e-Health Implementation in Lebanese Teaching Hospitals: What Can

We Learn from Their Successes and Imminent Challenges

Nabil Georges Badr

, Elissar Chami

and Michele Kosremelli Asmar

Higher Institute for Public Health, Saint Joseph University, Beirut, Lebanon

Keywords: e-Health, Implementation, Teaching Hospitals, Success Factors.

Abstract: We set on an exploration to learn from two major implementations of eHealth in teaching hospitals in Lebanon.

After an explorative qualitative empirical work; we summarize learnings from these successes and present

them as a backdrop for future studies. The main value of this study is in the discovery of the importance of

technical and process readiness with an emphasis on dedicated stakeholder engagement to guarantee the

successful outcome. The focus on the patient journey and the wellbeing of the practitioner in the new digital

ecosystem are as important as financial preparation and infrastructure readiness. Researchers are still

pondering the unintended consequences of EMR implementations and the effect of such implementations on

the stakeholders of the healthcare ecosystem. In this paper, we argue that the road to success in the

implementation of eHealth must be through stakeholder engagement as a means to increase the satisfaction

of practitioners with the new work environment.

1 INTRODUCTION

“e-Health is the cost-effective and secure use of

information and communication technologies in

support of health and health-related fields, including

health-care services, health surveillance, health

literature, and health education, knowledge and

research” (WHA 58.28

& 66.24

Resolutions).

Since more than two decades, e-health has taken

center stage in the healthcare technology discourse

(Eysenbach, 2001 and Healy, J., 2008). In 2015, the

concept of, “eHealth for all”, was launched by the

WHO in 2015 with a backdrop to support the

sustainable development goal of “Good health and

wellbeing for all” – SDG3.

eHealth, is a vast medium of software, hardware,

and network facilities, focused on managing medical

related data, audio or videos collection, storage and

transmission amid all healthcare collaborators,

turning the healthcare ecosystem into a boundless

engine for diagnosis, treatment and prevention,

fuelled by artificial intelligence relying on data

https://orcid.org/0000-0001-7110-3718

https://orcid.org/0000-0001-7001-9231

https://orcid.org/0000-0001-5526-0924

https://www.who.int/healthacademy/media/WHA58-28-en.pdf

https://www.who.int/ehealth/events/wha66_r24-en.pdf?ua=1

(Police et al, 2010). Technologies such as

“telemedicine, m-health (mobile health), electronic

medical/health records, etc.” make up this rich field

of practice (Ahern et al, 2006).

At the point of care, eHealth is a platform for

practitioners to enhance the quality of care via

advanced systems to manage health records, make

informed decision techniques using informatics

applied to healthcare data from a patient or

population. As a facilitator of equitable access to

primary healthcare (Saleh, et al, 2018), eHealth has

been touted for enhancing advanced research,

achieving educational goals, formulating preventive

approaches to disease and informing legislation

(Minichiello et al, 2013).

1.1 The Context of Lebanon

For this paper, we choose the context of Lebanon. A

small country in the eastern Mediterranean, with a

population estimated around 4.8 Million and

304

Badr, N., Chami, E. and Asmar, M.

e-Health Implementation in Lebanese Teaching Hospitals: What Can We Learn from Their Successes and Imminent Challenges.

DOI: 10.5220/0010192503040311

In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 304-311

ISBN: 978-989-758-490-9

healthcare expenditure around 6% GDP

. Growing to

meet increasing demand on healthcare services, the

Lebanese are in the process of adding more than

1,000 beds, as well as many operating rooms and

intensive care units, to their hospitals. Established

hospitals have allocated at least $700 million to

expand their premises, and improve the quality of

their services (Business News, 2019). The American

University of Beirut Medical Center has plans to add

135 hospital beds, and Hôtel-Dieu de France 115

beds, representing 20-30% additional capacity.

According to the Lebanese Ministry of Public

Health (MoPH) in 2013, the national e-health

program initiator, has set a primary objective to

encourage and enable sharing of Health Information

(MOPH, 2014). Local resources public and private

have dedicated significant resources to improving the

state of eHealth services. The American University of

Beirut has collaborated with the MoPH to develop the

country’s digital health records (moph.gov.lb). The

“Health Card” project was followed by point of use

mobile APPs, developed by the WHO to locate

available hospitalization resources with the use of

Geographic Information System (GIS).

In Lebanon, a developing country, the majority of

the primary care providers are ready to implement

eHealth services (Saleh et al, 2016). However, the

usage of the Information and Communication

Technologies in primary health centres is still residual

and reserved to highly financed institutions. Attempts

have been made to improve the situation and

obstacles are still extant to date, primarily due to lack

of serving infrastructure such as internet and telecom

services (Telecom Review, 2018), especially in

underserved rural areas. Consequently, the Ministry

of Public Health (MOPH) has announced the

introduction of the first mass deployment of remote

health in primary healthcare centres in the region.

Using a technology designed to be deployed at home

to remotely connect patients and physicians this

solution offers the capability of running 16 different

tests including ACG and sugar levels, for diabetic

patients, etc. (Telecom Review, 2018) The

deployment of tools and technologies continues to

proliferate; hospital eHealth implementations are no

exception.

https://www.who.int/ageing/projects/intra/phase_one/alc_

intra1_cp_lebanon.pdf

1.2 Motivation

Shifting from traditional healthcare to e-health can be

challenging, especially if the country's health sector

has not quite evolved lately and rural areas still lack

access to primary healthcare services. To date, the

absence of e-health policy and standards, influenced

by many other factors in the country, such as political

instability, privatization control, and political power,

have aggravated the impact of the high cost of

technology, already hindered by the lack of funding

resources in addition to budgetary constraints. The

reluctance to change from the traditional health

practice to e-health practice was also a significant

factor.

Still, major hospitals have managed to successful

deploy health information systems such as the

American University of Beirut (AUB) and Hotel-

Dieu de France (HDF), focusing on the efficiency and

speed of services in the hospitals’ departments,

optimizing and enhancing the practice, tracing,

monitoring and evaluating in a transparent manner.

Both hospitals are recognized today as the leading

digital hospitals in the country.

As our brief literature review will show, the lack

of fiscal expenditure and funding, non-conformity to

standard and standardization can slow the rate of

technology adoption in hospitals. The extant gaps

related to technical requirements, staff’s

preparedness, motivation and computer’s knowledge

can hinder the implementation of innovation in a

hospital setting – Especially in the case of teaching

hospitals where a variety of distraction can add to the

complexity of adoption.

Our aim is to learn about the factors and practices

that led to such successful implementations and

explore the adoption roadmap of these two pioneer

teaching Hospitals in Lebanon. We set out on this

project to answer the question of “What were the

facilitators of e-health implementation in Lebanese

Hospitals?”

Such learnings have the premise to establish a

precedence and serve as an example for other health

institutions in Lebanon, attempting to integrate

eHealth into their practices. Our paper summarizes

the empirical research launched to collect the

evidence from these two institutions and draws some

interesting conclusions.

e-Health Implementation in Lebanese Teaching Hospitals: What Can We Learn from Their Successes and Imminent Challenges

305

2 BACKGROUND

In preparation for the empirical research, we carried

out an investigation of the existing research and found

a scarcity of academic work published on facilitators

of e-health development, implementation,

maintenance and solutions in Lebanon. Expanding

the scope of our review to include similar developing

country settings, we identified three main themes

related to financial factors, technical and process

readiness and related sociodemographic factors of the

healthcare delivery team.

2.1 Financial Factors

The lack of fiscal expenditure and funding is a barrier

to e-health implementation in hospitals (King et al,

2012). Jha et al (2009) and Stroetmann et al (2011)

agree that financial support, motivators and

repayments are a positive contributor in the

implementation process. Financial support from

several funders such as pioneer banks and innovative

technologies companies, who belong to the private

sector, is a crucial enabler for the implementation

process. Ajami & Bagheri-Tadi (2013) and Ross et al

(2015) explain that the expenditure element may also

become an obstacle, especially when selecting the

funders, specifying the cost of the accessibility,

networking process, obtaining the appropriate tools,

continuous upgrading, evaluation and auditing, thus

limiting the available funding sources. Ross et al,

(2015) also highlight on the significance of having a

clear contract between the vendor-installer, and the

hospital-end user, where an unclear agreement

between these stakeholders can lead to a hurdle in the

implementation process.

2.2 Technical and Process Readiness

Standard and standardization are primordial in

automating processes and paving the way for a

successful implementation of a hospital system.

Beyond the somewhat classical funding issue in such

large scale and involved implementations, the lack of

unified criteria and standards, anonymous knowledge

of the expenditure (payers, cost), present remarkable

and ad hoc changes in clinical workflow, eroding the

trust and security in the radical shift from paper to

electronic work (Collins et al, 2014). The early and

comprehensive assessment of the infrastructure,

identifying the gaps related to requirements, and the

diligent preparation of the infrastructure are crucial

prerequisites for a solid start of the implementation

project (Hamadeh, 2019). The lack of hardware

portability, or slack of software and hardware

upgrades are as damaging as the inadequate electrical,

cooling, connectivity and space needs for the new

system implementation.

2.3 Managerial Support

Unplanned managerial and administrative conflicts

may slow down the implementation process, already

burdened by ethical and privacy concerns concerning

patient data, privacy, accountability, safety and

confidentiality (Stroetmann et al, 2011). Zayyad &

Toycan (2018) and Woodward et al, (2014) tackled

the enablers of a successful e-health implementation

from healthcare practitioners’ view. Their findings

agree that staff’s preparedness, motivation and

computer’s knowledge were likely to increase the

chance of the software’s adoption. In the absence of

managerial and leadership sponsorship, lack of

motivation, poor infrastructure readiness, etc., human

resource obstacles related to resistance, reluctance to

learn, poor computer skills and literacy are significant

barriers of e-health implementation in the hospitals

(King et al, 2012). Prescriptive guidance was

presented in the literature encouraging department

level engagement and the encouragement of group

work, in the aim to emphasize adoption (Palabindala

et al., 2016). Moreover, managing the interaction

between practitioners, managers and vendors, was as

important in ensuring successful adoption (Hamadeh,

2017).

2.4 Human Resources and

Sociodemographic Factors

Palabindala et al (2016) and Cashen et al (2004) cited

that healthcare practitioners’ resistance to change, can

slow down the implementation process.

Resistance to change can be rooted in

practitioners’ poor computer skills, unprepared and

unwell trained employees, educational linguistic

background, limited knowledge and literacy, low

socio-economic level for enhancing their education,

age and gender. For example, Shiferaw & Mehari

(2019) found that internet and e-health knowledge

and education among healthcare providers in

Ethiopia, varied by age, gender education level and

role within the ecosystem of health services.

Practitioners 21 - 29 years of age have scored a high

level of e-health knowledge, females than males, with

physicians and nurses more knowledgeable that

pharmacists and other healthcare practitioners.

Likewise, in Lebanon, Saleh et al (2016) have linked

readiness levels to e-health implementation to

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practitioners’ sociodemographic, computer

proficiency and expertise, managerial backing,

changes’ effectiveness, and personal benefits.

Authors considered that practitioners’ preparedness is

a crucial component for a successful implementation

Findings indicate that the perceived usefulness of the

system was different among the care team as

physicians expected a higher benefit from the

implementation more than nurses did.

3 METHODS

We conducted the semi-structured interviews in two

Lebanese hospitals located in Beirut. Both have

successfully implemented e-health. Open ended

inquiries, included focusing questions (Appendix) to

enrich the data collection. The field activity included

8 participants as a whole, based on the participants’

availability and willingness, distributed between 2 IT

managers, IT employee, 1 archiving employee, 1

nurse and 3 physicians (Radiologist,

Gastroenterologist and Anaesthesiologist). We

conducted the interviews during the month of January

2020, lasting around 30-40 minutes with each

informant. The latter, purposefully chosen healthcare

practitioners have worked in the organization before

and after the implementation so they will be able to

offer a deeper knowledge on the subject. We then

perform key point coding to isolate and group the

findings into themes of financial, Human and

technical. In section 4 to follow, we present the

findings followed by a discussion on the success

factors for the implementations and we close with a

summarized list of these findings. We introduce the

learnings from this study in Section 5. Then, in

section 6, we conclude with contribution statement of

this paper that is essentially part of a larger project.

3.1 Site Selection

For our study, we have chosen two of the leading

hospitals in Lebanon where successful

implementation of eHealth services were concluded.

Both are teaching hospitals located in the Lebanese

capital.

3.1.1 Hospital A: HDF

The Hôtel-Dieu de France is one of the three leading

Lebanese medical centres, located in the capital

Beirut. Established in 1883, HDF transformed into a

https://hdf.usj.edu.lb/indexen.php

teaching hospital in 1984. Today, HDF is a non-profit

hospital, affiliated with Saint Joseph University with

the capacity of 430 beds, 43 beds for the Intensive

Care; 125 Doctors ; 90 Surgeons ; 450 Nurses; 1000

deliveries/year; 11.300 surgeries/year, 29.000

admissions/year and 30.000 emergencies/year

. As

part of the eHealth initiative at HDF, the

implementation of the Hospital Information System

started late 2015 (ITG Holding, 2015) and took more

than two years to complete placing HDF at the

leading edge of the eHealth services.

3.1.2 Hospital B: AUBMC

Affiliated with the American University of Beirut, the

AUB medical centre (AUBMC) operates 376 beds,

serving more than 40,000 inpatients annually

(AUBMC.org). On November 3 2018, AUBMC

launched AUBHealth to replace its existing

homegrown electronic health record and provide a

platform for integrated care, ensuring patients have

convenient digital access to their health information

(AUBMC.org). “Within AUBHealth, physicians

have access to real-time patient data and information,

which saves time, avoids duplicate diagnostic tests,

and could reduce clinical costs. AUBHealth

empowers patients and their designated caregivers

with easy access to health records. Using apatient

portal, MyChart, patients can connect with their

healthcare providers, schedule appointments, and

access test results easily. The paperless system

provides a secure and seamless patient experience”.

Quoting the Hospital’s chief Medical Information

Officer. The project was executed over 3 years of

planning, preparation, and training. AUBHealth, is

deigned to integrate clinical documentation with

ancillary systems such as radiology, pharmacy,

laboratory, ambulatory, perioperative, patient

transport, blood bank, and billing.

4 FINDINGS AND DISCUSSION

In this section, we select a few notions from the

interviews in order to frame the empirical discoveries

shaping the successful endeavours at each hospital.

From healthcare practitioners’ point of view, the

main technical obstacles of the implementation were

on the technical and infrastructure factors, pointing at

equipment, electrical needs, hardware and software

upgrades. After a careful evaluation, the

infrastructure preparation started and included the

e-Health Implementation in Lebanese Teaching Hospitals: What Can We Learn from Their Successes and Imminent Challenges

307

implantation of tools to monitor proper performance.

The data centre was designed with high availability in

mind. The selection process started with a careful

review of the requirements and a purchasing process

that narrowed down the potential vendors. Both

Hospitals reported similar issues with infrastructure

readiness having to plan for physical expansion of

their premises and the rehabilitation of 100+ year old

components of the structures.

The IT director of HDF, tenured of 26 years at the

hospital, stated that the most crucial step in success

was to draft the patient’s journey through the hospital

services. “The project was not a technical project, it

was a project of rebuilding processes”, the IT

Director (HDF) explicated. The hospital assigned a

special and dedicated team for the implementation.

To reinforce adoption, the project manager at

AUBMC in coordination with the IT department,

assigned a Champion from every department in the

project implementation activities designated as

“super users”. “We have picked about 120 people

from departments, each geographical location at

least had 1 or 2 super users, by roles”; the Project

Manager, who has witnessed the entire

implementation process, explained. The objectives

for the implementation aimed at better patient

outcome, a more efficient hospital operation,

enhanced interaction among the care team and a more

effective data driven decision-making. They then

evaluated a few software products, to settle on a

French based firm because of its modularity and its

best fit to the processes at the hospital, mainly the

admission, discharge and transfer (ADT) including

the billing standards. Participants to this study shared

some insight into financials and grants, underscoring

the burden of high cost of compliant hardware and

software. Even after implementation, HDF has

designated a centre of excellence to continuously

monitor, detect opportunities for improvements and

apply the changes necessary. The system that was

implemented was designed as a patient centric

ecosystem which includes outpatient services,

pharmacy and other services.

Similarly, the implementation team at AUBMC

managed the implementation project as a clinical

transformation project with “Standardized Care” as

the central notion. It was also a people and process

transformation project rather than a technical

challenge. The project stakeholders at the hospital

identified nurses as the primary users and assigned a

focal point in the implementation of the process and

workflow through the system. The implementers

integrated opportunities for improvement directly

into the system design. Here too, a project team of all

practitioners was assigned to direct the project at the

direction of the Chief Medical Information Officer.

Though the system was American built and

standardized, it was customisable to meet the local

processes, workflows and currencies. Hundreds of

sessions with stakeholders were necessary to

normalize the processes and integrate them through

the system. The project management team included

steering committees, advisory councils (by practice),

readiness groups of champions and early adopters,

super users who test the systems and provide early

insight.

A cost-effective budget plan was well prepared, in

addition to compensatory approaches demonstrated

by the employees, as participants mentioned, where

they had to deduct some expenses from certain factors

and compensate in others to maintain a balanced

expenditure, in addition to eased budgeting loan

obtained from the central bank. The informants

emphasized the advantage of early adoption

incentives (in some cases monetary or career path).

Additionally, frequent trainings of highly

qualified employees, focused on role-playing was a

major plus. These trained members later dispatched

all over the hospital as problems fixers. Innovative

techniques performed by the employees facilitated

the integration of the system in the work stream of

each practice. A radiologist, with 4 years of service,

who was appointed as trainer on the use of the

integrated PACs interface reported that practitioners

had the flexibility to adjust the software’s settings in

a suitable manner for their workflows; consequently,

some participants mentioned that only some additive

software and hardware were required as they tuned

their tasks.

Whereas elements that enabled the

implementation were many, teamwork and

departments, community and stakeholders’

engagement lead to a successful implementation.

To improve the adoption of the Electronic Health

Records (EHR) at AUB, the implementers set their

sight on meeting the Electronic Medical Records’

(EMR) criteria. They exploited international

standards provided by the Healthcare Information and

Management Systems Society (HIMSS). A pilot

implementation phase made tuning and adjustments

possible, easing the way for a full implementation that

is more swift and resilient. Users in each department

evaluated the new system before implementation and

were trained before use. They were able to provide

valuable input on process and user interface

parameters for more successful wider adoption.

Testers role-played to test the patient navigation

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through the system and provided the necessary

adjustments before launch.

5 WHAT WE LEARNED

Learning from this research emphasize the need for

technical and process readiness, consideration of

important resources to mobilize for stakeholder

engagement in addition to the obvious financial

consideration. We can therefore, line up the guidance

of this work with a fundamental requirement for an

EMR implementation to align with the Quadruple

Aim of quality care through an improved patient

journey, improved overall health, through a measured

cost model, ensuring practitioner’s satisfaction (Sikka

et al, 2015). This is especially important in the context

of teaching hospitals where the workload of the

medical body is compounded by the extended

collaborative nature of medical work and reduce the

burden on the practitioners who are pulled (Park et al,

2012).

5.1 Focus on the Patient Journey

The main theme echoed by both case studies was the

resolve to focus on the patient journey. Processes and

workflows were carefully modelled to ensure that the

ecosystem is covered with a standardized care model

and safeguard that the system is implemented as a

patient centric ecosystem, which includes outpatient

services, pharmacy and other services. This implies

the emphasis on defining the implementation

objective in terms of better patient outcome, a more

efficient hospital operation, enhanced interaction

among the care team and a more effective data driven

decision-making.

5.2 Selecting the Best Fit Scenario

Both studies indicated the need to respect a measured

cost model with a solution sized for the contextual

setting. This means choosing a product / software that

best fits the objective – Evidenced by the choice of

two different systems based on their support and

alignment with the existing workflow and culture of

the hospital.

5.3 Technical and Process Readiness

Technical and process readiness are of great

importance in the implementation of an eHealth

system at a hospital. The technology ecosystem and

process transformation must align for successful

outcome. This reinforces the importance to prepare

the infrastructure technical and infrastructure

components, pointing at equipment, electrical needs,

hardware and software upgrades as transcribed by one

of the participant.

5.4 Ensure Practitioner’s Satisfaction

Both teaching hospitals have gone to great length and

measures to maintain stakeholder engagement at all

levels of the organization and communicate clear

assignments and process changes widely - incentives

for early adopters recommended.

We can henceforth summarize four main lessons

in stakeholder engagement that can provide for a

sustainable practitioner satisfaction:

First, involving users in the evaluation and

deployment encourages open innovation by all

members of the eHealth ecosystem and provides

means for the stakeholders to improve on the overall

experience in their process of care.

Second, the emphasis on training for rapid

adoption and long-term success is a precursor to

success. Frequent trainings of highly qualified

employees and role-playing are key success factors –

sustained by proper and timely logistics.

The third lesson here relates to the methodology

of deployment that proves more effective in

introducing incremental change in the environment,

empowering the practitioners to tune the system to

their workflow. The advice here is to deploy in pilots

while improving the process and handling the

incremental adjustments and nominate champions

from every department.

Lastly, maintaining traction on improvements

post implementation can result in a lasting value

realization of the system deployment – preferably

through the designation of a centre of excellence to

continuously monitor, detect opportunities for

improvements and apply the changes necessary.

6 CONCLUSION

In addition to the usual suspects of financial

constraints in implementation of this scale, the study

has identified key enablers for engagement between

all involved stakeholders. Vendors, suppliers,

implementers, hospital staff, management and

practitioners are all stakeholders in the process. A

process that requires a level of technical and process

readiness to succeed. Interaction between

stakeholders, the universal commitment of all levels

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309

of the health care delivery is key to successful

implementation of eHealth services in Hospitals.

The informants to this study noted the logistics

around training as barriers of the implementation,

such as time-consuming commitments, delays,

attendance, low training frequencies, incomplete

training, varying training time and location. In some

cases, as the project implementation got at scale, the

implementers observed some resistance, occasional

lack of personal efforts and cooperation, potential due

to unclear job assignments and changes in processes,

managerial support was fundamental to improve

adoption.

In conclusion, this research provides a descriptive

approach on addressing several factors that enable e-

health implementation process in hospitals of

developing countries. The context of Lebanon could

also be extended to similar models across developing

nations and will prove valuable to inform current and

future adopters of eHealth in Hospitals.

6.1 Contribution

Though our paper did not significantly change or add

to what is already known as best practices in EMR

implementation (Keshavjee et al, 2006), nevertheless,

it does focus on teaching hospitals, where the

collaborative work is intense, rendering greater value

to the objective of maintaining practitioner

satisfaction. Consequently, the paper serves to

underscore the focus on patient journey, process and

workflow, user engagement, managerial support and

a solid implementation plan that includes a phased

approach to a measured success.

Furthermore, our work ties the success factors of

an EMR implementation to the Quadruple Aim of

quality care through an enhanced patient journey,

improved overall health through technology

innovation, implemented based on a measured cost

model sized for the contextual setting, while ensuring

a sustainable practitioner’s satisfaction.

Researchers are still pondering the unintended

consequences of EMR implementations and the effect

of such implementations on the stakeholders of the

healthcare ecosystem (Alami, 2020). In this paper, we

argue that the road to succeed in the implementation

of eHealth must be through stakeholder engagement

as a means to increase the satisfaction of the

practitioners with the new work environment.

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APPENDIX

Questionnaire

Socio-demographic information:

⋅ Can you please introduce yourself?

⋅ For how long have you been at hospital?

⋅ What is your profession?

Knowledge of the concept:

⋅ Did you work in this hospital before the

implementation occurred?

⋅ Have you ever worked on such technology in any

healthcare field?

Implementation process:

⋅ How do you describe working in the hospital

prior and after the implementation?

⋅ Do you find it user-friendly and easy to use?

⋅ How long did it take you, so you practiced it

efficiently?

Outcome:

⋅ Have you noticed any changes in healthcare

delivery?

⋅ Can you summarize your professional

experience concerning e-health implementation

as a comparison form between the old

informatics system and the new one?

⋅ Would you suggest any further modifications to

the process of implementation?

e-Health Implementation in Lebanese Teaching Hospitals: What Can We Learn from Their Successes and Imminent Challenges

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