News Column

RFID, RTLS aims to keep pace with demand, supply

February 1, 2014

Barlow, Rick Dana

Just a few short years ago, radiofrequency identification (RFID) and real-time location systems (RTLS) that may use a variety of highand lowfrequency "modalities" to work represented the next-generation track-and-trace technologies for healthcare supply chain executives.

For some supply chain execs, employing RTLS, which can include RFID, would complement bar coding and provide additional capabilities, a strategy and tactic well-known and used in the retail sectors.

But as retailers and prominent shippers learned during the recent holiday shopping season, stocking your logistics armory with high-tech software and equipment doesn't necessarily mean you'll meet and satisfy customer demand - specifically, last-minute and late surges. At worst, RTLS as a panacea saw its silver bullet tarnished.

Even though retail may be farther along than healthcare provider organizations in using bar coding and RTLS processes, supply chain execs must remain vigilant and diligent in their application of those processes to meet clinician demands for supplies.

Within the last decade, Healthcare Purchasing News has explored a plethora of issues surrounding bar coding, RFID and RTLS, from 35,000-foot viewpoints to ground-level applications on the shelf or at the bedside. Editor's Note: To examine HPN's editorial breadth and depth in these areas, go to HPN Online and search for "bar coding," "RFID" and "RTLS."

Last fall, HPN revisited some of the "back-to-basics" fundamentals in bar coding for those either new to the game or needing quick updates on the latest developments potentially affecting their business. This month we examine the RFID and RTLS expanse.

We reached out to more than a dozen executive leaders at some of the leading bar-code, RFID and RTLS suppliers for their insights and perspectives on a variety of relevant issues. Here's what they shared with us.

HPN: What are some of the real, practical differences between the various RTLS modalities (e.g., RFID, infrared, ultraviolet and others), in terms of equipment needed (e.g., Wi-Fi, sensors)?

"If you need RTLS down to 15 feet and can afford a $60 tag and larger footprint, then Wi-Fi is the way to go. Active and passive RFID also have their role but are better suited with content that has been moved from one location to another versus verifying every 'X' period of time that the asset is still there."

- Ken Varteresian, Channel Business Manager, Intermec Technologies Corp., Everett, WA

"The most popular RTLS option for clinical settings and enterprise-grade location tracking is RTLS using active radiofrequency identification (RFID) tags - active meaning that tags have an internal power source (battery) and provide location updates in 'real-time' as they move. Active RFID tags can communicate with software GUIs, which display the tag's location on virtual maps or floor plans of a building using networking technology. Furthermore, some RTLS systems use basic triangulation of signals from three points to determine location while others use software algorithms taking into account a variety of factors to determine location on a more granular level.

"The main advantage of Wi-Fi-based RTLS is two-fold: First, some require wired readers and in Ekahau's case, there is no wired infrastructure required because the network (Wi-Fi) exists and is of sufficient quality to enable RTLS; second, Wi-Fi is often deployed facility-wide and offers a means of deriving analytics or business intelligence across the entire organization, using RTLS software-based location rules. Wi-Fi-based deployments are approximately 50 percent lower in costs and shorter than non-Wi-Fi RTLS solutions and there is little to no disruption to operations. Lastly, by leveraging existing infrastructure RTLS ROI improves and amortizes the cost of the network across additional applications, namely, RTLS.

"Although active RFID using Wi-Fi is the most widely deployed real-time location approach in use today, there are some key considerations when evaluating vendors' solutions. First, each Wi-Fi network footprint and design standard is unique. However, knowing your Wi-Fi network's strengths and weakness will help in RTLS deployment, since active RFID tags with Wi-Fi chips are like any other Wi-Fi client such as a laptop and other devices. Due to the 'Bring Your Own Device' (BYOD) trend in enterprises worldwide, enterprise Wi-Fi networks are often designed for data density and can thus enable RTLS, with little to no downtime or major upgrades. Note that even networks not designed for VoIP and data offer location, it is simply less granular, for example zone level versus room level location accuracy. Also, most RTLS solutions using Wi-Fi have little impact on network capacity and consume significantly less to untraceable capacity, than an average laptop or VoIP phone user.

"RTLS solutions can also deliver location-related information over Wi-Fi (802.11 protocol) networks or using ultrasound, ZigBee nodes or infrared (IR) technology. Ekahau uses infrared light wave receivers in conjunction with active RFID tags to improve or to enhance Wi-Fi-only location granularity, which is often room-level (8 to 15 feet) and bring that down to sub-room level. Some RTLS providers, such as Ekahau, that obtain one-meter location accuracy use IR beacons with Wi-Fi technology in one active RFID tag. Other vendors rely solely on IR to provide location-tracking capabilities.

"ZigBee networks offer low-rate wireless personal area networks using the IEEE 802.15.4 standard and tags that data to sensor network nodes, plugged into the wall outlets for power. These networks are often referred to as 'meshed' because they are 'meshed' together using a series of nodes that communicate with one another and a main node or hub. ZigBee mesh networks are designed to be low cost and they are ideally suited to short-range operations. ZigBee networks do not [use]a significant amount of power and unlike Wi-Fi, they do not require an exhaustive site survey process.

"The density requirements and complexity of building a ZigBee network that covers large square footage like a hospital floor is very difficult to achieve and will include a high volume of plug-in sensors everywhere. The largest market share of ZigBee networks installations offer 'smart metering' applications not any clinical applications.

"Lastly, interference issues have been reported between ZigBee networks and various 802.11 networks, due to the fact that it can share channel spectrum with the 802.11 protocol, and thus impact VoIP phone systems. If there is inference between medical equipment and ZigBee nodes, data transfer rates and location update refresh rates decrease. Since there are identified interference issues with ZigBee networks, it is important to consider asking for a Proof of Concept on-site.

"RTLS using ultrasound requires a dense deployment of receivers, offering granular roomand bay-level location visibility, but at a greater relative cost as compared to Wi-Fi and other alternatives. In addition, ultrasound requires dedicated cabling infrastructure, which can make facilitywide RTLS adoption cost-prohibitive and impact an organization's ability to gain wide-spread business intelligence from the solution.

"These deployments are dense because ultrasound waves cannot penetrate walls, ceilings or floors; therefore a large number of receivers are needed to gain the high-level of accuracy advertised because ultrasound requires line of sight. The more receivers used for an RTLS solution, the more the solution will cost in the long run. However, ultrasound RTLS solutions can ideally be deployed during the construction phase of a facility so that it does not disrupt operations. In addition, most IT departments lack expertise in USID and outsourced management is often required, increasing total cost of ownership for these networks.

"Since the 1980s, logistics and consumer goods industries have depended on passive RFID solutions because of the low cost and versatility, relying on handheld scanners and passive RFID tags (i.e., barcode stickers) to enable applications such as inventory tracking. A disadvantage of using a passive RFID technology is that only 'point-in-time' location is offered, not real-time location. Also, the tagged object's location is only when a reader is nearby (e.g., 10 feet), simply because passive tags are not powered by a battery or an outside power source. Passive RFID tags have to be interrogated in order to register the tagged object's location information. This is one reason that passive tags are commonly used in logistics, attached to a crate or pallet tracking. For example, as the pallet leaves the shipping facility, an RFID sensor stationed at the exit or someone using a reader captures the pallet tag's data to transmit the pallet's location. However, if one were tracking patients, one would want to know where they are even if they were not about to leave the room or near a reader."

- Mark Norris, CEO, Ekahau Inc., Reston, VA

"Intelligent InSites is in a unique position to answer a question like this as its operational intelligence software is the industry's only open software platform that has implemented in healthcare facilities with all leading forms of RTLS modalities, including Wi-Fi supplemented with infrared (IR), Wi-Fi supplemented with ultrasound, traditional IR/RF, 2nd generation IR/RF, ultrasound/RF, ZigBee, low-frequency exciters, other proprietary RF formats, passive RFID and 2-D bar codes.

"One of the differences between Wi-Fi and other modalities is that facilities already have Wi-Fi across their enterprise. If an organization only wants to do 'zonal' asset tracking, Wi-Fi will work. However, as the industry has learned, the 'zonal' location provided by Wi-Fi is insufficient for true equipment management, workflow optimization and realizing the majority of hard-dollar ROI benefits from RTLS.

"Fortunately, most RTLS technologies allow Wi-Fi signals to be overridden when the tag interacts with a supplemental RTLS modality that provides room-level accuracy, such as infrared or ultrasound. As a result, most healthcare organizations are choosing to augment their Wi-Fi with IR or ultrasound to improve location accuracy and unlock the full range of use cases from RTLS. In addition, leading healthcare systems are selecting open software platforms that can support these multiple modalities across their enterprises."

- Marcus Ruark, Vice President, Intelligent InSites Inc., Fargo, ND

"Modern Real-Time Location Systems take advantage of Wi-Fi infrastructure and deliver both spatial and temporal resolution, giving users near-real time visibility into the location, status and condition of people and assets. Because Wi-Fi is highly prevalent in healthcare today, the major benefit of Wi-Fi RTLS is that it leverages an organization's investment in its existing wireless infrastructure. This reduces the total installation and operating costs and speeds deployment. Healthcare organizations can also easily extend their Wi-Fi RTLS to include additional applications/ use-cases, scale it to track more items, or expand it into new departments.

"The typical Wi-Fi RTLS consists of active RFID tags (that come in a variety of form factors and with a range of features, such as call buttons or various sensors), a location engine, which, through triangulation, calculates the location of the tag, a graphical user interface, and APIs for integrating with other hospital management systems. Healthcare organizations also often add additional components to their RTLS to provide higher levels of spatial resolution for features such as room-level specificity or chokepoints. This is very important for high-risk patients who may wander into restricted areas and who may need closer location monitoring.

"With today's RTLS solutions, hospitals should avoid offerings that are built on proprietary wireless technologies. This can be limiting and expensive. It's important to have the ability to add supplemental components when and where needed."

- Joel Cook, Healthcare Solutions Director, Stanley Healthcare, Waltham, MA

"First off, to enable RTLS, a combination of RFID and infrared can be used. Infrared is highly sensitive, focused on smaller reception ranges, can contain a single sensor that can ID multiple data packets and is used to precisely locate people and assets. Whereas the infrared is for in-room, RFID can emit a signal that can go through walls to ID the badge's general location. Ultrasound is a high-resolution, indoor-based tracking for RTLS made for room-level and even sub room. Ultrasound is plug-and-play and relatively easy to install. Other equipment needed for ultrasound includes tablets, computers and PDAs, as well as sensor/receivers and tags."

- Andrew Tippet, North American Healthcare Practice Leader, Zebra Technologies, Lincolnshire, IL

"For real-time location service, the primary modalities are Wi-Fi, ZigBee, ultrasound and infrared. All provide legitimate ways to locate tagged items. The challenges are accuracy, cost, and ease of deployment. Wi-Fi is accurate only within three-to-nine meters (about 30 feet), so if an organization is attempting to track an asset or person to the room level, in a closet or basement, for example, Wi-Fi is not the solution.

"Infrared and ultrasound, by contrast, deliver room-level accuracy but the sensors are too expensive to deploy hospital-wide, which generally precludes hospital-wide tracking of assets and people. ZigBeebased RTLS solutions can deliver the best of both worlds - room-level and bay-level accuracy as well as hospital-wide tracking. Additionally, ZigBee is a simple 'plug and play' mesh network that typically deploys in 45 days vs. all other modalities that generally take eight or more months.

"Equipment needs are roughly the same for each of the RTLS modalities with the exception of Wi-Fi. For Wi-Fi-only tracking, wireless access points likely are already in use. But the low accuracy of Wi-Fi requires hospitals to add a second tracking technology. Both infrared and ultrasound leverage Wi-Fi as the 'back hall' to transfer signals from the tags on assets and people to a server. Infrared typically requires a device in a room that shines an infrared light from the ceiling. As long as the asset or person is under the light, their tag's signal can be detected. Leading infrared vendors typically deploy 'virtual walls' that transmit directional IR light while also blocking IR light from flooding into the opposite direction. This requires attaching several virtual walls at the edges of patient bays.

"Ultrasound can be deployed in patient rooms, clean/dirty rooms and other key locations. Similar to infrared but slightly more accurate, ultrasound receivers called 'exciters' are typically mounted above the patient bed. Both infrared and ultrasound devices can run on battery power, though some require hard wiring. Both solutions require tags to be placed on the assets or people being tracked, to pick up the light or sound and relay it back to the network. They both need an RTLS server to process the location data. Some but not all provide software fine-tuned to their hardware.

"ZigBee-based RTLS is the fastest, least disruptive RTLS in the industry - a wireless, self-healing mesh network that assures consistent location accuracy. ZigBee is a protocol specification and industry standard wireless communication known as Low-Rate Personal Area Networks. The technology is characterized by low-cost low-power wireless devices that self-organize into a short-range wireless communication network. The network returns precise, room-level accuracy and eliminates floor hopping, which can be problematic in Wi-Fi-based deployments.

"ZigBee-based RTLS requires installation of a network of ZigBee sensors across the hospital as well as a server-based appliance and physical tagging of all identified assets. ZigBee-based solution providers use virtualized servers so no physical servers are required for the software. Sensors simply plug into electrical outlets to automatically create a self-healing mesh network. The non-disruptive installation does not involve removing ceiling tiles, opening walls or running cables, and can even be installed in occupied patient rooms and sterile areas, making it easy to get started and easy to expand.

"And a ZigBee-based network is selfcalibrating and self-healing, requiring very little time and energy on the part of organizations to manage and maintain. There is no need to recalibrate the ZigBee network every three-to-six months as with the other technologies - it self-calibrates every 60 seconds to provide optimal location accuracy 24/7, and requires no routine maintenance on the part of the organization. If a sensor malfunctions, the surrounding sensors take over the missing sensor's signal receipt and transmission tasks, ensuring signal reliability and avoiding single point of failure. Moreover, a ZigBee network doesn't interfere with mission critical applications using the Wi-Fi network such as the EMR (with its ever-expanding breadth and depth of use), telemetry/EKGs, PACS images, training videos and other live video feeds."

- Merrie Wallace, R.N., MN, Executive Vice President & CNO, Product Solutions, Awarepoint Corp., San Diego

"Our experience in RFID/RTLS is limited to a pilot conducted in one facility. While RFID and other RTLS applications work wonderfully in certain applications (who would give up their EZPass or the ability to track a mobile X-ray unit?), in our current distribution model, it is cost-prohibitive to add static readers, RFID printer capabilities and RFID-capable scanning equipment. We continue to monitor products and technologies to insure we are providing the maximum service for the least cost to our customers."

- Tom Meier, Senior Project Manager, Henry Schein Inc., Melville, NY

"To pinpoint where an item is, wireless technologies require multiple receivers to triangulate a location. Different technologies use different frequencies, affecting range and the ability to penetrate different materials. The RF characteristics also determine how many receivers are required to locate an item and the accuracy of the location information.

"RFID essentially provides identification, not location. While RFID may be used to locate a tagged item, the cost of setting up antenna receivers to cover a large area like a full building is typically prohibitive. However, some applications such as inventory verification are ideally suited to RFID. For small areas it is commonly used to quickly identify if tagged items are present in the coverage area (and in what quantities), helping make a quick determination when items need to be reordered."

- Glenn Aspenns, Senior Media Applications Analyst/Product Manager, Intermec Technologies Corp., Everett, WA

"All RFID systems comprise a tag and a reader. Active systems, such as Wi-Fi, ultra-wide band, and others are tag-talkfirst systems in which the battery-powered tag 'chirps' at regular intervals and is heard by a reader. Passive RFID systems are reader-talk-first configurations in which the reader sends out a signal and it is received, modulated and returned to the reader. Active systems typically triangulate to determine a location, much like GPS, so there is a need for enough readers covering the area to receive the tag's signal in multiple locations. The battery-powered tags also can be quite costly. Passive systems do not attempt to cover every square inch but determine general location from a 'last seen' position such as a specific doorway. This means fewer readers are needed. Battery-free tags cost much less, but are not as precise."

- Randy Briley, Healthcare Director, Motorola Solutions, Schaumburg, IL

"RTLS technologies are typically aimed at the same general goal - informing when and where a meaningful event has occurred. The real practical differences between the various RTLS platforms can be attributed to what modalities the platform uses to accomplish this event detection.

"RTLS systems typically employ a mix of modalities to accomplish two primary functions - backhaul communication and endpoint detection.

"Backhaul detection is the method by which the sensors communicate events with the host system - i.e., tag movement, temperature change, button press and tamper alert. These typically require some form of High Frequency or Ultra-High Frequency (HF/UHF) technology such as Wi-Fi or proprietary band tailored for long-range communication.

"Endpoint detection is the method by which the system identifies meaningful endpoints within the facility, i.e., which room a staff member is located in, which side of the wall a particular wheelchair is on, or which bed a patient is in. Detecting endpoints requires technologies that are optimized for localization such as Ultrasound (US), Infrared (IR), Low Frequency (LF), and sometimes short range HF/UHF. The main differences between platforms are in how they accomplish endpoint detection, and each has use cases for which they excel."

- Todd Scarola, Chief Engineer, Global Asset Management, GE Healthcare

"The basic differences in any of these are read accuracy, read range, read frequency, the infrastructure required to transmit the data and then the ambient 'noise' that they may create. We don't really have experience with modalities other than RFID, but most technology emits some form of 'radiation' or 'frequency noise/ which, based on their environment (e.g., healthcare), could impact adaptation and implementation, depending on the sensitivity of any nearby equipment."

- James Casavant, Chief Operating Officer and Chief Technology Officer, LPIT Solutions Inc., Grand Rapids, Ml

"There are several main differences between the technologies mentioned:

* Carrier type and infrastructure

* Level of accuracy required

* Actual need for real-time data

Infrared tags, for example, can be placed on a patient, but each time their clothing covers the tag, it will interfere with the information transmitted and stored. Therefore, the report accuracy will be damaged.

"In addition, does the hospital need the reports in real-time or can there be a delay in information transfer? Wi-Fi will not be able to provide real-time information. Depending on the hospital's specific needs, they must examine tampering possibilities (by patient, user, security threat). This also means the information is not secure or accurate."

- Shlomo Matityaho, Founder and CEO, LogiTag Ltd., Mamaroneck, NY

Where specifically might these modalities be best applied (e.g., tracking devices/ products, equipment, people)?

Wallace: "Wi-Fi-only RTLS is good only for general asset tracking with 30-foot accuracy. It will reveal that a piece of equipment is within a 30-foot wide area in a structure. Ultrasound and infrared RTLS provide more accurate tracking to determine the precise location of an asset, patient or staff member in a room. However, both technologies are considered too expensive to deploy across an entire hospital so they can cover only specific areas such as the ER or clean/dirty rooms. By contrast, the more affordable ZigBee-based RTLS systems can provide both hospitalwide coverage and bay-level accuracy and so are well suited to both hospital-wide asset tracking and patient and staff tracking."

Varteresian: "All assets can be tracked, though there is no single technology that fits each form from an ROI standpoint. Keep biometric solutions in mind as well."

Norris: "Passive RFID tags - for shelflevel accuracy for medication, inventory tracking - data enter/exit and are interrogated, with no power source needed on the tag. Tags are low-cost, passive, flat bar-code stickers that may require higher cost readers which require staffing (if handheld scanners are used). Passive RFID is popular in shipping and manufacturing facilities but not ideal for intelligent and real-time tracking applications of people and high-value assets or for safety applications because they do not offer real-time updates. This technology is not ideal for facility-wide adoption, clinical settings or for obtaining 'business intelligence' beyond inventory tracking applications.

"Active RFID tags - for room and subroom level accuracy in real-time - are used for patient, workflow and high-value asset tracking and security and safety alerting applications. Active RFID is reliable and oftentimes Wi-Fi-based, making it an ideal means of deriving facility-wide business intelligence across a variety of location-events such as patient movements/ flows, nurse workflows, customer traffic patterns and RTLS-derived data fed into Big Data platforms for further analysis."

Ruark: "Different use cases can use different modalities, but the majority of use cases require room-level RTLS accuracy and full enterprise coverage. Patient flow solutions - in which patients and/or staff members are located in real-time and specific patient flow processes are monitored and managed, proactively, by a patient flow software application - certainly require accurate and timely room-level RTLS modalities such as infrared and ultrasound. Such patient flow processes can include ED patient flow, OR patient flow, inpatient flow and ambulatory patient flow. Asset management applications, which go beyond basic asset tracking to provide inventory optimization, infection control and asset workflow management, also require room-level accurate RTLS. Other applications, such as surgical instrument tracking, supply management, or cath lab supply tracking, can be accomplished with other modalities, including 2-D barcodes and/or passive RFID technologies."

Aspenns: "RFID can offer significant benefits for identifying assets and people. Unlike bar codes, RFID does not require a direct line of sight and can save a lot of time and effort in identifying hard to reach items like diagnostic equipment. For tracking the identity of patients, it does not need to be uncovered to be read. However, to offer positive patient ID, it must have a short read range to ensure that multiple patients are not simultaneously identified, limiting its benefits over conventional barcoded wristbands.

"RFID can also be used to prevent counterfeiting of drugs and high-value items. Some manufacturers use RFID to quickly track the contents of high-value implantable kits that contain multiple parts and sizes. When the kit (or a portion of it) is returned to the manufacturer, missing components can be quickly identified to complete the kit."

Matityaho: "In the ideal environment, if the information required is not real-time, and there is no fear that the tag will be tampered or touched, than this type of technology is great. Otherwise, the hospital must look for something more advanced. Let's take the example of using an existing Wi-Fi network. The information may be completely open to security threats."

Briley: "The logical start is to track expensive, mobile assets such as infusion pumps, beds, monitoring equipment, etc., as they move throughout a facility. Studies show that nurses spend more than an hour per shift searching for equipment and that millions of dollars are spent replacing 'lost' equipment. Once the infrastructure is in place, the same readers can track the flow of supplies such as pacemakers, implants, catheters, etc., and can trace the movements of clinicians and patients to better understand where people are, track dwell times and optimize staffing."

Cook: "Wi-Fi RTLS is ideal for a wide range of applications, from asset management to staff and patient safety and security to staff workflow and patient flow. What makes Wi-Fi RTLS particularly well suited for these applications, versus other modalities, is that it provides facility-wide or campus-wide visibility - wherever you have Wi-Fi coverage you can track assets or people.

"Healthcare organizations typically first deploy Wi-Fi RTLS to monitor and manage assets with the goal of improving efficiency and productivity. Then, based on the significant benefits they realize as a result of the first application, they extend it to additional departments or to include additional use cases such as environmental monitoring and patient/staff tracking.

"Monitoring staff or patient safety and security are other common uses of Wi-Fi RTLS. Emergency departments, psychiatric departments, memory care facilities and assisted living facilities all include high-security areas where it is important to monitor staff in duress or patients or residents in need of assistance. At the room level, hospitals can also track staff workflow as well as hand hygiene practices of clinicians and staff. Wander management is an example of how RTLS can be used to precisely monitor patient location and offer residents assistance as needed."

Tippet: "There are four primary uses that include: Track patients through their time in the facility, track clinicians to identify productive and personnel enhancements, use two-way tags to enable nurse call support for emergencies and track equipment to determine location. In one example for RFID, hospitals could use 13.56 MHz RFID to monitor supplies on shelves and to signal replenishment, plus RTLS technology to automatically locate defibrillators, monitors and other critical equipment throughout the facility."

Scarola: "IR and US modalities are strong tools for achieving physicallybounded detection - determining whether an asset is in a particular room or what side of the wall an asset is on. IR-based platforms typically have smaller tag form factors relative to ultrasound (due in part to the higher power consumption for US based technologies) and are generally easy to deploy.

"LF is an effective technology for achieving proximity detection in a well-defined boundary or small area. It provides a very tunable field of detection for precise threshold crossing identification, which is particularly useful for scenarios such as detecting assets at facility exits, wander prevention and infant security.

"HF technologies are typically very short range and found in passive RFID applications where contact confirmation like badge access is required.

"UHF technologies are typically employed for backhaul communications, have long range communication capabilities and can be used for general positioning of an item. This can be adequate helping a hospital know broadly where a piece of equipment is positioned - for example, knowing a particular telemetry unit is located in the cardiovascular wing. Hospitals can gain more specific, granular information on where a device is located with some other form of endpoint detection for higher granularity.

"In many use cases, hospitals benefit from employing multiple modalities to detect events. For example, basic asset location and security could be accomplished with a combination of UHF and LF. Effective patient tracking can be done with UHF and IR. Tracking hand-hygiene related events often involves three different modalities: UHF for low latency communication, LF for dispenser interaction and IR for room egress." HPN

For the sidebar, "Supply Chain's retail allure of RFID, RTLS" visit inside/2014-02/1402-SF-sidebar.html

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Source: Healthcare Purchasing News

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