Month: October 2016

Enactment of Healthcare Reforms, Including PPCA, Drives the HCIT Solutions Market by Deepa Tatkare

According to the Bureau of Labor Statistics in the U.S., about 1.2 million vacancies would be available for registered nurses from 2014 to 2022. 

The demand of home healthcare is expected to increase and drive the healthcare IT solutions & services such as telehealth, telemedicine, and mHealth during the forecast period to meet the demand-supply gap

Enactment of Healthcare Reforms Including Patient Protection and Affordable Care Act (PPACA) Drives the Healthcare Information Technology (HCIT) Solutions Market 

Healthcare information technology (HCIT) deals in creation, design, development, and maintenance of information systems for healthcare organizations. It is expected to improve medical care, curb costs, minimize manual errors, and enable the optimization of reimbursement for ambulatory and inpatient healthcare providers.

Many government healthcare policies promote the use of both non-clinical and clinical solutions, especially electronic medical/health records (EMR/EHR), mHealth, and telehealth. While, EHRs benefit healthcare organizations by curbing treatment costs; mHealth utilizes mobile phones and communication devices to provide immediate care to patients. Increasing number of patients have adopted mHealth, as it is economical, and provides insights on preventive health care services, chronic disease management, disease surveillance, epidemic treatment support, outbreak tracking, and reducing overall healthcare cost. 

Patient Protection and Affordable Care Act (PPACA), commonly termed as Obama’s Health Care, is one of the most important healthcare policies that has affected the adoption of HCIT solutions. 

This law is effective in promoting enrollment of uninsured population, boosting use of HCIT solutions & services, and stimulating the adoption of electronic medical/health records. There are nine major separate legislative titles under PPACA, which include:

  • Affordable health care for all Americans
  • The role of public programs for the implementation of this act
  • Improving the quality and efficiency of health care facilities
  • Prevention of chronic diseases
  • Organized management of healthcare workforce
  • Transparency and program integrity
  • Improving access to innovative medical therapies
  • Community living assistance services and support
  • Revenue provision

For complimentary access to more information on this research:

Some key sections of PPACA that are expected to impact healthcare information technology market are:

Section 2401: 

offers home- and community-based medical services for qualified individuals. These services assist patients to accomplish regular life activities and ensure continuous care for them. This section will have a direct impact on the HCIT industry, as it guides patients on their health status via telehealth or mHealth, enabling them to be in real–time communication with their doctors. 

Consequently, the demand for such services has significantly increased, which stimulates the adoption of telehealth and mhealth market. In fact, Telehealth segment is expected to grow at a CAGR of 33.27% during the analysis period.

Section 2703: 

provides home-based medical services for patients with chronic diseases such as cardiac condition, cancer, diabetes, and others. This section promotes the use of IT–based care management systems and stimulates the integration of IT in healthcare industry. 

The subdomains of healthcare include laboratory management, practice management, financial management, patient, and billing management, payment management, and others. Increasing incidence of chronic disorders among individuals has posed a key challenge to healthcare organizations. 

Hence, different management solutions are available for different levels in the market. This act stimulates the demand for healthcare management solutions & services, thereby driving the market growth.

Section 10410: 

establishes national center’s for treating depression. It is anticipated that EHRs would be used. It also promotes the use of telemedicine.

Section 4103: 

mandates medicare patients to have an annual wellness visit. It is expected that these visits would encourage patients to self-manage their medical problems. Moreover, they would be trained in self-management through the use of healthcare IT.

Section 2717: 

aims to establish quality reporting for both group and individual health insurers. This section focuses on regular reporting of healthcare insurance companies about their performance, and promotes the implementation of different healthcare payer solutions such as claim management, fraud management, and others. Stringent government rules for proper and timely reporting of healthcare-related financial documents have fuelled the demand for IT-based payer solutions.

These sections would propel the growth of EHR market in North America; affecting the world HCIT market. Moreover, dearth of skilled medical staff in healthcare facilities has hampered the market growth in the region. 

For instance, according to the Bureau of Labor Statistics in the U.S., about 1.2 million vacancies would be available for registered nurses from 2014 to 2022. 

The demand of home healthcare is expected to increase and drive the healthcare IT solutions & services such as telehealth, telemedicine, and mHealth during the forecast period to meet the demand-supply gap.

The article has been published with the Author’s permission
Deepa Tatkare

Deepa Tatkare, has an experience of more than 3.5 years in market assessments and forecasts in healthcare & medical device industry. She is actively involved in providing critical insights on business research to clients with her subject matter expertize. Her profile includes planning, commissioning, and executing syndicate as well as customized research projects. She has successfully analyzed and presented data for studies related to medical devices, biotechnology, and pharmaceutical domains

What 2017 has in Store for Physicians? by Aiden Spencer, @aidenspencer15

The coming year is going to be tough if you’re a physician. There are several things that are going to change. It is important to be prepared about the coming changes in regulations, and what is required from a practice. This article will provide a brief summary about the coming changes, and what you can expect from 2017.

Before 2017

The year hasn’t completed ended yet but the healthcare industry has been bombarded with changes. The recent ending of the ICD-10 grace period has been the first major change leading into 2017. It has effected many practices in a number of different ways. It should be remembered that in the long run going electronic will benefit the entire industry. 

The possibilities are endless in the future, collaborative studies using patient data, the entire industry coming together to create something that could very well change the way the industry has worked for many years. 

Of course in the short run there will be certain problems especially as practices get used to the changes. Many physicians have even expressed concerned over productivity dropping because of all the regulations that have been imposed. These are minor setbacks in the grand scheme of things, and productivity is bound to rise in the long run.

Conclusion of Grace Period

The ICD-10 changes are something that every practice needs to know about. There have been almost around 3000 code changes starting October 1st. The biggest problem for practices is how to deal with the advent of these new codes. It is important to have a medical billing software to get through the paperwork. Whether your service provider has complied with the recent updates is a good question to ask. However if there hasn’t been an automatic update than you need to think about changing your service provider.

There are practices which still do not use a medical billing software, and it is important for them to know which family of codes has been changed and whether the changes affect your practice. The practices that aren’t totally electronic yet are going against the tide, and it is recommended that they shift if they wish to keep afloat in the long run especially with Medicare Incentive Payment System, and the changes that will entail. 

Claim Denials

The new ICD-10 codes, and the end of the grace period means that a practice can no longer use unspecified codes. This many have said will increase claim denials in the short run, and this could upset the budgeting of many practices. However practices that have medical billing software from reliable companies and vendors will not have to worry about claim denials going drastically up. Practices that aren’t using a software, should make sure they know the code changes especially the ones that effect their practice.


There are other changes that a practice needs to be aware about. The upcoming elections will truly decide the fate of the healthcare industry. Both the candidates are going in different directions. While Hillary Clinton wants to ‘tweak’ the Affordable Care Act (ACA), and keep going in the same direction, the Republican nominee Donald Trump wants to repeal the ACA. 

It is imperative that a practice be prepared for both outcomes. Whether that means more regulations, or less. In a Trump presidency, not only will the ACA be repealed, but insurance would be sold across state lines. This could potentially open up companies to more competition. Whereas a Hillary Clinton presidency would support state-based public option, and even limit covered consumers out of pocket liability.

Both the parties have disagreed on a problem of fundamentals. The future of healthcare industry hinges on the basic problem of how much spending should be done on federal level? The republicans have the view that there is too much spending currently on healthcare and not enough revenue. They plan to fix this by relying on the private market, which through competition would reduce costs.

The Democratic Party suggests that the amount of spending is not too much, it is however a problem of extracting revenue. This could be done according to the democrats by improving current government programs.     

What does this mean for a Physician?

For a practicing physician there isn’t much of a change as far as the elections are concerned. This is because it is important to first see the results of the elections. However one rule of thumb that we can go with is that there will always be regulations. This would mean that a practice should have meaningful use and HIPPA compliance. There are many Electronic Health Records (EHR) software that have integrated all updates, including the changes in the ICD-10 codes.

With the addition of Medicare Incentive Payment System, or MIPS, there will be a significant increase in transparency since reporting on performance measures will begin in 2017. Although the composite performance score (CPS) will be calculated and posted in 2019 it is important that all practices pace themselves along with these changes. The future of the healthcare industry is electronic, and regulated. Thus physicians should prepare accordingly. However after November 8th we will have a clearer picture as to which direction the healthcare industry is going towards. 

The article has been published here with the Authors permission. 

Aiden Spencer

Aiden Spencer is a health IT researcher and writer at CureMD who focuses on various engaging and informative topics related to the health IT industry. He loves to research and write about topics such as Affordable Care Act, electronic health records, Medical Practice management and patient health data.

3 P’s framework – 7D’s Process Foundation by Prashantha Sawhney

focus on Process as it relates to the “how” the work is to be done

This article is a continuation of my previous post – 3 P’s framework – People are the key. We now focus on Process as it relates to the “how” the work is to be done.

There is a plethora of options in terms of processes one can follow to be successful. Across software literature one come across many variations and combinations of the “D..” verbs typically used in software development. One that is simple to use and remember is called 7D’s.

These can be easily understood by asking the quintessential questions of Why, Who (whom/ whose), What, When, Where and How.


Why are we doing this feature/ product? The other question to answer is for Who(m) is this required? These are the hard questions that need to be clearly answered on what the problem/ solution space is and the potential customer base being looked at. This is generally addressed by Product Managers or Portfolio Managers.


What is the expected functionality? This corresponds to the requirement analysis phase and there are different methodologies that can be used for capturing and validating the requirements or use cases. This is generally addressed by Business Analysts, Product Managers or Product Owners.


How are we going to achieve the requirements? This corresponds to the design phase and based on the organization approach, the level of documentation required can vary. Some level of prototyping is also done in this phase to help validate the designs. This is generally the forte of Technical Architects, Development Leads.


How is this to be developed given the requirements and design? Focus is on coding/ development, additional steps involved include testing, debugging, documentation and demos before this is considered complete. The development and Quality Assurance teams handle this important phase with help from Project Managers and Scrum Masters.


When and how is this expected by the customer? Additional questions that need to be clear are the mode of delivery (packaged build on a disc or digital delivery), any requirements specific to on premise/ Cloud/ SaaS deployments, any specific requirements from a platform perspective (Windows/ Linux/ Apple/ Android/ Xbox/ PlayStation etc.) that need to be addressed? The Configuration Management Team manages this with help from the development team.


Where is this tool/ product to be deployed? After the delivery has been made, the actual deployment is done and it is the critical step to get the tool finally in the hands of the customers. There are quite a few projects that do not get past this stage though due to different reasons and sort of lie on the shelf. In case of SaaS/ Cloud offerings, internal DevOps teams manage this phase. In case of on premise installations, this is handled by the customer IT teams along with specialist Implementation Consultants who understand both the product and the customer environments.


Whose Success is it that we aim for? It is obviously for both the end customer as well as the product teams who have toiled to give a final shape to an idea/requirement. There are sometimes roll-out related challenges, performance and stability issues, hard to reproduce issues and sometimes silly defects, but if we keep the Delight of our customers in mind, we work hard towards debugging and resolve the issues. This is best achieved by having a good communication channel between customer and product teams and is built on a strong foundation of trust.

Remember a delighted customer will come back to you and you will have many more cycles starting again from the Define phase.

The article was first published in Mr. Prashantha Sawhney’s LinkedIn Pulse post. The article is reproduced here with the authors permission. The views shared by the author are shared in his personal capacity.

Prashantha Sawhney

Results-driven engineering professional with ~17 years of experience in leading high performance product teams

3 P’s framework – People are the key – Prashantha Sawhney

We focus on People – “who” do the work. While it is important to have a good efficient team, it is equally important to have some norms for them to be successful

This article is a continuation of my previous post – 3 P’s framework to be successful. We focus on People – “who” do the work. While it is important to have a good efficient team, it is equally important to have some norms for them to be successful.

One question that comes up as we look at staffing up or after we have staffed a team is  – will just getting a group of people make them successful in solving problems and making good progress? 

There are many books/ papers suggesting different ways of solving this. The approach that has worked well for me is CHASM. Well, as per the Cambridge dictionary, Chasm means “a profound difference between people, viewpoints, feelings, etc.” Interestingly, in a different perspective and useful way CHASM is an acronym, that I have used for approaching the people aspect:


In small as well as large organizations, we see how working in silos (teams/ departments) causes issues in quality and delivery. This also impacts customer experience, where he/she feels that nobody is really understanding them/ their issue or trying to solve their problem, but tossing the ball across to the next person or department. Collaboration is the key and is an action that the leaders need to demonstrate in their daily work and help inculcate in their teams. This aspect is more of an organizational behavior that individuals need to model.


In today’s world, everyone is trying to prove themselves every minute/second. In the process, we tend to focus a lot on ourselves, our team and trumpet our success. This may at times lead to having a superiority complex. While this is important, it is even more important to stay humble – so we can learn when we make a mistake or to seek help when we are stuck. It also enables team members to be approachable. This aspect is an individual trait and need to be practiced.


Having clear priorities and goals for different team members/ departments that align with the overall company goals is critical. When team members/ departments are not aligned, they can pull in different directions which can cause confusion to the rest of the team/ department. This is an area that the leaders need to work among themselves to get clarity first and then percolate it down the organization. This aspect is more of an organizational behavior.


When people have the right skills and are equipped with the right knowledge/ tools, they can be very effective. However in today’s world with plethora of knowledge sources and learning avenues, this is something that can be easily picked up/taught even after a team is formed based on the time available and nature of work. This aspect focuses on individual growth and can be substantially aided, with the right organizational support/ policies.


With all the other pieces in place, this is the last critical area. When people are aligned with the goals, are challenged at work and believe in the work they do, their motivation levels are the best, There are somethings an organization can do – to provide a good work environment, good recognition and rewards programs, competitive compensation and benefits. However in this aspect, a lot is also the responsibility of the individuals and how they deal with their own internal upkeep and self motivation.

Here’s wishing you have a team that is successful and is able to cross the chasm, from ordinary to very successful teams using CHASM approach.

The article was first published in Mr. Prashantha Sawhney’s LinkedIn Pulse post. The article is reproduced here with the authors permission. The views shared by the author are shared in his personal capacity.

Prashantha Sawhney

Results-driven engineering professional with ~17 years of experience in leading high performance product teams

Reducing Leakage in Admissions, Pharmacy and Diagnostics at Hospitals by Baljit Singh, @mtatva

Typical advised diagnostics in OPD in hospitals ranges from 20% to up to 50% depending on specialty and month of the year. You really need to see how many of these are being lost to competition nearby

Hospitals have two big challenges to stay profitable. First, they have to continuously work to get new patients to discover their hospital. Second, most important aspect, is to get as much revenue from each patient visit. The second one drives both top-line and bottom-line significantly, but is also the least understood process due to inherent limitations.

Many hospitals achieve great OPD inflow but very little sales in IP, diagnostics and pharmacy. If you are facing this problem, then this article is for you!

Typical advised diagnostics in OPD in hospitals ranges from 20% to up to 50% depending on specialty and month of the year. You really need to see how many of these are being lost to competition nearby.

Understanding patient flow at hospital

For multi-specialty hospitals, OPD is like a landing place where patients first land. Based on the treatment advised on OPD records (mostly prescriptions), patients can either use pharmacy, diagnostics or IP services inside the hospital or from other providers outside. For example, a patient coming to OPD with chronic pain would need to get scanning, medicines, surgical belts and physiotherapy. Patient could do these either inside the hospital or outside hospital.

Typical Patient Flow at a Hospital and Revenue Loss

Hospital would like patients to avail facilities inside the hospitals rather than outside. Hospital management is always worried about the losses due to patient going out of the hospital for follow-on diagnostics, pharmacy or procedures.

Need to measure leakage

Unfortunately with current set of tools available with hospitals, they cannot measure this leakage effectively and continuously. Although hospitals know very well on who is landing on their pharmacy, lab and admissions, they do not know who were advised one of these but chose to go out for fulfillment. If somehow their OPD records became digital they could measure this easily. But this does not happen and hence the fallout. 

What they actually need is digitization of their OPD records. The only option available to hospitals is using EMR which is very costly in terms of allocating resources or equivalent cost of doctor’s time for electronic-entry. Nor are the specialists and super-specialists inclined to do it.

The benefits of digitizing OPD records are obvious but how can this be achieved efficiently? How can this be done with no changes to current work-flows for the hospital and the doctors?

Proposed solution to reduce leakage

Do hospitals need to live with this till EMR becomes a reality? No! There is a solution.

Stop Admissions, Diagnostics and Pharmacy Leakage

Health-PIE service available as of now can digitize OPD records cost effectively. This solution uses artificial intelligence based technology to reduce cost. Also gives direct benefits of digitization to patients as well. Realizing hospitals are already overburdened, the solution comes with zero need of training to hospital staff or any major change in workflows.

Health-PIE helps hospital understand their OPD patients and flow, helping hospital with measurement of leakages and analysis. Health-PIE will also uses artificial intelligence to continuously communicate with patients through their treatment creating stickiness. This stickiness helps increase OP to IP conversion. This double-pronged approach of Health-PIE is a killer solution which can increase top line as well as bottom line of any hospital!

Baljit Singh, CEO, mTatva

Baljit Singh having more than a decade experience in variety of roles in Technology, business, strategy and management. He worked with multiple companies including one of top semiconductor companies as well as startups. Baljit is passionate to work in healthcare IT industry to solve some of key issues in primary healthcare. He also started SPOG

Why Do We Want #Interoperability? by @Matt_R_Fisher

Interoperability, to a large degree, comes down to having a fully unified healthcare system where data is always available

A lot of time and attention has been put into the notion of interoperability by almost every stakeholder in the healthcare system. Those interested in the issue include patients, providers, vendors and the government. Why has interoperability received so much focus, though? It may be possible to answer that question by stating that interoperability contains a large element of the common good.

Defining interoperability can be challenging, but a definition adopted by HIMSS in 2013 offers a good, comprehensive version: “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.” Putting that into even plainer English, interoperability is the movement of data as expected and without hindrance. Ultimately, that likely expresses the expectation of many, individuals want data to be where it needs to be without a hassle.

Depending upon an individual’s role within the healthcare system, that individual may have a different perception as to the importance of interoperability. Patients want data moving without thought because patients expect seamless transitions in care. If a patient is traveling or goes from one provider to another, the medical data should be there. Other industries have mastered the ability to allow data to move around, but healthcare is still working on that issue. As such, the patient viewpoint on interoperability is that it should just exist.

Providers, much like patients, likely want to have all information about a patient available. For example, if a medication has been administered in one setting and a patient presents elsewhere, the subsequent provider wants and needs to know what has already been done in order to avoid a very easily preventable error. Additionally, providers want to know a patient’s full history, which may be more easily obtained from previous records than from the patient. The provider viewpoint on interoperability is that it forms a basis for good care and ensuring all data is available.

Electronic medical record and other HealthIT vendors may see interoperability as either a product challenge or potentially an impact on business. Clearly, the healthcare industry relies on vendors of products to build those products in a manner that permit interoperability. All the wishes for interoperability will go for naught if the tools being used are not set up to support it. That being said, are the right incentives in place? That question may be a bit unfair to the vendors because, optimistically, vendors are not necessarily trying to create public harms. Accordingly, the vendor viewpoint on interoperability may be a bit muddled, but at the end of the day should be favorable.

Given those potential viewpoints on interoperability, why is it so important? Interoperability is considered an essential element to succeeding with value-based care and/or population health, the government is turning its attention to the matter, and increasing patient demand. From the industry perspective, the value-based care and population health reasons are likely the most compelling drivers for wanting interoperability. 

Value-based care forms the basis for many alternative payment models, which is where the healthcare industry is quickly heading. If the right data are not available to understand how a provider is performing, then the likelihood of success decreases and in turn puts financial pressure on the provider. The government is also related to the push toward alternative payment models. 

The government, specifically the federal government through Medicare, is causing a seismic shift in the reimbursement system. The government wants these efforts to work, which means that all tools must be aligned. Rumblings have suggested that if interoperability is a problem, then the government may force the outcome it wants.

Ultimately, interoperability, to a large degree, comes down to having a fully unified healthcare system where data is always available. Thinking of the banking industry, this is true of account information because an individual can readily access it through an online account or at an ATM, for example, and then be able to access that money from almost everywhere too. Similar examples can readily be pulled from numerous other industries. The question continually comes back to why should healthcare be any different.

As suggested above, solving the interoperability conundrum comes down to a common good. Arguably everyone wants patients to be able to receive the best care possible. That means having data available and on hand.

Hopefully, this post results in an open dialogue about the issue of interoperability. I will be presenting at VITL Summit 16 on this same topic and welcome comments and thoughts that I can incorporate into my presentation. Please post in the comment section, email me, or engage on Twitter. If we can all focus on the issue and begin to reach a consensus understanding, that would be a good outcome.

Matthew Fisher

I am the Chair of the Health Law Group and an associate with Mirick O’Connell. I am also a member of the firm’s Business Group. I focus my practice on health law and all areas of corporate transactions. My health law practice includes advising clients with regulatory, fraud, abuse, and compliance issues. With regard to regulatory matters, I advise clients to ensure that contracts, agreements and other business arrangements meet both federal and state statutory and regulatory requirements.

Steps to Performance Transformation by Ritesh Dogra @Ritesh_Medium

Take a step back and think on the fundamental question – ‘Have I created enough value in my current business model?’

Since the last year, we undertook quite a few ‘Performance Transformation’ projects. This was a pleasant change – existing healthcare providers trying to transform themselves and this had nothing to do with increasing bed occupancy either! So what is performance transformation?

Simply stating, Performance Transformation is Creating Value in Existing Infrastructure which will differentiate an existing set up in the market. To understand this, lets step back and reflect on a familiar concept, the S-Curve.

Redefining the S-Curve
Quite often, a business model in its maturity reaches a stable state. The revenue and margins become stagnant and at this time the promoter is faced with a fundamental question – What Next? This is followed by expression of interest from investors to scale up or providers evaluate new business models. It is at this point of time healthcare providers should take a step back and think – Is this real or perceived S-Curve? And on going deeper, the answers can actually redefine the ‘maturity state’. It is our inherent biases and preexisting knowledge that prohibits us from doing this. In the following section, I will try to elaborate the key steps which can actually help an existing organization transform itself.

1.Start with Immersion and Eliminate the Structure
We are all familiar with the term micromanagers, how about creating new creed of people who we call ‘micro-observers’ and ‘micro-listeners’? Even the best of managers fail to observe and listen to real patient problems and quite a bit of this is attributed to our ability to structure every element of our life– right from structured feedback to structured questionnaire to structured problem solving. Structure is great but never works when you need to understand your customer! Let’s start with unlearning all structures and just immerse ourself, spending our valuable time sitting in lobbies and corridors to understand our customers and break preexisting notions. This will throw up a lot of questions and answers!

2. Stop Gossiping and Start Talking
Our employees right from frontline staff to executives are in midst of action everyday. In fact, few other industries would offer the type of action that healthcare does. Let’s start listening to them and avoid side gossips, else soon we could be competing with Facebook! Spending time with employees to understand problems – their and customers, rather than skimming the surface, in my experience has been really helpful.

3. Identify Problems, Brainstorm and Lastly Don’t be a Super Hero!
While the first two steps will throw out problems and some indicative solutions, go ahead and dig deeper. Only super heroes in movies can save the world! In real life, understand the implications of problems followed by quantification of loss and the impact which solving them could mean for you. Prioritize problems, it always helps. And this is the stage where you can get into your familiar territory – structured problem solving!

4. Make Change Personal
Go ahead and implement solutions; align everyone in organization to your ultimate goals, make them a part of the larger cause, in fact create a mission. For any change to be effective to the core, it has to be personal. Create sub parts of larger solutions and assign everyone an implementation agenda and plan. You will gradually notice a change in your organizational culture, a change for good. And for this to be effective, never create incentives for culture change- it can be suicidal; only offer incentives for results which come unexpected.

5. Create Value and Monitor the ROI
After all, we started with the S-Curve. Start monitoring the impact and you will notice a shift in the S-Curve. And this is the time when you should make a shift to communicating the change – to your employees, target segment, investors and everyone in the ecosystem. More people should benefit from the change- shouldn’t they? And ultimately all of this will reflect in your financial metrics; Revenue, ROI and EBITDA.

So the next time you start thinking of larger than life problems such as trends shaping healthcare or attracting investors for scale, it would be worthwhile to take a step back and think on the fundamental question – ‘Have I created enough value in my current business model?’

Originally published in Healthcare Radius, March 2016:

Ritesh Dogra

Ritesh has been a member of the Founding Team at Medium Healthcare Consulting. He has led a number of engagements in areas as diverse as market expansion strategy for a Fortune 500 medical equipment manufacturer to planning and commissioning of novel healthcare concepts to performance transformation of a leading hospital chains in South and East India. He has received numerous accolades from clients for his rare insights and extraordinary commitment.
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