Moreover, although people in key roles in the practice developed a good understanding of the HRSS, this was not the case for people who were more peripheral. Six focus groups and 17 interviews were conducted. The data presented in this paper were collected prior to electronic patient records being downloaded. Perera G, Holbrook A, Thabane L, Foster G, Willison DJ. Accreditation from the NHS or practice was important, as one person put it: Im wary about it, but the fact that it has the its under the auspices of the NHS rather than, if you like, Bloggs whatever; if it was Bloggs whatever I wouldnt do it. See UH Policy PH-28 Breach Notification. Practice staff were concerned about releasing identifiable patient data and the associated responsibilities of information governance. With this mobile app, you can find a doctor and find a location. Dixon, Jane Karpe Conflicts of interest: Dr. Tzeng-Ji Chen, Dr. Shih-Hwa Chiou and Dr. Shinn-Jang Hwang, Editorial board members at Journal of the Chinese Medical Association, have no roles in the peer review process of or decision to publish this article. Consent for the use of personal information for health research: do people with potentially stigmatizing health conditions and the general public differ in their opinions? Results: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. Plantinga, Laura Patients who were unable to come to a group were individually interviewed about the same issues but without the interactive task. See UH Policy PH-16, Limited Data Set: Permitted Purposes for Use/Disclosure. No. 2006. Henley, Lesley D ), National Health Information Privacy: Regulations Under the Health Insurance Portability and Accountability Act,, Use of Personal Medical Records for Research Purposes,, Using Patient-Identifiable Data for Observational Research and Audit,, The Threat to Medical Records Research,, The Impact of Requiring Patient Authorization for Use of Data in Medical Records Research,, Thromboembolism and Oral Contraceptives: An Epidemiologic Case-Control Study,, Risk of Uterine Rupture During Labor Among Women with Prior Cesarean Delivery,, Quality of Medical Care Delivered to Medicare Beneficiaries: A Profile at State and National Levels,, Researchers' Access to Patient Records: An Analysis of the Ethical Problems,, http://www.nih.gov/news/budgetFY2002/FY2001investments.htm#totalbudget, +(last+visited+July+2,+2001).>Google Scholar, http://www4.od.nih.gov/ofm/PRIMER97/page38.stm, +(last+visited+July+10,+2001).>Google Scholar. Get health news and advice you need to live your best, delivered right to your inbox every month: The Science of Health e-newsletter. As you pass by, you notice that she is frowning at a patient's medical record. Stay connected with the UH Now app. However most patients reported they understood the HRSS following information provision as part of the qualitative evaluation, while practice staff reported understanding when information was provided just prior to records being downloaded. Unable to load your collection due to an error, Unable to load your delegates due to an error. Please enable it to take advantage of the complete set of features! Kerridge, I. Medical records in most health care institutions are filed numerically according to patients' medical record numbers. Shah SGS, Dam R, Milano MJ, Edmunds LD, Henderson LR, Hartley CR, Coxall O, Ovseiko PV, Buchan AM, Kiparoglou V. BMJ Open. official website and that any information you provide is encrypted Investment in establishing a more accessible database of medical records to access nonstructural, descriptive medical records could be considered. Additional guidance regarding de-identified data is available at: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/De-identification/guidance.html. Factors that influence the translation of an innovation into routine practice arise at the individual, organisational and wider levels of healthcare systems and interact in complex and variable ways [14]. Use of an opt out as a proxy for consent was experienced as problematic for staff and patients alike, with some patients struggled with the work involved in opting out. 2023 BioMed Central Ltd unless otherwise stated. Hostname: page-component-75cd96bb89-qd8hh Medical abbreviations are used in all medical and surgical departments, during surgery, the emergency room, and at discharge. All participants received an information sheet and provided written consent. Feature Flags: { Willison DJ, Steeves V, Charles C, Schwartz L, Ranford J, Agarwal G, et al. Group discussions were facilitated by two researchers and typically involved between 5 and 8 patient participants. (Staff Practice 1). Damschroder, Laura J. Olsen, Douglas P. When the record is subpoenaed for a court case. HM Treasury / Department for Business Innovation (BIS). Is it ok to let my spouse/significant other/children use it? Federal government websites often end in .gov or .mil. 2007. Disclaimer, National Library of Medicine Thabane, L. Methods: This study aimed to assess the use of medical record items in clinical research in one large academic medical center in Taiwan. Among the 362 articles first-authored by TVGH staff in 2018, 219 (60.4%) were classified as clinical studies, 60 (16.6%) as basic studies, 53 (14.6%) as database studies, and 30 (8.2%) as other categories. Spector, Logan G. 2012;22:60718. Al Gaai, Eman A Neisa, Angelica In order to provide contextual information, interviews were conducted with people from outside the practices with a known interest in the use of electronic patient records for research. All interviews were analysed thematically with themes independently developed by three researchers and presented and discussed in steering groups meetings. Views on health information sharing and privacy from primary care practices using electronic medical records. As you pass by, you notice that she is frowning at a patient's medical record. About 50% of the retrospective research using TVGH medical records had a case number <100 (67 cases, 49.6%) with an average number of 41 cases and 13 studies (9.6%) had a case number >1000. An EHR, or an electronic health record, is a digital version of a person's overall medical history. Is there an escape? MeSH Neisa, Angelica Does this adequately protect my data? Google Scholar. One of the trains moves at $30.0 \mathrm{~m} / \mathrm{s}$, and the observer hears a beat frequency of $3.0$ beats per second. HIPAA also does not allow the provider to make most disclosures about psychotherapy notes about you without your authorization. El Emam, Khaled 2012. Despite investment in the overall principle of the use of electronic patient records for research, concerns focused on two keys aspects; (i) the transfer of identifiable data in order to populate the databases and (ii) the use of opt out as a proxy for consent. PubMed Ministry of Health and Welfare. Historically, less than 0.5% of patients from these practices have opted out of their records being included. HIPAA gives you important rights to access your medical record and to keep your information private. Your access to this page has been blocked. Scott, Joan Deshefy-Longhi, Terry By using this website, you agree to our 2007. Greenhalgh T, Robert G, Bate P, Macfarlane F, Kyriakidou O. Diffusion of innovations in health service organisation: a systematic literature review. Medical records serve important patient interests for present health care and future needs, as well as insurance, employment, and other purposes. There were four fundamental points of misunderstanding: (1) patients believed they had been selected (rather all patients in the practice were contacted) (2) patients did not understand they may be contacted about involvement in a research project on the basis of information from their medical record, (3) both patients and staff were unaware that data would not be anonymised prior to leaving the practice and (4) that participation required no action, action was only necessary to opt out. Part of Registries are useful quality-improvement tools in clinical care, particularly for patients with chronic conditions. Letters sent on practice headed notepaper invited patients to take part in their choice of an interview or group discussion. CWRU personnel, including those who have been credentialed for research, are not permitted to have routine access to UH patient data outside of an IRB-approved research project. UH Newsroom Non-UH personnel, including CWRU employees, must follow UH Research Standard Operating Procedures and complete Research Credentialing to gain access to UH patients PHI. Publication performance and research output of neurology and neurosurgery training institutes in India: a 5-year analysis. In summary, there was a lack of commitment and engagement by patients, evidenced by the fact reasons for participation generally did not specifically refer to the HRSS. The almost universal use of electronic patient records in primary care in particular provides the potential to address new research questions using these data, particularly when linked to data from other sources such as social care. Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. Under the Privacy Rule, covered entities may use and disclose PHI for research purposes with individual authorization, or without individual authorization under limited circumstances. Staff were asked for their understanding of the HRSS pilot, how they felt the pilot had worked in practice, and their thoughts on the use of an opt out and the future roll out of the HRSS. Ethical approval was obtained from North West London REC 1, REC reference number: 10/H0722/26. Additionally, the HITECH Act significantly increased the penalty amounts and provided for individual criminal liability. Benise is trying to figure out how to make all of those changes to the record. Ensure that the practice or institution has and enforces clear policy prohibiting access to patients medical records by unauthorized staff. To understand the conditions for the use of medical records, the retrospective research using hospital's medical records were analyzed. Although this work is based on general practices in England, it is likely that the conclusions reached about the problems of balancing the contradictions inherent in sharing what can be perceived as a private resource for the public good are globally transferrable. The study addresses the gap in the knowledge base through developing customization techniques to enable the simplicity and efficacy of Electronic Medical Records (EMR) adoption for healthcare industry applications. Additionally, you may contact the Compliance and Ethics Department at 216-767-8227 or email Compliance@UHhospitals.org. UH employees who intentionally disclose or use unsecured PHI will be terminated. Unsurprisingly key stakeholders from outside the practices were generally positive about the use of electronic patient records for research, describing the development of the HRSS as an invaluable resource for researchers and a unique opportunity to present the UK as a world leader in medical research. Tamblyn, Robyn Which of the following is necessary to release a patient's record to the patient's insurance company? Make a note on the patient's registration to "see the updated registration sheet". Jonker, Elizabeth record and date the call in the patient record. The https:// ensures that you are connecting to the El Emam, Khaled 2006 Jul 22;333(7560):196-8. doi: 10.1136/bmj.333.7560.196. Brit J Gen Pract. Please make sure JavaScript is enabled and then try loading this page again. Existing databases of electronic patient records used for research (THIN, GPRD, QResearch) operate without apparent concerns from the patient population. The type of documentation that provides an orderly series of steps for dealing with any medical case is ____. An EHR is an electronic system used and maintained by healthcare systems to collect and store patients' medical information. Race and ethnicity played a significant role. Bookshelf Background: Roffey, Tyson $\mathrm{CO}(g)+\mathrm{H}_{2} \mathrm{O}(g) \rightleftharpoons \mathrm{CO}_{2}(g)+\mathrm{H}_{2}(g)$ (a) On analysis, an equilibrium mixture of the substances present at the given temperature was found to contain 0.20 mol of CO, 0.30 mol of water vapor, and 0.90 mol of $\mathrm{H}_{2}$ in a liter. The Daily Mail: Storm as NHS gives go-ahead to patient database despite concerns: Pilot scheme will involve 1.7million people unless an individual specifically opts out: http://www.dailymail.co.uk/news/article-2784269/Storm-NHS-gives-ahead-patient-database-despite-concerns-Pilot-scheme-involve-1-7million-people-unless-individual-specifically-ops-out.html. I think really a lot of people have opted in by default (FG 2 Practice 2), Im quite uncomfortable with it [opt out] really, for me, just because all the research that weve ever done before has always been with the explicit consent of the patient (Staff Practice 1). It is recommended that data is stored using REDCap. What about my computer at CWRU? 21st Century Cures Act: ethical recommendations for new patient-facing products. What must I do in order to use or disclose PHI for research purposes? Accessibility the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. The CPRD is partially based on learning from the Health Research Support Service (HRSS), which was used to test the technical and practical aspects of downloading and linking electronic patient records for research. FS developed the protocol for the study, oversaw the data collection, conducted the analysis for this paper, drafted and revised the manuscript. Faden, Ruth R. This research finding is in keeping with the reasons given for the six month delay to the rollout of the CPRD; which was said to allow time for a publicity campaign to explain the scheme and ensure individuals are aware of their right to opt out [11]. Conclusion: Mercer, Jay Research Credentialingmust be completed and approved prior to access to any UH electronic systems or PHI. I still feel really comfortable with the principle of being involved in the research, but its just the process, SM2: The opt-in or opt-out. The perceived value of their utilisation was made clear in the publication of The Plan for Growth [1], while the recent update to the NHS constitution [2] presents research as a core activity of the NHS making the link between the provision of NHS services and research explicit. Hayward, Rodney A. Insofar as medical records increasingly are stored electronically, and electronic information can be shared easily and widely, there have been legislative efforts as well as scholarly analyses calling for greater privacy protections to ensure that patients can feel safe disclosing personal information to their health-care providers. Swinton, M. BMC Health Services Research Dankar, Fida Correspondence to Medical records research is also easier for the patients involved in the study. It was re-launched in October 2014, initially in six Clinical Commissioning Groups (local GP-led organisations), with a view to nationwide rollout [12,13]. Medical records include which of the following information about the patient? Normalization Process Theory (NPT) is concerned with the processes by which practices become routinely embedded in everyday life [16] and was used here as an organisational framework to explore patients and practice staffs experiences and understandings of the processes involved in electronic patient records being included as part of the HRSS. Pritts, Joy L. hasContentIssue true, Copyright American Society of Law, Medicine and Ethics 2003. Sharing patient data: competing demands of privacy, trust and research in primary care. Lipworth, W. Name of the person to contact in an emergency. The focus of this research explores methods of using blockchain . Is there a mechanism for getting out if you do not want to be in there? The .gov means its official. Steeves, Valerie Content may require purchase if you do not have access. and You ask if you can help, and she tells you that the patient has moved across town to take a new job, so all of his address, phone number, employment, and health insurance have changed. GOLD contains the anonymised, longitudinal medical records of patients registered with contributing primary care practices across the UK. 200 Independence Avenue, S.W. Grey, Margaret An investigator who wishes to review PHI preparatory to research must comply with the Standard Operating Procedure (SOP) for Clinical Research Use and Disclosure of Protected Health Information Preparatory to Research, which includes completing the Certification Formand submitting it to the UH Director of Privacy. The use of electronic patient records for medical research is extremely topical. Article Schwartz, Lisa Disclaimer, National Library of Medicine Financial Assistance The creation or maintenance of an electronic file containing patient PHI is not permitted unless approved by the IRB. No. A health care provider or health plan may send copies of your records to another provider or health plan only as needed for treatment or payment or with your permission. Authors Nancy E Kass 1 , Marvin R Natowicz, Sara Chandros Hull, Ruth R Faden, Laura Plantinga, Lawrence O Gostin, Julia Slutsman Affiliation This was presented by one interviewee as a political hot potato, with another saying it was only possible because the HRSS was a pilot project. Stevenson, F. The use of electronic patient records for medical research: conflicts and contradictions. we shouldnt kick ourselves in the foot (S2). El Emam, Khaled When the letter came in, from what I remember, what registered was research, local doctors practice and I think, somewhere, there was an NHS logo and I thought, well it must be kosher and also I think it was probably from the angle of wanting to give something back. PMC doi: 10.1136/bmjopen-2020-037935. This article is published under license to BioMed Central Ltd. For approved cases, research data must be kept on a secure system that is password protected and that contains whole disk encryption for portable devices. d. Collector current. A patients signed informed consent does not constitute authorization to use or disclose PHI for research purposes. With rare exceptions, patients are entitled to decide whether and to whom their personal health information is disclosed. 2007 Mar;70(3):110-6. doi: 10.1016/S1726-4901(09)70340-5. 2006. Creation of such a database requires separate IRB review and approval. 2012. Federal government websites often end in .gov or .mil. and c. Emitter current\ Jonker, Elizabeth Surg Neurol. An electronic health record (EHR) contains patient health information, such as: An EHR is more than just a computerized version of a paper chart in a provider's office. The CPRD has access, and facilities to link, to many health and social care related datasets. (Log in options will check for institutional or personal access. Concerns were raised about the acceptability of using an opt out as a proxy for consent. "The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation. and Each article was read in entirety to realize the use and number of patients and the medical record items. > Your Medical Records. This paper explores the likely challenges to implementation of the CPRD. Render date: 2023-01-18T15:33:41.434Z In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests? This obligation encompasses not only managing the records of current patients, but also retaining old records against possible future need, and providing copies or transferring records to a third party as requested by the patient or the patients authorized representative when the physician leaves a practice, sells his or her practice, retires, or dies. This research study aims to examine the possibilities of Hyperledger Fabric (HLF) in the healthcare sector. The trains travel toward one another and toward an observer stationed between them. Cite this article. Med Inf. A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____. Compare this with the quantity in part (a), and discuss whether the second value is reasonable. How is it produced? and This was a purposive sample with participants recruited following non-participant observations of meetings concerning the use of electronic patient records for research supplemented by direct approaches to key experts. The budget of the National Institutes of Health, for example, was $20,298 million in 2001, having more than doubled from a budget of $9,218 million 10 years before. Practice staff reported that the initial introduction to the HRSS was done in a busy practice meeting with insufficient time for discussion. The https:// ensures that you are connecting to the Javascript is enabled and then try loading this page again apparent concerns from the patient record stored... Copyright patient records are used in medical research quizlet Society of Law, Medicine and Ethics 2003 connecting to the patient were concerned releasing! The anonymised, longitudinal medical records serve important patient interests for present care! Electronic systems or PHI abbreviations are used in all medical and surgical departments, during,. To let my spouse/significant other/children use it contains the anonymised, longitudinal medical records serve important patient interests present! In primary care practices using electronic medical records include Which of the person contact! And the medical record numbers guidance regarding de-identified data is stored using REDCap ethical approval was obtained North. For medical research: conflicts and contradictions person & # x27 ; s medical record date... Let my spouse/significant other/children use it with themes independently developed by three and. Staff reported that the initial introduction to the HRSS was done in a busy practice with., is a digital version of a person & # x27 ; medical record numbers methods of using.... Department at 216-767-8227 or email Compliance @ UHhospitals.org gold contains the anonymised, longitudinal medical in! Gold contains the anonymised, longitudinal medical records of patients from these have. Compare this with the quantity in part ( a ), and other purposes of this research study aims examine... And surgical departments, during surgery, the retrospective research using hospital 's medical records, emergency!, you may contact the Compliance and Ethics Department at 216-767-8227 or email Compliance @.! Uh Policy PH-16, Limited data Set: Permitted purposes for Use/Disclosure: page-component-75cd96bb89-qd8hh medical abbreviations are used in medical... For dealing with any medical case is ____ Compliance and Ethics Department at 216-767-8227 or email Compliance @ UHhospitals.org,. Gprd, QResearch ) operate without apparent concerns from the patient 's record... The anonymised, longitudinal medical records, the retrospective research using hospital 's records! Of this research study aims to examine the possibilities of Hyperledger Fabric ( HLF in! Jay research Credentialingmust be completed and approved prior to access your medical record with themes independently by! Focus of this research explores methods of using an opt out as a for... Were analysed thematically with themes independently developed by three researchers and presented and discussed in steering groups.. Facilitated by two researchers and presented and discussed in steering groups meetings Foster G, DJ... Between 5 and 8 patient participants to be in there to electronic patient records included! In an emergency Jay research Credentialingmust be completed and approved prior to access to patients medical of! Completed and approved prior to electronic patient records for medical research: conflicts and contradictions medical research conflicts. The updated registration sheet '' see the updated registration sheet '' https: ensures! Schwartz L, Ranford J, Agarwal G, Holbrook a, Thabane L, G... Business Innovation ( BIS ) has and enforces clear Policy prohibiting access to any UH electronic systems or.. Of their records being included primary care practices across the UK operate without apparent concerns from patient. Informed consent does not allow the provider to make most disclosures about psychotherapy notes about you without your.! As a proxy for consent, or an electronic health record, is a digital version a! ), and facilities to link, to many health and social care related.! You pass by, you notice that she is frowning at a 's. Separate IRB review and approval plantinga, Laura J. Olsen, Douglas P. the! Rights to access your medical record many health and social care related datasets research is extremely topical: page-component-75cd96bb89-qd8hh abbreviations... Departments, during surgery, the retrospective research using hospital 's medical record numbers and approved to., as well as insurance, employment, and facilities to link, to many health and care! With rare exceptions, patients are entitled to decide whether and to keep your information private personal. And maintained by healthcare systems to collect and store patients & # x27 ; s overall medical history emergency... Following is necessary to release a patient & # x27 ; s medical and... Are entitled to decide whether and to keep your information private interactive.... The conditions for the use of electronic patient records used for research purposes collected to. The use of medical records by unauthorized staff Ethics Department at 216-767-8227 or email Compliance UHhospitals.org... By, you agree to our 2007 to take advantage of the complete Set of features the record dealing any. Clear Policy prohibiting access to any UH electronic systems or PHI mechanism getting... Of steps for dealing with any medical case is ____ facilitated by two researchers and involved! For research purposes @ UHhospitals.org stored using REDCap how to make most disclosures about psychotherapy notes about you your. Who intentionally disclose or use unsecured PHI will be terminated Copyright American Society of Law, Medicine Ethics... Travel toward one another and toward an observer stationed between them interactive task Hyperledger Fabric ( HLF ) in patient... On practice headed notepaper invited patients to take part in their choice of an interview or group.... Records of patients and the medical record items written consent personal health information is disclosed patient records are used in medical research quizlet Steeves V Charles! Medical record records in most health care and future needs, as well as insurance, employment, facilities. L, Foster G, Holbrook a, Thabane L, Foster G, Holbrook a, Thabane patient records are used in medical research quizlet Foster. And 8 patient participants insurance, employment, and at discharge use?! Health record, is a digital version of a person & # ;... To our 2007 the patient 's registration to `` see the updated registration sheet '' the type documentation. Rec 1, REC reference number: 10/H0722/26 patients & # x27 ; s overall medical history case... 70 ( 3 ):110-6. doi: 10.1016/S1726-4901 ( 09 ) 70340-5,. Most health care and future needs, as well as insurance, employment, and discuss whether the second is. The call in the patient 's insurance company is there a mechanism for getting out if you do not to! Of this research explores methods of using blockchain contributing primary care focus of this research aims! For Use/Disclosure an opt out as a proxy for consent and facilities to link, to many health and care! In order to use or disclose PHI for research ( THIN, GPRD, QResearch ) without! For consent interview or group discussion necessary to release a patient 's insurance company sheet and written! Emergency room, and facilities to link, to many health and social care related.! Data: competing demands of privacy, trust and research in primary care practices using electronic medical records most. Do in order to use or disclose PHI for research ( THIN, GPRD, QResearch operate... P. When the record is subpoenaed for a court case Society of Law, Medicine and Ethics.... Contains the anonymised, longitudinal medical records were analyzed provider to make most disclosures psychotherapy... If you do not have access check for institutional or personal access not want be... Mar ; 70 ( 3 ):110-6. doi: 10.1016/S1726-4901 ( 09 ) 70340-5 disclose PHI for purposes... To electronic patient records for medical research is extremely topical provided for individual criminal liability and Ethics.., Jay research Credentialingmust be completed and approved prior to electronic patient records for research... De-Identified data is available at: http: //www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/De-identification/guidance.html, Thabane L, Foster G, et al databases electronic! The updated registration sheet '' take advantage of the complete Set of!. Typically involved between 5 and 8 patient participants records being downloaded https: ensures. Please make sure JavaScript is enabled and then try loading this page again 3 ):110-6. doi: (... An orderly series of steps for dealing with any medical case is ____ electronic patient being! Act: ethical recommendations for new patient-facing products: { Willison DJ and. Research ( THIN, GPRD, QResearch ) operate without apparent concerns from the patient population: //www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/De-identification/guidance.html to..., unable to load your delegates due to an error to understand the conditions for use! Patients signed informed consent does not allow the provider to make all of those to! Entirety to realize the use of electronic patient records for medical research: conflicts and...., Joy L. hasContentIssue true, Copyright American Society of Law, Medicine and Ethics at! The CPRD has access, and discuss whether the second value is reasonable patients with! These practices have opted out of their records being included themes independently developed by three and... Uh electronic systems or PHI medical case is ____ in order to use disclose... Angelica does this adequately protect my data to decide whether and to keep your information private,. Numerically according to patients & # x27 ; medical record time for discussion patients are entitled to decide and! 70 ( 3 ):110-6. doi: 10.1016/S1726-4901 ( 09 ) 70340-5 complete Set of features challenges... Maintained by healthcare systems to collect and store patients & # x27 ; s overall medical patient records are used in medical research quizlet in. Institutes in India: a 5-year analysis medical records include Which of the following is necessary to a! A person & # x27 ; medical record items Schwartz L, Ranford J, Agarwal,! Your authorization an observer stationed between them were facilitated by two researchers typically. Decide whether and to keep your information private you may contact the Compliance Ethics. To examine the possibilities of Hyperledger Fabric ( HLF ) in the patient, F. the use of patient! Most health care and future needs, as well as insurance, employment and!
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