Functional Screening as a lead generation tool

UBC BodyWorks Centre

UBC BodyWorks Centre

This past week the Bodyworks Fitness Center at the University of British Columbia School of Kinesology had an open house. They offered free functional movement screenings (FMS) and Titlest Performance Institute (TPI) screenings for golfers.

A few of us signed up for the 20 minute screens and walked away with a scoring sheet of results. The TPI was probably more useful as it specicially targeted golf and was pretty clear where the individual would need to improve to positively affect golf swing. The FMS was interesting in that it highlighted core stability issues that a person might not be aware of, however, the session could have been improved if the screener had engaged us in a few questions about our sports and exercise goals. Otherwise, it was hard to make the leap from the screening results to potential areas for improvement. It was nice to find out that an old shoulder issue has healed and is back to a full range of motion.

Titlest Functional Movement Screen

Titlest Functional Movement Screen

The real value to the center in providing these free screenings in getting the person to sign up for a program based on improving their weak areas. The open house also featured free access to the fitness center, talks on wellness, and tours. All of these activities were designed to raise awareness and hopefully gain new clients, especially before they become injured.

Our curiosity and love of the word “free” got us in the door, which is definitely a good first step. Did we join? No, and that’s because the location isn’t convenient, which is something for single clinic practitioners to consider. Unless you’re the local expert in a particular type of treatment or injury, your market is largely your local community.

Titlest Functional Movement Screen

Titlest Functional Movement Screen

We weren’t really the target market:  the Kinesiology student who showed us around mentioned that the target was mostly professors, students, and seniors who lived in the area. Apparently people won’t walk more than a block to a coffee shop, which is why in Seattle and Vancouver there’s one on every corner. We wonder if anyone’s figured out how far they would walk or drive to a clinic or a fitness center.




Posted in: Rehabilitation Business

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A Disruptive Solution for Healthcare

In order to deliver healthcare for all, we need to reevaluate the ‘gold standard’ of healthcare delivery and look to new models of care.

This was the message of a talk a few of us from Wellpepper attended last week given by Dr Jason Hwang. Dr Hwang is an MD and also an MBA who collaborated with Harvard professor Clayton Christensen on the book “The Innovator’s Prescription: A Disruptive Solution for Health Care.

IBM 704 Mainframe Circa 1964. Source Wikipedia.

Dr. Hwang used the familiar story of disruption in technology from the mainframe to the PC and now smart phone to draw analogies between the current state of healthcare, and where it needs to go. He calls hospitals the “mainframes” of the healthcare system. Highly powerful, capable of delivering great output, but not necessarily convenient or accessible, just like mainframes used to be. Consumer clinics, for example a nurse practitioner working out of a storefront in Walmart can be seen to be more similar to the convenience of a smart phone.  However, the industry hasn’t changed processes and regulations to accommodate these new models causing unnecessary overhead and barriers. Does a storefront clinic with no doctors need the same levels of documentation and EMR as a hospital?

Disruption makes what was once inaccessible more accessible, and eventually delivers it into the hands of consumers. The ridiculously powerful computer that 50% of us have in our pocket or purse is the perfect example of that. This computer is also democratizing healthcare. There are approximately 17,000 medical applications that enable consumers to track and sometimes even diagnose health issues that previously required visits to specialists.

Any doctor that can be replaced by a computer deserves to be. The idea is not to replace doctors but to free them up to do the work they were trained to do.

The same could be said of specialist and generalist roles in healthcare. Nurse practitioners can take on a lot of responsibilities that were previously tasks of doctors. Medical aides can take responsibilities from nurses. Advances in technology are helping to make expensive diagnostic tools cheaper and more ubiquitous.

What does all this mean for physical therapists? Dr. Hwang stressed that it’s very difficult for those within the system to disrupt it. For example, once a hospital exists there become all types of reasons for it to continue to exist: shareholders, board of directors, senior management, employees. It’s very hard for a company to cannibalize itself. He believes that those in the wellness, prevention, health and fitness industries have a greater opportunity to cause this disruption. Physical therapists have the unique position of being within the industry but not at the center of “how things have been done.” As they move into looking at the whole health of the patient, and more important in preventing injuries, they can be part of this change in medicine.

An interesting example of this is physical therapy combined with other health and wellness; for example, a clinic that has an MD, naturopath, nutritionist, and physical therapy practice, or a “medical gym” which combines a physical therapy practice with a traditional fitness center. This would be the perfect place to practice preventative medicine.

We’ve seen a lot of chat on Twitter about how physical therapy can be part of the positive disruption that’s happening in healthcare. At Wellpepper hoping we can help you move forward new models for patient engagement and involvement.

Posted in: Healthcare Disruption

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Best practices for Telemedicine

Telemedicine has great potential to deliver just-in-time physical therapy. While it’s not appropriate for all situations, where it is, it can be a cost effective way to stay connected to patients and deliver service.

Our previous recap from the American Physical Therapy Conference session featured Just-In-Time Management principles including telemedicine. There was so much good advice in the session we’d expand on some of the best practices for telemedicine outlined by Carol Jo Tichenor, Director Physical Therapy, at Kaiser Permanente.

Where to Implement Telemedicine

First consider where telemedicine can augment, improve, or streamline your practice. For Kaiser Permanente, telemedicine was very effective treating students who were part of Kaiser’s system in California but attending out-of-state colleges. A British study found that using telephone calls as an intial screening for back pain resulted in shorter wait times for patients, and fewer missed appointments.

As you consider where you might include telemedicine, ask yourself whether you have patients who:

  • Are remote or need to travel long distances for treatment.
  • Are ‘road warriors’ and travel frequently for their profession.
  • Have work schedules that make it difficult to schedule appointments.
  • Have physical difficulty getting to the clinic but are not candidates for home care.
  • Might need a short-check in rather than a full-scheduled visit.

How to Implement Telemedicine

Successfully implementing telemedicine, or any technology into your practice for that matter, requires not just a technical implementation plan but also a people and process plan. Technology projects fail if they are not integrated into the way people work.

Some things to consider.

  • Will you offer virtual appointments to all patients or just some who meet a certain criteria?
  • Will you use virtual appointments for pre-screening or will you require a face-to-face visit first? There are pros and cons to either approach. Pre-screening might help get patients to treatment faster. Face-to-face allows a hands on assessment and the ability to establish a rapport with the customer.
  • Do you have space in your clinic to run the telemedicine sessions? You will need a quiet location with good lighting.
  • What technology will you use? Does it work on existing computers? This could be an entire blog post in itself. A few key points for you to consider:
    • Is it secure? Skype and FaceTime do not provide the security required for HIPAA or other personal data protection laws. These are consumer technologies that will not guarantee that data is passed securely.
    • Is it easy for the provider and the patient to use? Does the patient need to install plug-ins?
    • How many people will need to use it?
      Teleconferencing with Microsoft Lync

      Teleconferencing with Microsoft Lync

Thinking about the way people work, do you have some providers who are better than others at patient communication? Telemedicine removes some forms of communication, so only your best communicators should probably participate. When will you schedule appointments? During the day or before or after office hours? If the equipment is shared, how do you make sure it’s available for an appointment.

Also think about how you will make technology adoption as easy as possible for practitioners. What types of training programs will you offer for them to learn the technology? How will you make sure it’s available?

How to Run the Session

With the adoption of telehealth there are starting to be best practices on how to conduct a session. Here are a few things for you and your practitioners to consider.

  • If possible, start with an in-person visit to establish rapport.Consider how you can make the technology adoption as easy as possible for practitioners.
  • Plan what is possible for the visit. Telehealth is better for check-ins than to establish a new program with a patient.
  • Practice using the technology before the session, and if you don’t have a lot of personal experience with video calls with consumer technology like Skype or FaceTime, make sure to do some practice calls first.
  • Start the session with some small talk to make communication easier.
  • Look at the camera. Make eye contact.
  • White coats add too much glare and it’s hard for the other person to see you.
  • Try not to move around too much.
  • Keep the background clear of distracting clutter.
  • Keep the patient aware of what you’re doing. If you’re looking something up or thinking about a response, tell them. Video calls often miss these queues.

Telemedicine might not be for every practice, however, increasing costs coupled with increasing expectations of consumers and patients, it will most likely become a key service in healthcare delivery.

Posted in: Healthcare Technology

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Just-In-Time Management Principles for Physical Therapy

Disruptive technologies and business models, paired with changing consumer expectations, will change healthcare.

In keeping with our theme of lean healthcare, today’s topic is a recap of the American Physical Therapy Conference CSM 2013 is a session called “Doing Today’s Work Today: How To Reduce Inefficiencies in Physical Therapy Service Delivery Through the Application of ‘Just In Time’ Management Principles.” Yes, the title was quite a mouthful, but the session was well organized, clear, and straightforward. Presenters Todd E. Davenport, Nicholas J. Ferlatte, Ivan Matsui, Carol Jo Tichenor, were all from Kaiser Permanente. Since Kaiser Permanente is a managed care consortium, they are able to experiment with programs and collaboration between disciplines all within the umbrella of their organization.

Starting with a recap of lean management principles applied to healthcare, presenters focused on case studies and learning from three programs at Kaiser, all designed to increase client satisfaction and decrease waste.

Roving physical therapists program

This program had physical therapists ‘on-call’ to be brought in if a consulting MD needed support. The therapist could quickly access the situation, make a prescription, and then decide whether the patient needed a referral. If the patient needed a referral to a physical therapist, they might have to wait 30 minutes to see that physical therapist rather than a few weeks. The results of the program were significantly happier patients, and a dramatic reduction in the wrong physical therapy prescription. Given that patients were seen sooner, there could also be assumed to be better recovery times as well.

While this program turned out to be the best for patients, some considerations needed to be taken on how to manage the physical therapist’s productivity. Kaiser’s structure of being a full-service managed care organization enabled this scenario, but it’s definitely worth considering how to bridge this gap with integrated care.


Telehealth is expected to grow 55% in 2013 and reach 1.8M patients. This is partially driven by Medicare’s penalties on readmission, but also as Kaiser Permante learned, by consumer preference. Patients liked the video check-in because it meant they didn’t have to leave work or battle traffic for their appointments. There was also a strong personal connection having the appointment at their convenience and location rather than a clinic. However, one extremely important reason they liked the Kaiser program was that it was free. This is a consideration that’s not possible for many clinics. However, we have seen changes in billing codes in most states that allow for telemedicine.

Patients Preferred Communication Modes

Patients Preferred Communication Modes

The presenters also shared some best practices if you’re thinking of implementing video visits into your practice which we’ll dedicate a separate post to in the coming days.

To judge whether telehealth is effective, you need to consider two factors: clinical outcomes and patient satisfaction. If you’re going to try a telehealth pilot, think about how you will measure in advance.

Workplace occupational injury prevention

Workplace injuries are decreasing, while workplace injury costs are actually increasing. That is, fewer people are being injured but it’s costing more to treat those injuries. The main users are younger men who work as laborers, and women 50-60 who work as tradespeople. Similar to other sessions, this session promoted physical therapists as ambassadors of total health and wellness, and in this case occupational wellness.

Kaiser Permanente implemented an occupational wellness program in their own workplace in two high-injury departments: radiology and materials management. Starting with an ergonomic assessment, they then created programs that include pre-shift and at-home exercise programs, and stress and weight management. The result has been a steady decline in workplace injuries over the last 15 years, and a general increase in the importance of health and safety.

While this program was internal to Kaiser Permanente, corporate wellness programs are quite common with their focus on preventative healthcare. This could be an interesting area of focus for physical therapy organizations.

Finally, the panelists encouraged the audience to start thinking about and embracing new business models by saying “It’s okay to ask for money for services provided.”

Posted in: Lean Healthcare, Rehabilitation Business

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Mobile health and the gap between professional and consumer tools

FitBit One Wireless Activity Tracker

FitBit One Wireless Activity Tracker

M-health, quantified-self, daily tracking, FitbitBodyMediaRunkeeperMyFitnessPalStrava, even Nike has gotten in the game. The ways in which consumers can keep track of their health seems to multiply each day. The average consumer device is about $200, often with a monthly subscription fee to track results. Some only charge a subscription if you want more detailed access to your results. At the same time, complex sensors and accelerometers used in medical research can cost thousands of dollars. Sure they are more accurate, but are they more effective in motivating behavior change?

These were some of the questions raised in the American Physical Therapy Conference Session “Mobile Health Technologies” presented by George D. Fulk, Edward Sazonov, and James Cavanaugh.

BodyMedia Tracker

BodyMedia Tracker announced at CES 2013

They reviewed popular consumer devices from a clinical research perspective and weighed them against professional healthcare devices, looking at accuracy, convenience, user preference, and price. While the professional devices are still more accurate, for all other factors it did seem like the consumer devices were winning. For example, many of the new devices, like FitBit can be easily hidden beneath your clothes, while ActivePal‘s anklet makes the wearer look like they are under house arrest. Female participants in one study using ActivePal removed the anklet when they wore skirts. At the Consumer Electronics Show this year, BodyMedia showed trackers that look like jewelry which would solve this problem, and provide some nice word of mouth marketing for them.  While professional devices may record more accurate results, is the overall study more accurate if the subject isn’t being consistently monitored?

Another criticism of the consumer devices was the inability to get raw data, and that if the data were shared, it wasn’t encrypted for HIPAA compliance. Given the price difference, market potential, and popularity of consumer devices, we can imagine these differences will fade in the long run. 

The New York Times reported this past week that more and more people are turning to electronic health monitoring. There are over 13,000 personal health tracking apps available. While some track automatically, self-tracking has shown promise in chronic disease management.

Nike+ Activity Tracker

Nike+ Activity Tracker

A study by Pew research referred to in the NY Times article found “most people with several chronic conditions said that tracking had led them to ask a doctor new questions, led them to seek a second opinion or influenced their treatment decisions.” As well, at Wellpepper we’ve noticed that FitBit has driven a new level of awareness around the number of steps a person should be taking each day, 10K according to Locke et al, with technology venture capitalists challenging each other on a virtual leaderboard.

What does all of this mean for physical therapists? The panelists in the session admitted that the profession is often behind the game in technology adoption, and as a result the technology isn’t developed in a way to be most useful to physical therapists. They encouraged researchers to collaborate with engineering to see better results. Here at Wellpepper, we are technologists building our products in close collaboration with professionals in rehab and research. We are hoping to help bridge this gap between consumer and professional healthcare technology. If you’re passionate about how mobile technology could improve your practice, we’d love to hear from you!


Posted in: M-health

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Whole Health and Wellness in Physical Therapy

Physical therapists are uniquely positioned to look at the whole health of the patient, however,  many are still just treating the injury. Health promotion needs to be a key evolution of the profession.

These were themes  in a few sessions at APTA CSM 2013 last week in San Diego, particularly in “How Can We Integrate Wellness Into Orthopedic Physical Therapy?” and “Challenging PTs to Thrive in a Changing Healthcare Environment.”

Both sessions challenged physical therapists to think about how to expand their impact by focusing on whole wellness of the person, whether that is trying to understand other lifestyle factors that may affect their health, or how to keep people active after their treatment.  When they only focus on the injury, physical therapists get the patient to a certain point of recovery and then discharge. The patients then don’t continue their exercises and are likely to re-injure. The idea of “patients for life” was introduced, not that we want patients to be injured for life, but that patients can continue to look to their physical therapist for prevention of injuries and support for their general well being.

Behavior change was cited as a key tool in helping patients manage their entire health. It’s not enough to get them to do their exercises, they may also have to change their behaviors if these are also impacting their recovery. For example, diet might need to change. Physical therapists are urged to look at one unhealthy behavior and figure out how to change it.

7 Forms of Wellness from University of California Riverside

7 Forms of Wellness from University of California Riverside

Understanding the full picture of wellness, will help understand the full patient. The  University of California Riverside defines these 7 forms of wellness as:

  • Social
  • Physical
  • Emotional
  • Spiritual
  • Environmental
  • Occupational
  • Intellectual

Identifying whether any of these, besides physical, are inhibiting the patient from recovery is key. For example, a patient might be missing social support, like a friend who could go for walks with them, which could slow or impair overall recovery.

Although both talks were similar in their recommendation that physical therapists become more involved in helping the patient modify their behavior to get better, neither offered practical tips on how to do this in a clinical setting. As well, they both admitted that although physical therapists were uniquely suited to do this they didn’t have the right training or tools.

At Wellpepper, we’d say this is consistent with our experience during our research on patient exercise compliance. Some of the physical therapists we talked to had well-defined strategies for getting patients to do their exercises, for example, don’t assign too many exercises or get the patient to choose the time, while others just prescribed and hoped. Helping patients modify their behavior for positive outcomes is a key tenant of what we’re trying to do at Wellpepper, so we’d love help physical therapists take a more active role in this.

Both sessions also encouraged the profession to have a voice in public health on health promotion and wellness. Doing this could make health promotion a more systematic part of physical therapy practice, and give physical therapists a seat at the table in the larger health reform conversation. We’re all in favor of this, and hope we can help.


Posted in: Healthcare Disruption, Rehabilitation Business

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Learning about Lean Healthcare at APTA CSM 2013

We’re just back from the American Physical Therapy society Combined Sessions meeting in San Diego. How lovely, you say, San Diego in January. We think it was lovely but we spent most of the time in the convention center meeting people, and soaking up all kinds of information. Over the next few blog posts, we’ll go into detail about a few of the sessions.

One of the most interesting, was Lean Physical Therapy presented by Proaxis Therapy, a 20 location organization serving South Carolina and Colorado. Team members from Proaxis had completed the Belmont University Lean Healthcare certificate, and were sharing how they used these practices in improving their organization. Lean Healthcare comes from Toyota’s famous Lean Manufacturing philosophy. Wellpepper is following Lean Startup techniques so we were extremely interested to see how this could be applied to healthcare. Lean philosophy looks at eliminating wasteful efforts and continual improvement.

Lean Healthcare Observation sheet

Lean Healthcare Observation sheet

The session started with a video of a physical therapist at a Proaxis clinic running around trying to start a session with a patient, looking for equipment, trying to find gloves that fit, and muttering under her breath. The patient, meanwhile, was waiting on the table. A great thing about this session is that it was interactive, and we used this video to start our own lean training, first by practicing the art of observation. We broke into groups and watched the video again, focusing on observing waste. We tracked how many steps she took (120-150), how long it took before she got back to the patient (almost 5 minutes), what activities she did (see image), and how many times she retraced her steps (a lot).

Proaxis had done the same observational activity, and talked about how they used it to cut waste: organize supplies better, make each PT accountable for all the supplies, and completely reorganized the clinic layout based on user tasks.

From a software perspective, it was pretty fun to experience this type of usability study in the physical world.


Lean Healthcare Value Map for hand washing

Next we learned about value stream mapping: breaking down an activity into it’s component tasks, and looking for tasks that are waste, versus tasks that add value for the customer. (All of lean is focused on adding value to the customer.) Here’s a value chain for hand washing. You might not think of this as a valuable task, but it keeps everyone healthy.

In this value chain, not being able to turn the water on is waste. There are other potential areas for waste, for example, maybe the soap or paper towels are empty. All of these take value away from the patient, and frustrate the caregiver.

Again, we practiced this by trying to map out the value stream for what seemed like a simple task: patient cancelling an appointment. Our small group very quickly realized that there are no simple tasks as we got into a complex decision tree about whether this was a chronic canceler or an isolated incident.

Our value map became quite messy.

Lean Healthcare Value Map Exercise

Lean Healthcare Value Map Exercise

Next step was to ask the 5 Whys, a series of 5 questions designed to get to the root cause of an issue. We figured out that the root cause on this problem was wanting to make sure that physical therapists were being as productive as possible, and scheduling was a key part of this. Although, at this stage you’re not supposed to problem solve, our little group discussed briefly how airlines solve this type of problem by overbooking.

When we came back together as a full group, Proaxis Therapy shared a few case studies on how they had implemented these techniques in their clinics in two key areas: reception/registration, and documentation.

Lean Healthcare Case Study Results

Lean Healthcare Case Study Results

The results were pretty amazing, especially in the area of documentation, saving physical therapists 2 weeks a year, and they had feedback that could really improve their EMR system. For lean software companies, having a user do this type of analysis would be invaluable.

This blog post only scratches the surface of the session, and presenters Sean Mc Enroe, Robbie Leonard, Nicole Kluckhohn, and Shannon Irish reminded us that they were distilling a 5-day course and months of work into 2 hours. They did a great job of it!

Posted in: Lean Healthcare

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Wellpepper is attending the American Physical Therapy Association 2013 Combined Sessions Meeting. We’re having a great time, although are quite exhausted with all of the amazing sessions and people to talk to. When we catch our breath, we’ll blog a bit more about what we found, but for now here are some brief impressions.

  • People are very friendly. We know that PTs are the 3rd happiest profession in the US (behind clergy and firefighters), but we’ve been really impressed with how friendly and helpful everyone is here.
  • Healthcare is at a crossroads. There are a number of sessions on Lean PT and using Toyota’s lean imagemanufacturing principles to improve clinic performance. One we attended was an interactive session that had us mapping out all the steps when someone cancels an appointment and looking for ways to improve. Kaiser Permanente led a session where they talked about the coming disruption in healthcare, stressing that it doesn’t matter what the billing codes say, patient expectations of service have increased and while budgets have decreased so figuring out better ways to deliver care is paramount.
  • Technology can change lives. We’ve seen some pretty amazing exoskeletal ‘machines’ that are enabling spinal cord injury patients to walk around the show floor. How’s that for a demo?
  • There’s a lot of talk about holistic health, health promotion, and seeing the whole patient. Physical therapists are uniquely suited to look at the broader picture and participate in prevention, because that’s what they already do.
  • Behavior change is key to improving outcomes, but it’s not necessarily something that PTs are trained in or good at. How can we help change this?

Those are just some high-level impressions, we’ll have more detail over the next few days. One day left to learn more!

Posted in: Rehabilitation Business

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What can you expect from the Wellpepper blog?

We’re not physical therapists. We’re working with some great ones, and with some university researchers, but we are software people.

With that in mind, here are some of the topics we’re planning to blog about

  • Mobile healthcare and healthcare technology
  • Behavior change and motivation
  • Games for health
  • Gesture and gaming technology
  • Wellpepper product development
  • Wellpepper news
  • Best practices for using Wellpepper and any findings from our research
  • General exercise and physical therapy news
  • Strategies for improving client exercise compliance
  • Customer profiles

We will occasionally have guest blogger posts from our physical therapy, chiropractic, and researcher clients and partners which will be more technical in nature on the practice of rehabilitation, but this won’t be a blog for in-depth study of the field. There are lots of people who can do a much better job of that!

We hope you’ll find something of interest and start a dialog with us here on this blog.

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Hello World from Wellpepper

We’re really happy you’re here. Welcome to the inaugural blog post from Wellpepper. Wellpepper is a new application that helps people remember to do their physical therapy exercises and tracks progress between clinic visits.

We’re currently in a private beta with a number of clinics in the United States and Canada. We’re getting great feedback and suggestions and are hoping to launch in early Spring 2013. Our beta customers will tell us when we’re ready to launch.

We started exploring this path in 2009 when co-founder Anne Weiler’s mother became seriously ill, and spent 6 months in a rehabilitation hospital. Initially, Anne was looking at how video games like Kinect and Wii could be used to help people do their exercises, which we think is still a great idea. However, we quickly realized that there are a number of problems facing physical therapists and their clients that could be solved using advances in technology. Those problems included the difficulty of assigning exercises, the difficulty or reluctance of patients to do their exercises, and the inability to do anything but manual tracking of results.

In late 2012, with the realization that a mobile app could offer some really interesting solutions to these problems, co-founders Anne and Mike took the big leap to start-up world to deliver on this vision. We’re focused on helping to change human behavior: how can we help people to do their exercises so they will get better faster? At the same time, we know if for the therapists, assigning exercises isn’t as fast and easy as drawing stick figures, they’re not going to use Wellpepper.

We’re using all our experience in software design and all the benefits of the mobile and web applications to help with this change. Thanks for joining us on the ride!

Anne and Mike

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