Quote Of The Year

Timeless Quotes - Sadly The Late Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"


H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Saturday, July 25, 2015

Weekly Overseas Health IT Links -25th July, 2015.

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.

UCLA Health breach puts data at risk for 4.5M

By Joseph Conn  | July 17, 2015
(Story updated at 3:30 p.m. ET.)
Four-hospital UCLA Health said Friday that cyber criminals hit part of its network that contains the records of an estimated 4.5 million people.
“At this time, there is no evidence that the attacker actually accessed or acquired individuals' personal or medical information,” UCLA Health said in an initial announcement, but followed with a later statement from UC President Janet Napolitano that added “we cannot rule out that possibility.”
The UCLA Health statement said the system first discovered suspicious activity on its network last October, but not until May 5 did it learn that the attackers had accessed parts of the network that contained “personal information such as names, addresses, dates of birth, Social Security numbers, medical record numbers, Medicare or health plan ID numbers and some medical information.”

One CIO's case for making medical records available online

July 17, 2015 | By Katie Dvorak
Anyone who wants to sift through the medical records of John Halamka can--the Beth Israel Deaconess Medical Center CIO's information can all be found online as part of the Personal Genome Project.
Halamka voluntarily made his full medical record and genome available, as well as that of many of his family members.
"Have I lost stature in the community because of my genetic risks, my treatment for glaucoma, or my occasional episodes of supra ventricular tachycardia? Have I been denied insurance, lost employment, or experienced tension among family/friends?" he writes in a commentary at Politico.

'New value propositions' emerge for HIE

Posted on Jul 17, 2015
By Mike Miliard, Editor
The push toward value-based outcomes means health information exchange technology has new opportunities for value-add, according to reports published this week by IDC Health Insights.
With the expansion of accountable care and patient-centered medical home models, opportunities now exist for HIEs that didn't in a fee-for-service environment, according to IDC.
Now that incentives to exchange data are much more closely aligned than they were under older reimbursement models, platforms have the chance to prove their worth as the need for analytics and ability to aggregate and centralize health information come to the fore.

Ancestry.com launches health website, positions itself as budding 23andMe competitor

By: Jonah Comstock | Jul 16, 2015
Ancestry.com, one of the biggest sites for genealogy in the world, is getting into health. The company officially launched a new website, AncestryHealth.com, in beta today and announced the hire of a Chief Health Officer, Dr. Cathy A. Petti, who has previously held executive roles at HealthSpring Global, TriCore Reference Laboratories, and Novartis.
“Ancestry fundamentally believes family history is a powerful tool that not only can educate individuals about their past and where they came from, but can inform their future,” Tim Sullivan, CEO of Ancestry, said in a statement. “This new service leverages expert research and delivers customized information to consumers about the risks and prevention measures to help empower them to make healthy lifestyle choices. Combined with the breadth and scale of Ancestry data, we expect AncestryHealth to be a key piece of the puzzle as we look to understand how health is passed down through generations, and we are excited to have Dr. Petti lead this effort.”

Docs' views of EHRs still lackluster

July 13, 2015 | By Marla Durben Hirsch
There's still not much buy-in from physicians regarding their electronic health records, even though more of them are adopting the systems, according to a new survey from Physicians' Practice.
The 2015 Technology Survey found that 53.3 percent of the 1,181 respondents have fully implemented an EHR, and 19.6 percent didn't have one. The remainder either were using a hospital-based system or were in the process of implementation. Of those practices that did not have an EHR, the top reasons included that they did not believe it would improve patient care, followed by the expense and the inability to find a product that met their needs.
Those that had an EHR reported that the system didn't necessarily make their lives easier, with 15.5 percent noting a drop in productivity, and 36.9 percent seeing fewer patients per day after implementation. Half of the respondents (51.4 percent) saw no change in the number of patients seen.

Patients Are Still Skeptical About Telemedicine

JUL 16, 2015 7:45am ET
Telemedicine may hold plenty of promise in bringing more accessible and specialized care to more people, but patients are still skeptical about it, according to a new survey.
The survey, conducted by consultancy TechnologyAdvice, revealed nearly 65 percent of respondents nationwide said they would be somewhat or very unlikely to choose a virtual appointment, while only 35.4 percent stated the opposite. Approximately 75 percent of people reported they either would not trust a diagnosis made via telemedicine, or would trust this method less than an in-doctor visit.
However, in the event a relationship between a physician and patient had already been established, the majority of patients would be comfortable with a telemedicine diagnosis: 65 percent of respondents said they would be somewhat or much more likely to use a virtual appointment system if they had first seen the doctor in-person, and a combined 70 percent of respondents reported at least one of the following factors would make them more likely to use a virtual appointment: more convenient scheduling options, lower cost, less time spent in the waiting room, and ability to conduct virtual appointments at home.

Ambulatory IT shows 'adverse impacts on workflow'

Posted on Jul 16, 2015
By Mike Miliard, Editor
The report, "Examining the Relationship Between Health IT and Ambulatory Care Workflow Redesign," examines the relation between technology implementation and ambulatory workflow, with a focus on how that might be magnified by various "disruptive events."
AHRQ took a look at six practices from two participating healthcare organizations, three each on the East and West coasts.
"Organization West" rolled out a so-called "clinical advancement project" – including computerized provider order entry, e-prescribing, an electronic homepage, a standardized message center – to an existing electronic health record.

Merseyside shares 5.5m records in a year

The GP records of patients in North Merseyside have been shared 6.5 million times amongst health and social organisations in the region as a result of the area's iLinks Transformation Programme.
The bulk of the sharing has happened in the past year, when records held by local practices on the Emis Web system were shared 5.5 million times with hospital staff, social workers and other professionals working in health and social care and using different record systems.
This is a significant leap since work on information sharing began in 2008. Between the start of the project and 2014, records were shared one million times across the region, which covers a population of around 750,000 people across three clinical commissioning groups in Liverpool, South Sefton and Southport and Formby.

Care Connect disconnected

NHS England’s patient feedback service Care Connect is not in use anywhere in the country, more than a year after pilots were completed.
Care Connect was due to be rolled out across England by February 2014, but following the end of the pilots early last year, the service is no longer being used.
Built by mySociety using open source architecture, the multi-channel service was piloted in 22 trusts in London and the North of England starting in July 2013.
It allowed patients to go online, ring a telephone number, text or use social media to log concerns that need resolving, ask a question or provide feedback on their experiences. Feedback was to be published online and where necessary, passed on to providers to respond.

Global patient monitoring market grows to $31.4B billion

July 16, 2015 | By Katie Dvorak
The demand for wireless and streamlined health devices has led to growth in the patient monitoring market, which currently boasts a global valuation of $31.4 billion, according to a report from Kalorama Information.

John Halamka and Deven McGraw: HIPAA not 'behind the times'

July 16, 2015 | By Dan Bowman
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is not as "behind the times" as some detractors of the law maintain, say Beth Israel Deaconess CIO John Halamka and newly named Office for Civil Rights Deputy Director for Health Information Privacy Deven McGraw.
Halamka and McGraw, in a commentary posted to the Agency for Healthcare Research and Quality's online journal and forum WebM&M (Morbidity and Mortality Rounds on the Web), detail HIPAA's history and examine how the law's interpretations have changed in the 19 years since its enactment.
They call the legislation's privacy rule--which applies to both electronic and paper-based information--"medium-agnostic," and label the security rule--which applies only to electronic health information--"flexible," particularly in the wake of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the basis for the Meaningful Use incentive program.

Hadoop Overcomes Shortfalls of EHRs, Data Warehouses

JUL 15, 2015 7:37am ET
As a flexible, open source storage technology that enables healthcare organizations to store data in its native form, Hadoop is head and shoulders above electronic health records and enterprise data warehouses when it comes to the ability to run algorithms and query the sheer volume of data required for population health management to drive better outcomes.  
That’s the view of Charles Boicey, enterprise analytics architect for Stony Brook Medicine, an academic research institution and medical center located on Long Island, N.Y. Boicey, who is responsible for Stony Brook Medicine’s population management ecosystem, spoke on Tuesday at Health Data Management’s Healthcare Analytics Symposium in Chicago.
“I was really hooked on the ability to store this data and then retrieve it in sub-second time,” he told the conference. In addition, Boicey said that a clinician with a user interface has the ability to ask a simple question such as “I want to see all my diabetic patients that haven’t had an A1C in the last 6 months,” which he argued providers can’t do with an EHR system.   

7 pain points of big data

Posted on Jul 15, 2015
By Healthcare IT News, Staff
Hospital datacenters are being overwhelmed by the ongoing data explosion. Pushed to acquire, analyze, secure and deliver actionable intelligence to business managers, clinicians, or customers, many datacenters are struggling to keep pace.
A new report by the BPI Network, "Accelerate How You Innovate: Data Center Evolution in the Era of the Cloud," examines how organizations are adapting to a new model of business-responsive datacenters and networks. And as they do healthcare IT leaders are starting down seven critical pain points.
1. Moving datacenters into the cloud. The worldwide market for in-house datacenter equipment and solutions skyrocketed to $122 billion in 2014, according to the report. Yet despite this growth, many hospitals are not keeping up with business needs. What they need is the ability to manage data, including the flexibility to add compute power and storage capacity quickly when needed. Many executives said that due to the choices that companies face trusted advisors will play a key role helping them design the hybrid solution that works best for them as they bring their data centers into the cloud era, the report said.
2. Mastering compliance and security. Today, cyberattacks spring from foreign governments seeking economic advantage, highly organized criminal gangs who re-sell personal data on the black market, and even competitors gunning for trade secrets. And the more data collected in one place, the report said, the more valuable a target it becomes for hackers. On the compliance side, security regulations can be their own nightmare. Each situation needs to be addressed in the context of other regional considerations such as the practices at local telecommunication services, political realities, state regulations, or anything that involves moving data from one point to another, the report said.

Hospital slashes false-positive diagnoses with CDS platform

Posted on Jul 15, 2015
By Bernie Monegain, Editor-at-Large
Children's Hospital of Pittsburgh of UPMC's electronic surveillance framework for hospitalized kids is poised to significantly reduce false-positive identification of serious health conditions.
This according to new peer-reviewed research published today in the journal Pediatric Critical Care Medicine.
The retrospective study of 16,239 Children's Hospital pediatric admissions between January 2006 and December 2013 compared the use of vital signs, a common indicator of patient condition, to that of PeraHealth's Pediatric Rothman Index, or PRI.
PRI is a patient condition score that uses an algorithm composed of vital signs, lab tests and nurse assessments (skin issues, mental state) to identify patients requiring urgent intervention with pediatric ICU transfer.

Federal report discusses benefits and barriers with new health IT

Jeff Rowe
Jul 14, 2015
One of the trickier aspects of health IT implementation efforts is gauging how new programs and processes will impact an organization’s workflow.  While the assumption and hope, of course, is that new IT will lead to improvements in both care outcomes and the efficiency of delivery, considerations such as proper staff training and the introduction of new administrative processes often impede an organization’s progress toward these and other goals.
According to a new report from the federal Agency for Healthcare Research and Quality, to date there has been little examination of the effect of new health IT on clinical workflow.  As a step toward addressing that deficit, researchers undertook a study of one specific form of health IT: applications that allow patients to share information with clinics electronically. At the same time, they also studied how clinics redesign their information workflows to incorporate information shared electronically by patients.

Why healthcare's lack of interoperability is unethical

July 15, 2015 | By Dan Bowman
The current lack of interoperability between medical devices and other healthcare IT tools represents both a safety dilemma and an ethical issue, according to leaders with the Center for Medical Interoperability.
Michael Johns, M.D., founding chairman of the center, and William Stead, M.D., chairman of the center's technical advisory committee--in a post to Becker's Health IT & CIO Review--call data sharing efforts of healthcare organizations "complex" and "redundant," noting that most tools have their own separate interfaces. To that end, they say, hospitals are forced to invest precious resources in additional systems to ensure all devices and systems talk to one another.
"This lack of plug-and-play interoperability can compromise patient safety, impact care quality and outcomes, contribute to clinician fatigue and waste billions of dollars each year," Johns and Stead write. With that in mind, they say the industry has "an ethical obligation" to push for improved tools.

Patients wary of telemedicine, distrust virtual diagnosis

July 15, 2015 | By Katie Dvorak
Patients responding to a recent survey said they would be less likely to use telemedicine services compared to an in-person visit with a physician. 
The findings come from a study by TechnologyAdvice Research, which surveyed 504 adults in the U.S. about their opinions on telemedicine services.
Roughly 65 percent of respondents said they would be "somewhat or very unlikely" to use telemedicine in place of a face-to-face meeting with their provider. However, the same amount said they would be more accepting of a telemedicine appointment if they had previously met with the doctor in person.

Cost, Outcomes Mixed for Tele-ICU

ICUs are expensive, intensivists in short supply. Bringing telemedicine to the ICU may help the situation, but doubts linger about what that will achieve.
Nan Myers
Peter Wehrwein
Picture this scene: A middle-aged man who is having difficulty breathing is brought to the emergency room of a community hospital. His condition is serious, and he is immediately put on a ventilator and admitted. It’s Saturday, so the ICU has a skeleton staff. But an experienced intensivist is patched through. She asks the nurse to swivel a camera, so she can get a close-up view of the patient.
Or this: A nurse contacts a doctor at 5 am and describes an agitated ICU patient. With a click of the button, a virtual intensivist is “in” the patient’s room and can see her thrashing around. The doctor speaks to the nurse and orders medication to treat the agitation.
These are not fantasy situations. Scenarios like this are occurring every day in hospitals throughout the country. With intensivists in short supply, the cost of maintaining a fully staffed ICU extremely high, and an aging population that is likely to mean a growing demand for ICU care, hospitals have turned to telemedicine to staff their ICUs. According to a study published last year in Critical Care Medicine, the number of tele-ICUs increased from just 16 in 2003 to 213 in 2010, and the number ICU beds involved increased from 598 to 5,799, a 10-fold increase. Most (91%) of the tele-ICUs were established in not-for-profit hospitals, the study found, and about half were located in the Midwest.

Survey: Patients Dubious About Telemedicine

July 14, 2015
Despite the promising future that telemedicine holds within the U.S. healthcare system, patients remain dubious about this remote option and the quality of diagnosis made during virtual appointments, according to new research from Nashville, Tenn.-based TechnologyAdvice Research.
According to the survey, which included more than 500 U.S. adults over age 18, nearly 65 percent of respondents said they would be somewhat or very unlikely to choose a virtual appointment, while only 35.4 percent stated the opposite. Approximately 75 percent of people reported they either would not trust a diagnosis made via telemedicine, or would trust this method less than an in-doctor visit. Yet, 65 percent said they would be more likely to conduct a virtual appointment if they had previously seen the doctor in-person.
“This is perhaps the largest issue that telemedicine vendors and healthcare providers will need to overcome,” Cameron Graham, managing editor at TechnologyAdvice and the study’s author said in a statement. “If patients don’t trust the diagnoses made during telemedicine calls, they may ignore the advice given, fail to take preventative steps, or seek additional in-person appointments, which defeats the point of telemedicine.”
Also disagree on the impact of EHR on note quality, but agree on purpose of progress notes
MONDAY, July 13, 2015 (HealthDay News) -- Internal medicine attendings and housestaff disagree on the impact of electronic health records (EHRs) on the quality of progress notes, according to a study published online July 2 in the Journal of Hospital Medicine.
Elizabeth Stewart, M.D., from the University of California in San Francisco, and colleagues examined the perceptions of internal medicine housestaff and attendings on inpatient progress note quality after implementation of an EHR at four academic institutions. Data were included from 99 completed surveys from interns, 155 from residents, and 153 from attendings.

What is Big Data?

JUL 15, 2015 2:26pm ET
The term is everywhere—Big Data. Everyone talks of Big Data. Everyone is excited about Big Data. How many of us really know what that means?
“Big Data is the capture and use of more data in more daily activities,” explained Paul Sonderegger, a Big Data strategist at Oracle Corp., during a session at the Healthcare Analytics Symposium, sponsored by Health Data Management. Big Data, he added, is the economic rise of data capital, the collection of recorded use of information necessary to produce a good or service.
What makes Big Data so important is that it is proprietary. Sonderegger used the Uber car service as an example. Uber’s surge pricing kicks in when demand for rides becomes very high. Data is collected from all the rides hired, the data drives the pricing algorithm and only Uber can do this as their competitors cannot.

Clinical decision support: no longer just a nice-to-have

Posted on Jul 14, 2015
By Mike Miliard, Editor
Since Hippocrates first brandished a pair of bronze forceps, care providers have aimed for quality. It's always been the goal to deliver safe and effective care to best extent possible.
But there's always room to improve. And nowadays, with the shift from volume to value finally taking hold, moving toward better clinical care is no longer optional.
This past fall, the U.S Department of Health and Human Services announced it will invest $840 million over four years to help 150,000 clinicians improve patient outcomes, reduce unneeded tests and avoiding unnecessary hospitalizations. One of the central pillars of its Transforming Clinical Practice Initiative is to help providers regularly use electronic health records to examine data on quality and efficiency.
A few months later, in January of this year, HHS upped the ante – making an 'historic' announcement of ambitious new timelines toward value-based care. Furthering its embrace of alternative reimbursement models such as accountable care organizations and bundled payments, HHS set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016.

Risk analysis could have prevented OPM misery

Posted on Jul 14, 2015
By Mary A. Chaput, Clearwater Compliance
The massive data breach at the Office of Personnel Management has already brought down director Katherine Archuleta and launched a class-action lawsuit by the American Federation of Government Employees. The breach has compromised sensitive records (including Social Security numbers) of an estimated 21.5 million people.
The two biggest takeaways from the OPM breach are:
  • This fiasco could have been prevented by conducting a bona fide information risk analysis on the front end
  • Data breaches often come in stages, where the first round of mistakes leads to a second round of breaches, etc.

Hospital M&A: Why CIOs are critical

July 14, 2015 | By Katie Dvorak
Chief information officers are key players when entities merge or are acquired, responsible for making sure the technologies from both parties can seamlessly integrate.
Ensuring that technologies merge quickly and in a cost-efficient way can have a big impact on the success of a merger, Richard Raysman and Francesca Morris, partners in the New York office of Holland & Knight, write at the Wall Street Journal.
CIOs at healthcare providers and companies, in particular, have a great deal of responsibility when two entities combine.

Digital Health gets a new online home

Digital Health Intelligence Limited has today launched a new website to provide a home for Digital Health’s News, Networks, Intelligence, providing a platform to enable users to make smarter connections.
We aim to provide a really helpful resource for everybody interested in helping to understand and shape the fast evolving field of digital health.   
The new website has been built to be responsive and uses the Bootstrap framework to provide a site that will work equally well on smart phones, tablets, laptops and desktops.
Digitalhealth.net brings together the most exciting and innovative parts of the old EHI portfolio. Starting with trusted, independent news and features; coupled with the data, analysis and benchmarking tools of the intelligence business; and now underpinned by the best practice events and collaboration communities of the CCIO and Health CIO networks.

10,000 patients using Emis PHR

More than 10,000 people are recording personal health data using Emis Health’s personal health record, which runs on Apple’s HealthKit platform.
The company’s chief medical officer Dr Shaun O'Hanlon said these users have made 2.6 million observations since the product was launched in September last year, recording information such as activity data, weight, pulse and glucose levels.
O'Hanlon, who was speaking at this month’s iLinks event in Aintree, said that peak usage is among people aged 40-49, although there is one user over the age of 100.
The tool can process data from a variety of devices, including blood pressure monitors and wearable fitness trackers, and collate this in HealthKit – Apple’s platform for health monitoring tools.

12 budget considerations for implementing an EHR

Written by Akanksha Jayanthi (Twitter | Google+)  | July 13, 2015
The financial implications of implementing an EHR can be severe, especially when considering adoption of electronic records can cost upwards of hundreds of millions of dollars.
Hayes Management Consulting offers the following 12 budget items to address when preparing for an EHR go-live, according to a Health Data Management report.
1. Estimate the build costs of the EHR, including the costs of building out each individual application module. Some vendors require more work to construct the final product, and customization always costs more to complete.
2. Consider compensation, both in terms of financial and time, for physicians who are involved in the rollout, as they will be taking on additional duties to help with the implementation.

AHRQ to Fund Clinical Decision Support Learning Network

July 13, 2015
Goal is to help CDS artifacts become more shareable, health IT standards-based, and publicly available
The federal Agency for Healthcare Research and Quality (AHRQ) plans to launch an initiative to disseminate and implement patient-centered outcomes research (PCOR) findings through clinical decision support (CDS) at the point of care.
This initiative includes creating a PCOR CDS Learning Network to drive the field of CDS forward and to conduct CDS projects to extend existing or develop new CDS based on PCOR findings.
This is not AHRQ’s first foray into clinical decision support. The agency also funded the Clinical Decision Support Consortium (CDSC), a five-year project to find ways to make CDS knowledge more easily shareable. That project involved health systems consuming CDS as a web service generated by Partners HealthCare System in Boston.

Telemedicine's rapid rise: Examining the factors

July 13, 2015 | By Dan Bowman
Mobile technologies and an increased push by states demanding coverage from insurance companies for telemedicine have prompted rapid growth in the industry, even as sluggishness from Medicare on the issue looms, according to a recent article in the New York Times.
Regarding the former, both hospitals and telemedicine companies are taking advantage of the fact that consumers increasingly want on-demand care, the article notes. For instance, Thomas Jefferson University Hospital in Philadelphia, it points out, now enables patients to conduct virtual follow-up visits with internists, urologists and ear, nose and throat specialists. The hospital has built a program to allow physicians to perform consultations using video apps so patients with less-critical needs are treated in other settings besides the emergency room.

HealthPartners launches online therapy for the blues

HealthPartners offering self-directed therapy. 
By Jeremy Olson Star Tribune
July 10, 2015 — 8:28pm
A growing movement to help people cope with anxiety, stress or mild depression — therapy without the therapist — has reached the Twin Cities, with Bloomington-based HealthPartners offering a new online tutorial that patients can use at home.
“Beat the Blues,” a Web-based program used frequently in England alongside antidepressant drugs and talk therapy, will debut in Minnesota as an early warning system to help people before their symptoms reach clinical or disruptive levels.
“What we are trying to do is get upstream,” said Karen Lloyd, HealthPartners’ senior director of behavioral health.

68% of physician practices say they haven't seen ROI from their EHRs

Written by Carrie Pallardy | July 10, 2015
More than half of physician practices, 67.7 percent, do not believe their EHRs have produced a return on investment, according to the 2015 Tech Survey sponsored by Kareo.
Though physician practices may find ROI to be lacking, they have also seen benefits; 74.6 percent of practices say EHR use has improved patient documentation.

BREAKING NEWS: 21st Century Cures Act Passes U.S. House of Representatives, Moves to Senate

July 10, 2015
On July 10, the U.S. House of Representatives passed the 21st Century Cures Act, which now moves to the Senate
On Friday afternoon, July 10, the U.S. House of Representatives passed the 21st Century Cures Act, H.R. 6, by a vote of 344-77, sending it to the U.S. Senate. The main focus of the legislation is an attempt to remove regulatory roadblocks in the review process for new pharmaceuticals and medical devices on the part of the Food and Drug Administration (FDA). In addition, according to Congress.gov, the federal government’s official legislation tracking service, “Requirements are established [in the bill] for interoperability and certification of health information technology. Practices that discourage the exchange of electronic health information are prohibited.”
After the House’s passage of the bill, the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) released a statement attributed to Leslie Krigstein, interim vice president of public policy, praising the bill’s focus on interoperability.  “The 21st Century Cures Act is a landmark piece of legislation that will move our nation closer to a 21st Century healthcare system,” Krigstein said in the statement. “As recognized in this bill, health information technology will serve as the foundation to foster many of the ideologies in delivering lifesaving cures to patients more rapidly.”

Use of e-health services still at early stage - Nivel

Monday 13 July 2015 | 10:19 CET | News
E-health services still have a long way to go in the Netherlands before achieving their stated aims, according to a study by Nivel, a healthcare research institute, in cooperation with Nictiz, an expertise centre on healthcare standards. The survey found that around 10 percent of chronically ill patients could access their medical information with care providers over the internet in the past year. Many were not aware of the opportunities for accessing such information online, Nivel said. The Dutch health ministry targets 80 percent of chronic patients and 40 percent of all the Dutch to have access to online medical information within five ears. 


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