risk.

I’m sure you’ve heard about the recent cyber breach at UCLA Health Systems. Hackers broke into the network and may have accessed personal patient information from 4.5 million patients’ medical records. 

My physician’s practice was bought by UCLA a while back, so this could directly affect me. Maybe you too.

This comes on the heels of the major cyber breach into Anthem, Inc., which affected 80 million Americans.  Anthem is the 2nd largest health insurer in the U.S.

Last year alone, health records on 88.4 million people were breached as a result of theft or hacking. Data that was exposed were names, birthdays, medical IDs, social security numbers, street addresses, email addresses, employment information and income data.

UCLA and Anthem are only two of the major organizations whose networks were hacked for all kinds of valuable information for cyber criminals to sell on the black market. The list includes Premera Blue Cross, Community Health Systems, The U.S. Postal Service, The U.S. Government Office of Personal Management, Sony, Staples, Kmart, Home Depot, JP Morgan, and many more.

With the onset of electronic medical records (EMR), healthcare organizations are particularly vulnerable. Their security is often less sophisticated than other organizations.

Reuters reported, “Your medical information is worth 10 times more than your credit card number on the black market.” 

Fraudsters use your personal data from medical records to create fake IDs, take out loans, open up lines of credit, and buy medical equipment or drugs that can be resold. They can also combine patient numbers with false medical provider numbers and file false claims with health insurers.

These criminals can also impersonate you to obtain health services.

After the Blue Cross cyber security breach, one patient discovered that his medical records were compromised after he started receiving bills for a heart procedure he never had. In addition, his personal info from his medical records was used to buy expensive medical equipment which incurred thousands of dollars in fraud.

“All healthcare organizations, regardless of size, are at risk for data breach,” revealed the Ponemon Institute study.

It’s time to wake up.

Unlike stolen credit cards, which can be easily detected and cancelled, if your personal medical information is stolen from your medical records, it might not be detected for years. Your medical records could be compromised with diagnoses that don’t belong to you, wrong blood types, and other errors. This could be serious if you have an urgent medical situation.

Note: If you are a caregiver for a patient, it is very important to be vigilant for him/her too, especially if the patient is elderly. 

Tips to Protect Yourself (or a patient you care for)

1. Ask your doctor or hospital about the security of their electronic medical records.

2. Request copies of your medical records and review them for errors.

3. Review your Explanation of Benefits (EOBs) that you receive by mail or have access to on your health plan’s website. Check for errors.

4. If you notice any errors, alert your healthcare provider or health insurer immediately.

5. Each time a medical provider requests your social security number, ask if the last four digits will suffice.

6. If you store copies of your medical records online be sure it has a secure platform.

7. Keep an eye on your credit report. Unpaid medical bills can be reflected in your credit rating.

8. If you have been informed that your healthcare provider or insurer has suffered a security breach:

-Change all your passwords.

-Contact a major credit reporting agency and request that a fraud alert be placed on your account.

-If you received a letter about a security breach that could affect you, accept the free offer for credit monitoring, if applicable.

For further information, see my article published on KevinMD, How Much Health Care Data is Mined Without Your Knowledge?  

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Patient as Data Hub: get copies of your medical records

For years I’ve encouraged patients to obtain copies of their medical records at the time of service. Whether an MRI, CT scan, lab results, reports from surgeries, procedures and more, it is essential that patients have their own copies so they can personally hand over what is needed for meetings with specialists, second opinions, or new consultations with medical providers. No one wants to have waited a month for a second opinion with a busy specialist only to find out during the appointment that requested medical records never arrived from a previous doctor’s office, hospital, imaging center or facility. It happens all the time.

In my latest book, The Take-Charge Patient: How You Can Get The Best Medical Care, I devote an entire chapter to the importance of gathering copies of pertinent medical records and placing them in a health file at home. You never know when you’ll need that MRI and if you do, timing might be crucial and you might not have time to wait.

It’s all about independence as a patient and taking charge of what you can.

Take Cheryl, a Medicare patient in an extremely busy internist’s office. She is scheduled for necessary surgery and has the required pre-op exam. Checking out at the office front desk, she requests that her pre-op exam report be sent to her surgeon’s office ASAP as her surgery is scheduled for the following week. “No problem,” the front desk person says.

Four days before her surgery, Cheryl receives a phone call from the surgeon’s office. She is informed that they still have not received a copy of the pre-op exam and that she cannot have the surgery without it. Cheryl calls her internist’s office, and again speaks to the front desk person who insists that her record was already sent to the surgeon’s office. Cheryl tells her that Dr. X hasn’t received it and asks if it could be sent again.

Another day goes by and still Dr. X’s office has not received a copy of her pre-op exam report. Out of frustration and a sense of urgency, Cheryl arrives at her internist’s office and requests a copy of her medical record for herself so she can send it to Dr. X’s office. Her surgery is important and the wait time for it would have been six weeks had it not been for a cancellation. Cheryl has to pay a small fee but leaves the office with a copy of her medical record in hand.

This could have so easily been prevented.

Ask for a copy of your medical record at the time of service. I’ve done it myself several times. For example, I had an MRI of my foot at an imaging center. I asked for a copy of it on CD and after waiting only 15 minutes, I received a copy for free (I cannot guarantee it will be free.) I have it in my health file at home just in case I ever need that MRI for a future medical consultation.

Finally, the media is picking up on the importance of this issue, not just for the sake of patients being in charge of themselves, but to increase patient safety. See WSJ article, How to Take Charge of Your Medical Records

I can almost guarantee there are errors in your medical records. You’ll want the chance to correct those so that misdiagnoses or other medical mistakes don’t follow you from provider to provider, often without your knowledge. It’s a mistake to rely on your medical provider’s electronic medical records for this reason alone.

In case you’re wondering if you are entitled to copies of your medical records, see this You have a legal right to copies of your medical records. In California the requirement is within 15 days.

You can scan your records onto a flash drive or some other means of storage that is portable. If you choose an online cloud-based storage platform via apps or websites, you run the risk of your records being hacked or mined for data without your permission. If you choose to go this route, be mindful of selecting a very secure cloud-storage platform, if secure is even possible right now.

Personally, I choose to house copies of my medical records without any connection to the internet. It might sound old school but it’s the safest way until internet security can be absolutely guaranteed.


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Over Medicating the Elderly Patient: 10 tips for caregivers to protect patients

Our 85-year-old neighbor, Dorothy, was taking 14 medications a day. She could barely get out of bed because of fatigue and mental confusion. With her adult children living out of state, my husband and I look out of her. Even with 24/7 caregivers, additional oversight is important.

When I spoke with her son, I strongly encouraged a medication review with Dorothy’s primary care physician (internist.) He soon visited and took his mom to her doctor, complete with a list of all her medications and dosages, over-the-counter medications, herbs and supplements. Her physician cut her prescription medications in half and changed a couple of others. Weeks later, Dorothy is nearly her old self again and is back to walking with her caregiver down our street.

Over-medication in the elderly is a serious and very common problem. According to The Journal of Family Practice, nearly 9 out of 10 U.S. residents who are over the age of 60 take at least one prescription medication. More than a third take 5-9 medications, and 12 percent take 10 or more. The risk of adverse drug effects and dangerous drug interactions increases significantly when a person takes more than 5 medications.

Such was the case with Dorothy. Several of her medications were causing side effects and those side effects were then treated with more medications. Multiple specialists were involved in her case and none communicated with one another. Each prescribed more medications to treat her symptoms. This is a phenomenon known as “the prescribing cascade.” Her caregivers did as instructed by helping her take her 14 medications a day and her adult children weren’t aware that “polypharmacy”  can be downright dangerous for the elderly.

Why is “polypharmacy” such a problem in the elderly? Aging affects how the body handles medications, meaning the elderly metabolize and eliminate medications less efficiently. 

If you’re caring for an elderly patient who is taking multiple medications you need to know that they can be at high risk for drug related problems.

Following are 9 strategies to help:

1. If your elderly patient is taking multiple medications and sees more than one medical provider (doctor, nurse, PA, NP), create a list of all prescribed medications and their dosages. Include over-the-counter medications, herbs and supplements. In addition, add allergies to medications. Bring this list to each visit with the patient’s medical providers.

2. Ask the patient’s primary care physician to review the list of medications. Ask questions. 

3. Talk to the patient’s pharmacist and ask for a medication review. A pharmacist’s training, education and expertise is in medications. They are there to help you. Ask questions.

4. Use one pharmacy to fill all of the patient’s prescriptions. Drug interactions, duplicate medications and allergies to medications will be caught.

5. Different medical providers might unknowingly prescribe duplicate medications for the patient if the patient does not present a list. This confusion can also occur with brand and generic medications. For example, the patient takes the generic, which has a different name than the brand. Both are the same medication. Medication samples are always brand.

6. Keep a symptom diary in partnership with the patient. If you notice new symptoms, keep a log of what the patient experiences on a daily basis. Ask the patient to contribute or if he/she is unable, document your own observations. Ask the following questions:

-When did the symptoms begin?

-Was a new medication started when symptoms began?

-How long do the symptoms last?

7.  Modern Medicine states that if the patient starts experiencing GI distress, it can be because of a new medication. Be on the look out for nausea, vomiting, diarrhea, constipation and stomach pain.

8. If there is a change in the patient’s mental status such as drowsiness, impaired memory, confusion, prolonged sedation, it might be because of medication. Some antidepressants, muscle relaxants, antispasmodics and antihistamines can also cause confusion, blurred vision, dry mouth, dizziness and difficulty with urination. Ask the patient’s primary care physician questions. Speak up. 

9. If any of these or other symptoms occur, bring it to the doctor’s attention and show him/her the patient’s symptom diary.

10. If you are an advocate or caregiver for an elderly patient, it is very important to be informed about the patient’s medications. Older patients may see several different specialists who don’t communicate with one another and have no idea which medications the patient is taking. 

Good resource: Beers Criteria (medication list) of potentially inappropriate medications for the elderly


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