Saturday, November 12, 2011

Weekly Overseas Health IT Links - 12th November, 2011.

Note: Each link is followed by a title and few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.

Study: EMRs with decision support improve patient monitoring, not outcomes

November 2, 2011 — 1:58pm ET | By Marla Durben Hirsch - Contributing Editor
Electronic medical records linked with clinical decision support technology don't necessarily improve patient outcomes, a study recently published in the Archives of Internal Medicine finds.
Published Oct. 24, the study analyzes the use of a vascular tracking and decision support system linked to EMRs used by primary care practices in Ontario, Canada. The decision support system tracked patients' body mass index, blood pressure and cholesterol levels, as well as other risk factors. It also included personally tailored electronic risk monitoring and treatment advice between physicians and patients. The linkage led to increased monitoring of the patients' risk factors, but didn't improve their risk factor profiles, according to the study.
"Computerized decision support systems [CDSSs] linked with electronic medical records are promoted as an effective means of improving patient care. consistent evidence of an effect on patient outcomes has been found," the authors said.

Oracle Apps to Manage Cerner's Cloud Services

HDM Breaking News, November 3, 2011
Cerner Corp. is using enterprise cloud management software from Oracle Corp. with its new Skybox initiative to provide cloud-based hosting of information systems.
The service, announced in October, will use cloud storage technology from San Diego-based Nirvanix and support usage-based pricing, data analytics and access to aggregate data from other providers using the service. The Oracle Enterprise Manager suite of applications will support an on-demand infrastructure with such functions as messaging and virtual desktops.
By Joseph Conn

A guide for the health IT-perplexed

Encountering the world of healthcare information technology is a lot like being a first-time foreign tourist in Las Vegas. We've all been puzzled by the flash and the alien language of this industry at one time or another.
Some of my own memories of that befuddlement came flooding back this week when I started reading a new guidebook to the healthcare IT, "Meaningful Use and Beyond," published by O'Reilly and co-authored by open-source health IT mavens Fred Trotter and David Uhlman.
The target audiences of the book are veteran IT professionals from other industries and recently minted college computer science majors who might be looking to start careers in health IT.

Software issue blamed for bad Rx instructions

Posted: November 3, 2011 - 4:00 pm ET
Lifespan Corp. said it notified the Rhode Island Health Department after discovering that 2,000 patients from its hospitals in the state had been discharged with incorrect prescription instructions because of a software issue.
Lifespan has contacted 90% of the patients who may have received a prescription for a time-release form of medication rather than a regular formulation prescription. The software error started in July 2010 at Bradley Hospital, according to the news release.

4 best health IT innovations within the past year

October 24, 2011 | Michelle McNickle, Web Content Producer
New health IT was anywhere and everywhere in 2011, promising ways to streamline data and increase patient care. Now, with even more technology on the cusp of the mainstream market, it’s only natural to wonder what’s the best.
That’s why we asked Ahmed Ghouri, MD, co-founder and CMO of Anvita Health, what he believes were the most influential new technologies within the past year and what will be game changers in the years to come. “If you look at the stages of healthcare we’re going through, the first is structural, which includes CPOE, EMRs, and health information exchanges," said Ghouri. “So data management in storage, and data exchange. I think once we solve the structural problems, it will be like creating a Web browser; dramatic value is created once everyone is on the Internet. It’s not just getting online, but also doing things with the data online.”
Ghouri believes we’re making progress in the structural aspects of healthcare, and the most innovative health IT isn’t in the area of data gathering but rather data interpretation. “I would say they’re the most important things in terms of their long-term significance,” he said. “But we’re still early in their widespread adoption.” 

Hospitals Fall Short On Meaningful Use

While more hospitals say they meet stage 1 of the electronic health record incentive program, 53% say they still aren't ready, finds study.
By Nicole Lewis,  InformationWeek
November 03, 2011
There's good news and bad news in the latest research from the Healthcare Information and Management Systems Society (HIMSS). The good news is that from February to September 2011 there has been a 16% increase (from 25% to 41%) in the number of eligible hospitals saying that they are likely to meet criteria for stage 1 of Meaningful Use. The bad news is that 53% of hospitals say they cannot meet 10 or more of the 14 core requirements set out in stage 1.
The survey, Summary of Meaningful Use Readiness, reflects that hospitals increasingly recognize the need to adopt health IT, but also face many challenges as they attempt to transition from paper-based medical charts to digitized medical records.

Stimulus funds will build state health exchanges but might not sustain them

Federal stimulus funds are paying to build or expand systems enabling health care providers within each state to share patient information, but state officials are concerned about how to keep paying for the programs once the federal money runs out, an iWatch News survey reveals.
And with states adopting a wide variety of different software for electronic health record exchange, officials are also worrying about how to get those different systems to talk to each other across state lines ( see sidebar [3]).
The creation of these exchanges within all U.S. states and territories is part of a much larger push for use of electronic records in health care. Most of the attention has been focused on $27 billion worth of Medicare and Medicaid incentive payments that are going out to doctors, hospitals and clinics for switching their patients’ information from print to digital; providers must also demonstrate they have followed government guidelines in using the technology in a “meaningful” way. But a less-noticed provision of the same 2009 stimulus legislation made $548 million [4] worth of grants available to the states to set up information exchanges that would allow health care providers to send, receive and share patient information within a state.

Physicians, patients disagree about EHR safety

November 2, 2011 — 10:14pm ET | By Marla Durben Hirsch - Contributing Editor
Physicians are more likely than their patients to view electronic health record systems as safer than paper records, according to a survey released this week by web-based EHR vendor Practice Fusion. 
Conducted by research company GfK Roper, the survey found that a little more than half of responding physicians (54 percent) believe that EHRs are safer, while only 39 percent of patients feel the same. Inversely, only 18 percent of physicians see paper records as the safer alternative, compared with 47 percent of patients who say that paper is safer.

Privacy and Security in the Implementation of Health Information Technology (Electronic Health Records): U.S. and EU Compared

By Janine Hiller, Virginia Tech; Matthew S. McMullen, Martinelli &McMullen Professional Services; Wade M. Chumney, Georgia Institute of Technology; and David L. Baumer, North Carolina State University
The United States spends the equivalent of 16% of its Gross Domestic Product (GDP) on healthcare, a larger percentage than any other comparably sized developed country. As the pressure to reduce ballooning healthcare expenditures continues to rise, information technology, and in particular the implementation of Electronic Health Records (EHRs), is identified as one potential method to create efficiencies and reduce costs. However, “studies suggest that fewer than one fifth of the doctors’ offices in the United States offer EHRs.”
Other countries have made more significant progress; Denmark, for example, has an e-health records system that almost universally links patients/citizens and medical professionals.
October 31, 2011, 11:24 am

Big Data, Speed and the Future of Computing

Big data is, yes, about more data — the rising flood from corporate databases, Web browsing trails, sensors and social network communications. But it is just as much about speed.
If “big data” is more than a marketing term, it has to be the raw material for making smarter decisions, faster. And that means, as the big-data industry evolves, the need for groundbreaking new approaches to computing, both in hardware and software.
A simple example: the Watson question-answering computer that beat two human “Jeopardy!” champions earlier this year had to pore through vast quantities of data and come back with an answer in less than three seconds.

ONC delays permanent EHR certification program

November 3, 2011 — 3:25pm ET | By Dan Bowman
The permanent health IT certification program for Meaningful Use of electronic health records, which was to go into effect on Jan. 1, 2012, has been pushed back until at least next summer by the Office of the National Coordinator for Health IT.
National Coordinator for Health IT Farzad Mostashari, in a Federal Register notice today, said that after consulting with current ONC-Approved Accreditor, the American National Standards Institute, the organizations said there will not be enough ONC accredited testing laboratories or authorized certification bodies until the summer of 2012, reports Health Data Management.
  • November 1, 2011, 12:10 PM ET

Doctors, Like Their Patients, Use Google for Health Information

Doctors: they’re just like us!
General web browsers like Google and Yahoo are behind only professional journals and colleagues as a source of information physicians frequently use to diagnose and treat patients, according to a survey of more than 300 doctors.
The survey, from Wolters Kluwer Health, covered a sample of American Medical Association members, both primary-care physicians and specialists.  We weren’t too surprised to hear that “spending more time with patients” ranked highest on a list of areas in which doctors would like to see improvement. Nor was it particularly shocking to read that expense is a big barrier to adopting new health technologies.

Docs believe EHRs safer than paper, but patients still ambivalent

November 02, 2011 | Mike Miliard, Managing Editor
SAN FRANCISCO – A new survey finds a majority of physicians believing that electronic health records are safer than their paper counterparts, citing accessibility of data as the top safety benefit.  But patient perception remains mixed with nearly half of respondents believing paper records are safer.
Conducted by GfK Roper on behalf of Practice Fusion, the survey polled patients about their views on the safety of EHR versus paper charts; a separate survey posed the same questions to medical professionals.
Written by Beth Walsh
October 31, 2011

CHIME: HIE growth continues

SAN ANTONIO—The health information exchange (HIE) market is wide and growing, said Jason Hess, research executive vice president for KLAS. He spoke on the topic during CHIME11, the Fall CIO Forum last week.

Other key factors of the current HIE market include:
  • The bulk of the growth is on the private side.
  • Most physicians have to leave their own workflow to view HIE data.
  • Future funding is a big concern for public HIEs.
  • The cream of the HIE vendors is slowly rising to the top.
  • HL7 is still more popular than clinical care documentation.
The number of public HIEs has increased from 37 to 67 since 2009, Hess said, and private HIEs have increased from 62 to 161. HIEs are not considered live until they are actually exchanging data, not just when they are populated or contracted.

HHS issues call to action with health app challenge

November 01, 2011 | Molly Merrill, Contributing Editor
The U.S. Department of Health and Human Services launched a new challenge Monday, calling on developers to create applications that can help solve the "Leading Health Indicators" (LHIs) that were identified as critical health priorities during the American Public Health Association's annual meeting.
The winning app will help public health professionals track, measure and report on progress in these critical public health areas, officials said.
 “The LHIs are a call to action in critical public health areas that demand our immediate attention,” said Howard K. Koh, MD, HHS assistant secretary for health. “We can solve the most pressing health problems in this country, and the LHIs prioritize our actions for a healthier future.”

NIST: Make EHRs More User-Friendly

National Institute of Standards and Technology solicits input on how to make electronic health records better, safer.
By Nicole Lewis,  InformationWeek
November 01, 2011
The National Institute of Standards (NIST), in conjunction with public and private sector stakeholders, has called on the healthcare community to help evaluate electronic health records (EHRs), examine the human factors that are crucial to their design, and assist with guidance on the development of usability engineering practices.
An October 27 webcast focused on NIST's recently released Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records, draft guidelines that review the rationale for an EHR usability protocol (EUP).
The guidelines outline procedures for expert evaluation of an EHR user interface from clinical and human factors best-practices perspectives. They also offer guidance on how to conduct validation studies of EHR user interfaces with representative user groups on realistic EHR tasks.

ONC will coach consumers about privacy, security in HIE

November 01, 2011 | Mary Mosquera
The Office of the National Coordinator for Health IT will conduct a nationwide campaign to educate the public about the importance of privacy and security in the electronic exchange of their personal health information. ONC said it will include consumer attitudes and preferences when mobile devices are used to communicate health data.
ONC will gauge responses from 40,500 consumers and health professionals over the next two years to help guide its strategies, messages and websites, according to an announcement in the Nov. 1 Federal Register.


A mobile health ‘ecosystem’ in Manchester is trying to find a cure for ‘pilotitis’. Shanna Crispin reports on an attempt to overcome a major stumbling block in the industry that is being watched across Europe.
If the European mobile healthcare market is suffering from a severe case of ‘pilotitis’, then Manchester is looking for a cure.
The European mHealth Alliance (EuMHA) has established an ‘ecosystem’ in the city; the first of what it hopes will be many ecosystems focussed on facilitating implementations of mobile health technology.
The intention is relatively straightforward. The Alliance wants to stop people simply talking about the potential of mobile technology and trying it out in small scale projects, and get it embedded into the healthcare environment.

Steve Jobs and e-health - The future of medicine

Pressemitteilung von: iHealth France
(openPR) - The untimely death of Steve Jobs has led to a number of testimonials from the medical community. The innovator, whose products have transformed the way doctors, nurses and other actors in healthcare provide patient care, died on October 5, 2011.
Mobile devices created by Steve Jobs, including the iPad, iPhone and iPod touch - and health applications developed specifically for these devices - have allowed doctors, nurses and patients to understand, access and share clinical data in a much easier manner than before. Similarly, medical information and data found on these devices have improved the way in which doctors perform their clinical duties on a daily basis and have improved the general level of healthcare. An example is iHealth, the first intelligent blood pressure monitor compatible with iPhone, iPod or iPad. iHealth is a major step forward for telemedicine because it allows patients to measure and transfer their blood pressure (BP) data and because it allows for better management of home health care. With iHealth, the user can send results directly to his doctor and can avoid many of the complications associated with medical examinations.

EHR Training: Are Your Doctors Fully Prepped?

Clinicians need more EHR instruction than they now receive, report says.
By Nicole Lewis,  InformationWeek
October 31, 2011
If clinicians hope to use electronic health records (EHR) to improve patient care, they will have to be fully versed in how to use them--but a new survey suggests they are not getting the training they need. An AmericanEHR Partners report reveals doctors need at least three to five days of EHR training, but nearly half (49.3%) receive three or fewer days.
The survey, summed up in The Correlation of Training Duration With EHR Usability and Satisfaction: Implications For Meaningful, interviewed more than 2,300 physicians, physician assistants, and nurse practitioners who use nationally certified ambulatory EHR products. The poll was conducted between April 2010 and July 2011 to gauge views and attitudes regarding the respondents' satisfaction with EHR systems.

CHIME: The difficult life after CPOE, EHR go-live

Written by Beth Walsh   
October 31, 2011
SAN ANTONIO—When Hospital Sisters Health System, a 13-hospital system in Wisconsin and Illinois, implemented computerized physician order entry (CPOE) and EHR, everything seemed fine—for a little while. Just a couple of months after the installation, William Montgomery, CIO, received a letter from the physicians listing 38 issues that they wanted fixed within two weeks.
Montgomery and Robert Schwartz, MD, MPH, physician executive with Dearborn Advisors, discussed Sisters’ situation during CHIME11, the Fall CIO Forum last week. The organization, with a $1.8 billion budget, 15,000 employees and 2,800 beds moved to “care integration” in 2008.
Half were known issues at other hospitals in the organization and another quarter were related to training, he said. The installation team was taken aback by the letter, including the physician champion.

10 technologies to embrace before EMRs

October 31, 2011 | Michelle McNickle, Web Content Producer
It's no secret EMRs can be complex and confusing, and despite the buzz surrounding their implementation, health IT expert Shahid Shah believes some organizations are better off taking things slow. 
"Although most people who are new to healthcare IT always point to EMRs as the most important application, there are many different healthcare IT applications that make up the 'industry' as a whole," said Shah. "When you’re dealing with healthcare IT, EMRs might be a good entry point for some folks, but it’s actually more likely that EMRs aren’t your first place to start your automation journey."
By Joseph Conn

Seeking EHR construction, not deconstruction

Health information technology pioneer Tom Munnecke has been thinking a lot these days about a plan by the U.S. Veterans Affairs Department to update the department's VistA electronic health-record system.
Munnecke would like to avoid replicating the multibillion-dollar problems that have befallen the Military Health System in first modifying the VA's health IT system—killing off its core interoperability functions in the process—and then degrading even further that result by squandering a bunch more money creating a wobbly successor system called AHLTA.
His concern, shared by others in the VistA community, is that VistA will be "refactored" from its current database and programming language, MUMPS, to something new, sleek and sexy, but that the redevelopers miss what made VistA great in the first place.

6 Steps to Creating a Connected Health Program

Gienna Shaw, for HealthLeaders Media , October 26, 2011

A successful connected health program, in which patients use information, technology, and other tools to engage in their own care and self-manage conditions such as heart disease and diabetes, involves a lot of preparation. In fact, the planning for a connected health program begins well before you even launch a pilot program.
Any kind of change will be resisted by an equal, opposing force, observes Susan Lane, RN, corporate manager of technology and operations for the Partners Center for Connected Health (PCCH), which hosted its annual symposium in Boston last week. To create a program that can grow, you must have a clear focus and put measurements in place that will translate to a final scaled program if the pilot is successful, she said. 
Connected health programs use technology to deliver care outside of the provider setting. For example, a program might connect patients and physicians via remote monitoring and e-visits and allow patients to upload their own data and track it online. The technologies and tools track medication adherence, weight, blood pressure, and other vital signs.

James Read remembered in lecture

1 November 2011   Lyn Whitfield
Tim Benson gave the first James Read Memorial Lecture last month in memory of James Read, the clinical coding pioneer, who died this summer.
The founder of Abies, who worked with Dr Read and others on some of the first GP systems in the 1980s, talked about how he came to start a coding system for diagnoses in computerised records.
He also talked about how the task grew as Dr Read realised that it would need to cover all aspects of a patient’s medical history.

GP2GP has busiest ever week

31 October 2011   Rebecca Todd
GP2GP had its busiest week this month, with nearly 18,000 patient records transferred electronically as students started university.
NHS Connecting for Health said 17,824 electronic healthcare records were transferred using GP2GP in the week commencing 17 October.
One quarter of patients registering with a practice using GP2GP now have their record sent electronically to their new doctor.

How e-health records improve healthcare: a cancer patient's story

By Lucas Mearian, Computerworld
November 01, 2011 11:20 AM ET
Pam Crum was 22 weeks pregnant in October 2004 when she noticed a red rash on one breast. Her doctor thought it was simply an inflammation that sometimes occurs in lactating mothers. Over a couple of weeks, the rash worsened. Then a lump formed.
Crum was sent to a breast surgeon for a more thorough examination, and a month later she got the diagnosis: stage 3 inflammatory breast cancer.
"I was just really shocked, because all along I had been thinking it was probably some odd issue related to the pregnancy," she recalled recently. "I remember thinking, 'I have to really focus on beating this illness because I have two daughters.' I knew my three-and-a-half-year-old daughter would be devastated. And, we were already so attached to the [unborn] baby, we just couldn't imagine something happening to her. I thought, 'I just take this day by day.' "
Tuesday, November 1, 2011

The Virtual Nurse Will See You Now

In the hectic world of a hospital, a computer-simulated nurse can be surprisingly comforting.
Researchers at Northeastern University have developed a virtual nurse and exercise coach that are surprisingly likable and effective—even if they're not quite as affable as the medical hologram on Star Trek. In fact, patients who interacted with a virtual nurse named Elizabeth said they preferred the computer simulation to an actual doctor or nurse because they didn't feel rushed or talked down to.
A recent clinical trial of the technology found that Elizabeth also appears to have a beneficial effect on care. A month after discharge, people who interacted with the virtual nurse were more likely to know their diagnosis and to make a follow-up appointment with their primary-care doctor. The results of the study are currently under review for publication.
"We try to present something that is not just an information exchange but is a social exchange," says Timothy Bickmore, associate professor in Northeastern's College of Computer and Information Science. Bickmore led the research. "It expresses empathy if the patient is having problems, and patients seem to resonate with that."

Healthcare Innovation Advice for Technology Leaders

Gienna Shaw, for HealthLeaders Media , October 31, 2011

Innovation and change were common themes at this year's College of Healthcare Information Management Executives annual forum—from the challenge of working in a disruption-averse industry to the changes that healthcare will face in coming years, whether healthcare leaders want to face it or not.
The U.S. must move toward lower-cost caregivers and venues of care, said keynote speaker Clayton Christensen. To do so, disparate groups must overcome their reluctance to collaborate and share power to adopt changes that make common sense, would make care more convenient, and save money.
For example, he said, nurse practitioners could play a bigger role in administering colonoscopies, but physicians object. Meanwhile, physicians say they could do colonoscopies in their own offices, but hospitals object.

Leavitt: HIT standards development slow, but U.S. on the right track

October 26, 2011 — 7:29pm ET | By Ken Terry
Michael Leavitt, the Secretary of Health and Human Services during the second term of President George W. Bush, expressed strong support for the Obama Administration's health IT incentive program during a keynote speech at CHIME's Fall CIO Forum this week in San Antonio.
Responding to a question about how he would rate the program, Leavitt said, "I would have loved to have had $18 billion" for health IT when he ran the Department of Health & Human Services (HHS).

To keep valued health IT staff, show a little love

October 28, 2011 | Bernie Monegain, Editor
SAN ANTONIO, TX – Steven Bennett, vice president of recruitment firm, Kirby Partners, got right to the point.
“I do love your unhappy employees,” he told an audience of about 100 CIOs Thursday at the annual fall forum of the College of Health Information Management Executives. “If it’s not me who calls, it’ll be some other recruiter."
Bennett noted that health IT employment, which has long been a buyers’ market, is now a sellers market. The applicant pool is quickly dwindling, he said, and with demand forecast to grow at 20 percent a year until 2018, it’s not likely to change soon.

IBM, Georgia Tech Point Data Modeling At Kids Health

Project seeks to identify factors contributing to health outcomes of pediatric patients with asthma, autism, and diabetes.
By Marianne Kolbasuk McGee,  InformationWeek
October 27, 2011
IBM and the Georgia Institute of Technology are launching a new data analysis and scientific modeling project to study the impact of socioeconomic status, education, transportation, and other factors on the health of kids in Georgia with diabetes, autism, and asthma.
The study, which also involves partnerships with Emory University, Children's Healthcare of Atlanta, Georgia Cancer Coalition, and the Georgia Department of Community Health, also plans to examine how current fee-for-service models of payment to healthcare providers in the United States might be transformed so that clinicians can better align time and care with treatments that show the best outcomes and cost effectiveness.

How To Get People To Fill Their Prescriptions

By Ed Silverman // October 27th, 2011 // 8:49 am
Everyone knows that getting some people to fill their prescriptions can take more effort than should be expected. Some forget. Some worry about side effects. And as the stagnating economy stagnates still more, it is not surprising that many people simply decide they cannot afford to pay for a medicine. A new study, however, suggests that greater use of e-prescribing may cure this ill.
To examine adherence trends, the researchers reviewed 423,616 e-prescriptions and learned that 24 percent went unfilled, a rather large chunk. Besides cost and formulary placement - the usual suspects when sorting out why prescriptions are not filled - the study authors say that more people would go the distance if prescriptions were transmitted electronically from doctor to pharmacy.

Bill would give EHR users legal protection

Posted: October 28, 2011 - 11:15 am ET
Rep. Thomas Marino (R-Pa.) introduced legislation that would offer limited legal protection to the Medicare and Medicaid providers that use electronic health records.
The Safeguarding Access for Every Medicare Patient Act would reduce costs, guarantee incentives for providers to continue to participate in the Medicare and Medicaid programs, and promote the use of health IT systems, according to a news release from Marino's office.

The 6 hidden costs of EHRs

October 27, 2011 | Drew Nietert, CPHIMS
If you haven’t spent much time analyzing the costs of EHRs, this part of the process may be an eye opener. Why should one consider the hidden costs of EHRs?
EHR costs are much more than just the initial purchase, implementation and maintenance fees.  If a budget misses the hidden costs, an implementation could fail, degrade over time and worst-case scenario – bankrupt an organization.
To help sort out these expenses, several broad cost categories should be considered: Initial, Repeat, Future and Special Project costs.  

VA wants 100,000 staff to take tablets

27 October 2011   Shanna Crispin
The US Department of Veterans Affairs is looking to implement a nationwide plan that will include giving up to 100,000 healthcare workers tablet computers.
The VA is the largest integrated healthcare system in the US, serving 5.4m veterans out of 7m eligible current and former service members.
In procurement documents, it says that providing efficient information technology for healthcare workers is key to delivering benefits and services to its members, and that this information should be made available efficiently at the point-of-care.

Blumenthal's 4 keys to successful health information exchange

October 22, 2011 — 3:18pm ET | By Dina Overland
The successful exchange of health information among providers and insurers, as well as other healthcare players, will "unleash capabilities we can't even imagine," making the entire healthcare industry "even more productive," David Blumenthal, former national health IT coordinator, told attendees at the Pega Collaborative Healthcare Summit in Boston on Wednesday.
That's why Blumenthal said that getting patient information flowing throughout the continuum of care is one of the most important steps the industry can take, calling it the "next frontier."
Successful health information exchange (HIE) requires an "ultra large system" that's dynamic, innovative, and emergent enough that it adapts as healthcare changes in the future. But before such an HIE system is implemented, there are multiple challenges to overcome. Blumenthal noted that creating a robust exchange system isn't only an IT problem; rather, it's a problem of social, cultural, legal, institutional, economic, and political proportions. "The technical part is actually the least challenging aspect" of getting an HIE system up and running, he said.

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