Electronic medical records in primary care: management of duplicate records and a contribution to epidemiological studies. / Prontuários eletrônicos na Atenção Primária: gestão de cadastros duplicados e contribuição para estudos epidemiológicos.

Primary health care electronic medical records were analyzedin Rio de Janeiro for two chronic diseases, namely, hypertension and diabetes, in a population-based study with a cross-sectional epidemiological design that considered the Rio de Janeiro population enrolled in Family Health Teams. Calculation of the prevalence rate was stratified by gender and age group, and the condition of the disease was measured by family doctors in their visits using the ICD-10.Except for the last two age groups (75-79 years and 80 years and over), with apparent under-registration of the diagnosed cases, a positive association was found between prevalence rates and age in both genders. The generation of objective and reliable statistical information is fundamental for local management, allowing the evaluation of demographic dynamics and the peculiarities of each territory, and assisting in the planning and monitoring of the quality of Rio de Janeiro people's records registered in each family health unit. Thus, the regular management of duplicate records in the registered user roster is essential to minimize the over-registration of clinical cases reported in the electronic medical records.

Analisaram-se os registros eletrônicos da atenção primária em saúde na cidade do Rio de Janeiro para duas doenças crônicas: hipertensão e diabetes, em um estudo de base populacional, com desenho epidemiológico transversal que considerou a população carioca que possuía "Equipes de Saúde da Família". O cálculo da taxa de prevalência foi estratificado por sexo e faixa etária, e a condição da doença foi mensurada pelos médicos de família nas consultas realizadas por estes, computando-se a CID-10. Excetuando-se as duas últimas faixas etárias (75 a 79 anos e 80 anos e mais), em que parece haver subregistro dos casos diagnosticados, observou-se uma associação positiva entre as taxas de prevalência e a faixa etária, em ambos os sexos. A geração de informações estatísticas objetivas e com confiabilidade é fundamental para a gestão no nível local, permitindo avaliar a dinâmica demográfica e as particularidades de cada território, e auxiliando no planejamento e monitoramento da qualidade dos registros dos cariocas cadastrados em cada unidade de saúde da família. Para isso, a gestão regular de registros duplicados nas listas de usuários cadastrados é fundamental para minimizar o sobreregistro de casos clínicos apontados nos prontuários eletrônicos.

Prontuários eletrônicos na Atenção Primária: gestão de cadastros duplicados e contribuição para estudos epidemiológicos / Electronic medical records in primary care: management of duplicate records and a contribution to epidemiological studies

Resumo Analisaram-se os registros eletrônicos da atenção primária em saúde na cidade do Rio de Janeiro para duas doenças crônicas: hipertensão e diabetes, em um estudo de base populacional, com desenho epidemiológico transversal que considerou a população carioca que possuía "Equipes de Saúde da Família". O cálculo da taxa de prevalência foi estratificado por sexo e faixa etária, e a condição da doença foi mensurada pelos médicos de família nas consultas realizadas por estes, computando-se a CID-10. Excetuando-se as duas últimas faixas etárias (75 a 79 anos e 80 anos e mais), em que parece haver subregistro dos casos diagnosticados, observou-se uma associação positiva entre as taxas de prevalência e a faixa etária, em ambos os sexos. A geração de informações estatísticas objetivas e com confiabilidade é fundamental para a gestão no nível local, permitindo avaliar a dinâmica demográfica e as particularidades de cada território, e auxiliando no planejamento e monitoramento da qualidade dos registros dos cariocas cadastrados em cada unidade de saúde da família. Para isso, a gestão regular de registros duplicados nas listas de usuários cadastrados é fundamental para minimizar o sobreregistro de casos clínicos apontados nos prontuários eletrônicos.

Abstract Primary health care electronic medical records were analyzedin Rio de Janeiro for two chronic diseases, namely, hypertension and diabetes, in a population-based study with a cross-sectional epidemiological design that considered the Rio de Janeiro population enrolled in Family Health Teams. Calculation of the prevalence rate was stratified by gender and age group, and the condition of the disease was measured by family doctors in their visits using the ICD-10.Except for the last two age groups (75-79 years and 80 years and over), with apparent under-registration of the diagnosed cases, a positive association was found between prevalence rates and age in both genders. The generation of objective and reliable statistical information is fundamental for local management, allowing the evaluation of demographic dynamics and the peculiarities of each territory, and assisting in the planning and monitoring of the quality of Rio de Janeiro people's records registered in each family health unit. Thus, the regular management of duplicate records in the registered user roster is essential to minimize the over-registration of clinical cases reported in the electronic medical records.

Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation.

OBJECTIVES: The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists. DATA SOURCES: An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists. STUDY SELECTION: Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models. DATA EXTRACTION: Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review. DATA SYNTHESIS: Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records. CONCLUSIONS: Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.

Improving documentation of presenting problems in the emergency department using a domain-specific ontology and machine learning-driven user interfaces.

OBJECTIVES: To determine the effect of a domain-specific ontology and machine learning-driven user interfaces on the efficiency and quality of documentation of presenting problems (chief complaints) in the emergency department (ED). METHODS: As part of a quality improvement project, we simultaneously implemented three interventions: a domain-specific ontology, contextual autocomplete, and top five suggestions. Contextual autocomplete is a user interface that ranks concepts by their predicted probability which helps nurses enter data about a patient's presenting problems. Nurses were also given a list of top five suggestions to choose from. These presenting problems were represented using a consensus ontology mapped to SNOMED CT. Predicted probabilities were calculated using a previously derived model based on triage vital signs and a brief free text note. We evaluated the percentage and quality of structured data captured using a mixed methods retrospective before-and-after study design. RESULTS: A total of 279,231 consecutive patient encounters were analyzed. Structured data capture improved from 26.2% to 97.2% (p < 0.0001). During the post-implementation period, presenting problems were more complete (3.35 vs 3.66; p = 0.0004) and higher in overall quality (3.38 vs. 3.72; p = 0.0002), but showed no difference in precision (3.59 vs. 3.74; p = 0.1). Our system reduced the mean number of keystrokes required to document a presenting problem from 11.6 to 0.6 (p < 0.0001), a 95% improvement. DISCUSSION: We demonstrated a technique that captures structured data on nearly all patients. We estimate that our system reduces the number of man-hours required annually to type presenting problems at our institution from 92.5 h to 4.8 h. CONCLUSION: Implementation of a domain-specific ontology and machine learning-driven user interfaces resulted in improved structured data capture, ontology usage compliance, and data quality.

Methodological description of clinical research data collection through electronic medical records in a center participating in an international multicenter study.

Data collection for clinical research can be difficult, and electronic health record systems can facilitate this process. The aim of this study was to describe and evaluate the secondary use of electronic health records in data collection for an observational clinical study. We used Cerner Millennium®, an electronic health record software, following these steps: (1) data crossing between the study's case report forms and the electronic health record; (2) development of a manual collection method for data not recorded in Cerner Millennium®; (3) development of a study interface for automatic data collection in the electronic health records; (4) employee training; (5) data quality assessment; and (6) filling out the electronic case report form at the end of the study. Three case report forms were consolidated into the electronic case report form at the end of the study. Researchers performed daily qualitative and quantitative analyses of the data. Data were collected from 94 patients. In the first case report form, 76.5% of variables were obtained electronically, in the second, 95.5%, and in the third, 100%. The daily quality assessment of the whole process showed complete and correct data, widespread employee compliance and minimal interference in their practice. The secondary use of electronic health records is safe and effective, reduces manual labor, and provides data reliability. Anesthetic care and data collection may be done by the same professional.

Impact of a targeted monitoring on data-quality and data-management workload of randomized controlled trials: A prospective comparative study.

AIMS: Monitoring risk-based approaches in clinical trials are encouraged by regulatory guidance. However, the impact of a targeted source data verification (SDV) on data-management (DM) workload and on final data quality needs to be addressed. METHODS: MONITORING was a prospective study aiming at comparing full SDV (100% of data verified for all patients) and targeted SDV (only key data verified for all patients) followed by the same DM program (detecting missing data and checking consistency) on final data quality, global workload and staffing costs. RESULTS: In all, 137 008 data including 18 124 key data were collected for 126 patients from 6 clinical trials. Compared to the final database obtained using the full SDV monitoring process, the final database obtained using the targeted SDV monitoring process had a residual error rate of 1.47% (95% confidence interval, 1.41-1.53%) on overall data and 0.78% (95% confidence interval, 0.65-0.91%) on key data. There were nearly 4 times more queries per study with targeted SDV than with full SDV (mean ± standard deviation: 132 ± 101 vs 34 ± 26; P = .03). For a handling time of 15 minutes per query, the global workload of the targeted SDV monitoring strategy remained below that of the full SDV monitoring strategy. From 25 minutes per query it was above, increasing progressively to represent a 50% increase for 45 minutes per query. CONCLUSION: Targeted SDV monitoring is accompanied by increased workload for DM, which allows to obtain a small proportion of remaining errors on key data (<1%), but may substantially increase trial costs.

Structured reporting of prostate magnetic resonance imaging has the potential to improve interdisciplinary communication.

BACKGROUND: Effective interdisciplinary communication of imaging findings is vital for patient care, as referring physicians depend on the contained information for the decision-making and subsequent treatment. Traditional radiology reports contain non-structured free text and potentially tangled information in narrative language, which can hamper the information transfer and diminish the clarity of the report. Therefore, this study investigates whether newly developed structured reports (SRs) of prostate magnetic resonance imaging (MRI) can improve interdisciplinary communication, as compared to non-structured reports (NSRs). METHODS: 50 NSRs and 50 SRs describing a single prostatic lesion were presented to four urologists with expert level experience in prostate cancer surgery or targeted MRI TRUS fusion biopsy. They were subsequently asked to plot the tumor location in a 2-dimensional prostate diagram and to answer a questionnaire focusing on information on clinically relevant key features as well as the perceived structure of the report. A validated scoring system that distinguishes between "major" and "minor" mistakes was used to evaluate the accuracy of the plotting of the tumor position in the prostate diagram. RESULTS: The mean total score for accuracy for SRs was significantly higher than for NSRs (28.46 [range 13.33-30.0] vs. 21.75 [range 0.0-30.0], p < 0.01). The overall rates of major mistakes (54% vs. 10%) and minor mistakes (74% vs. 22%) were significantly higher (p < 0.01) for NSRs than for SRs. The rate of radiologist re-consultations was significantly lower (p < 0.01) for SRs than for NSRs (19% vs. 85%). Furthermore, SRs were rated as significantly superior to NSRs in regard to determining the clinical tumor stage (p < 0.01), the quality of the summary (4.4 vs. 2.5; p < 0.01), and overall satisfaction with the report (4.5 vs. 2.3; p < 0.01), and as more valuable for further clinical decision-making and surgical planning (p < 0.01). CONCLUSIONS: Structured reporting of prostate MRI has the potential to improve interdisciplinary communication. Through SRs, expert urologists were able to more accurately assess the exact location of single prostate cancer lesions, which can facilitate surgical planning. Furthermore, structured reporting of prostate MRI leads to a higher satisfaction level of the referring physician.

The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department.

Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.

Indirect Estimation of Race/Ethnicity for Survey Respondents Who Do Not Report Race/Ethnicity.

BACKGROUND: Researchers are increasingly interested in measuring race/ethnicity, but some survey respondents skip race/ethnicity items. OBJECTIVES: The main objectives of this study were to investigate the extent to which racial/ethnic groups differ in skipping race/ethnicity survey items, the degree to which this reflects reluctance to disclose race/ethnicity, and the utility of imputing missing race/ethnicity. RESEARCH DESIGN: We applied a previously developed method for imputing race/ethnicity from administrative data (Medicare Bayesian Improved Surname and Geocoding 2.0) to data from a national survey where race/ethnicity was usually self-reported, but was sometimes missing. A linear mixed-effects regression model predicted the probability of self-reporting race/ethnicity from imputed racial/ethnic probabilities. SUBJECTS: In total, 508,497 Medicare beneficiaries responding to the 2013-2014 Medicare Consumer Assessment of Healthcare Providers and Systems surveys were included in this study. MEASURES: Self-reported race/ethnicity and estimated racial/ethnic probabilities. RESULTS: Black beneficiaries were most likely to not self-report their race/ethnicity (6.6%), followed by Hispanic (4.7%) and Asian/Pacific Islander (4.7%) beneficiaries. Non-Hispanic whites were the least likely to skip these items (3.2%). The 3.7% overall rate of missingness is similar to adjacent demographic items. General patterns of item missingness rather than a specific reluctance to disclose race/ethnicity appears to explain the elevated rate of missing race/ethnicity among Asian/Pacific Islander and Hispanic beneficiaries and most but not all among Black beneficiaries. Adding imputed cases to the data set did not substantially alter the estimated overall racial/ethnic distribution, but it did modestly increase sample size and statistical power. CONCLUSIONS: It may be worthwhile to impute race/ethnicity when this information is unavailable in survey data sets due to item nonresponse, especially when missingness is high.

Methodological description of clinical research data collection through electronic medical records in a center participating in an international multicenter study / Abordagem e descrição metodológica do uso do prontuário eletrônico como forma de coleta de dados em pesquisa clínica em centro participante de estudo internacional e multicêntrico

ABSTRACT Data collection for clinical research can be difficult, and electronic health record systems can facilitate this process. The aim of this study was to describe and evaluate the secondary use of electronic health records in data collection for an observational clinical study. We used Cerner Millennium®, an electronic health record software, following these steps: (1) data crossing between the study's case report forms and the electronic health record; (2) development of a manual collection method for data not recorded in Cerner Millennium®; (3) development of a study interface for automatic data collection in the electronic health records; (4) employee training; (5) data quality assessment; and (6) filling out the electronic case report form at the end of the study. Three case report forms were consolidated into the electronic case report form at the end of the study. Researchers performed daily qualitative and quantitative analyses of the data. Data were collected from 94 patients. In the first case report form, 76.5% of variables were obtained electronically, in the second, 95.5%, and in the third, 100%. The daily quality assessment of the whole process showed complete and correct data, widespread employee compliance and minimal interference in their practice. The secondary use of electronic health records is safe and effective, reduces manual labor, and provides data reliability. Anesthetic care and data collection may be done by the same professional.

RESUMO A coleta de dados para pesquisa clínica pode representar um desafio em que sistemas de registro eletrônico em saúde podem facilitar o processo. O objetivo deste estudo foi descrever e avaliar o uso secundário de registros eletrônicos em saúde na coleta de dados para um estudo clínico observacional. Usamos o Cerner Millennium®, software de registro eletrônico em saúde, de acordo com os seguintes passos: (1) cruzamento dos dados das fichas de coleta de dados do estudo e dos registros eletrônicos em saúde; (2) desenvolvimento de método para coleta manual de dados não registrados no Cerner Millennium®; (3) desenvolvimento de interface de estudo para a coleta automática de dados nos registros eletrônicos em saúde; (4) treinamento de colaboradores; (5) avaliação da qualidade dos dados; e (6) preenchimento da ficha eletrônica de coleta de dados no fim do estudo. Três fichas de coleta de dados foram consolidadas em uma ficha eletrônica de coleta de dados no fim do estudo. Os pesquisadores realizaram análise qualitativa e quantitativa de dados diariamente. Foram coletados dados de 94 pacientes. Na primeira ficha de coleta de dados, 76,5% das variáveis foram obtidas eletronicamente, na segunda, 95,5%, e na terceira, 100%. A avaliação diária de qualidade do processo como um todo revelou dados completos e corretos, ampla adesão dos colaboradores e mínima interferência na prática profissional. O uso secundário dos registros eletrônicos em saúde é seguro e efetivo, reduz o trabalho manual e produz dados confiáveis. O cuidado anestésico ao paciente e a coleta de dados podem ser realizados simultaneamente pelo mesmo professional.

A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin.

INTRODUCTION: Clinical documentation is the key determinant of inpatient acuity of illness and payer reimbursement. Every inpatient hospitalization is placed into a diagnosis related group with a relative value based on documented procedures, conditions, comorbidities and complications. The Case Mix Index (CMI) is an average of these diagnosis related groups and directly impacts physician profiling, medical center profiling, reimbursement, and quality reporting. We hypothesize that a focused, physician-led initiative to improve clinical documentation of vascular surgery inpatients results in increased CMI and contribution margin. METHODS: A physician-led coding initiative to educate physicians on the documentation of comorbidities and conditions was initiated with concurrent chart review sessions with coding specialists for 3 months, and then as needed, after the creation of a vascular surgery documentation guide. Clinical documentation and billing for all carotid endarterectomy (CEA) and open infrainguinal procedures (OIPs) performed between January 2013 and July 2016 were stratified into precoding and postcoding initiative groups. Age, duration of stay, direct costs, actual reimbursements, contribution margin (CM), CMI, rate of complication or comorbidity, major complication or comorbidity, severity of illness, and risk of mortality assigned to each discharge were abstracted. Data were compared over time by standardizing Centers for Medicare and Medicaid Services (CMS) values for each diagnosis related group and using a CMS base rate reimbursement. RESULTS: Among 458 CEA admissions, postcoding initiative CEA patients (n = 253) had a significantly higher CMI (1.36 vs 1.25; P = .03), CM ($7859 vs $6650; P = .048), and CMS base rate reimbursement ($8955 vs $8258; P = .03) than precoding initiative CEA patients (n = 205). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (43% vs 27%; P < .01). Among 504 OIPs, postcoding initiative patients (n = 227) had a significantly higher CMI (2.23 vs 2.05; P < .01), actual reimbursement ($23,203 vs $19,909; P < .01), CM ($12,165 vs $8840; P < .01), and CMS base rate reimbursement ($14,649 vs $13,496; P < .01) than precoding initiative patients (n = 277). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (61% vs 43%; P < .01). For both CEA and OIPs, there were no differences in age, duration of stay, total direct costs, or primary insurance status between the precoding and postcoding patient groups. CONCLUSIONS: Accurate and detailed clinical documentation is required for key stakeholders to characterize the acuity of inpatient admissions and ensure appropriate reimbursement; it is also a key component of risk-adjustment methods for assessing quality of care. A physician-led documentation initiative significantly increased CMI and CM.

Paro cardiorrespiratorio extrahospitalario. Realidad de un hospital terciario chileno / Out of hospital cardiac arrest events at an urban Hospital in Chile

Background: The incidence of out of hospital cardiac arrest (OHCA) is approximately 20 to 140 per 100.000 inhabitants. International registries, based on Utstein criteria have allowed standardized reporting of OHCA profiles and outcomes in different countries. We proposed to create a local OHCA registry. Aim: To assess the quality of the information about OHCA currently recorded in medical records according to Utstein guidelines. Material and Methods: A retrospective analysis of medical records of patients arriving in the emergency room of a public hospital with OHCA during a 3-year period. Data regarding the patient characteristics, event and outcomes were analyzed. Results: During the revision period, 317 patients arrived with an OHCA. None of the medical records had complete data on items that are considered a minimum requirement by Utstein guidelines. Mean age of patients was 63 years old, 60% were men, the most common arrest rhythm was asystole (43%) and 8% of patients were discharged alive. Conclusions: Data recorded in medical records is insufficient to inform the profile of OHCA. A prospective registry is currently being implemented based on the information provided by this study. This registry should optimize reporting and data analysis.

Creating a Physical Activity Self-Report Form for Youth Using Rasch Methodology.

Measurement of youth's physical activity levels is recommended to ensure that children are meeting recommended activity guidelines. This article describes the creation of an instrument to measure youth's levels of physical activity, where a strong test validation perspective (Benson, 1998) was followed to create the scale. The development process involved a mixed-method (qualitative followed by quantitative) framework. First, focus groups were conducted, where results informed item creation. Next, three alternative forms were created with different response formats to measure childrens' frequency of participation in various physical activities and intensity of participation. Lastly, a sample of over 500 middle school children was obtained, where three different response scales were investigated. The optimal scale considered measurement of physical activity using a three-point Likert frequency; intensity of activity participation did not strongly contribute to the measurement of children's activity levels. The final version form is thought to be acceptable for use with children in surveillance and large-group studies, as well as in smaller sample applications.

Improving the recording of clinical medicolegal findings in South Africa.

BACKGROUND: The accurate recording of findings in clinical medicolegal cases is important, yet the current J88 form used for this purpose in South Africa has been reported to have many flaws. In addition, there are reports of poor completion of the form, which could in part be due to its poor design and clarity. OBJECTIVE: To describe the process that was undertaken to revise the current J88 form. METHODS: A repetitive consultative process was used to revise the current J88 form and to obtain inputs from relevant government institutions. RESULTS: A brief outline of the changes that have been made to the current J88 form and the reasons why these changes were proposed by national experts is provided. CONCLUSION: The revised J88 form will provide clearer guidance to healthcare providers on the completion of necessary information in an expedited fashion. It is hoped that the form will soon be approved by the necessary government institutions.

Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction.

OBJECTIVE: To evaluate associations between the electronic environment, clerical burden, and burnout in US physicians. PARTICIPANTS AND METHODS: Physicians across all specialties in the United States were surveyed between August and October 2014. Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics. RESULTS: Of 6375 responding physicians in active practice, 5389 (84.5%) reported that they used EHRs. Of 5892 physicians who indicated that CPOE was relevant to their specialty, 4858 (82.5%) reported using CPOE. Physicians who used EHRs and CPOE had lower satisfaction with the amount of time spent on clerical tasks and higher rates of burnout on univariate analysis. On multivariable analysis, physicians who used EHRs (odds ratio [OR]=0.67; 95% CI, 0.57-0.79; P<.001) or CPOE (OR=0.72; 95% CI, 0.62-0.84; P<.001) were less likely to be satisfied with the amount of time spent on clerical tasks after adjusting for age, sex, specialty, practice setting, and hours worked per week. Use of CPOE was also associated with a higher risk of burnout after adjusting for these same factors (OR=1.29; 95% CI, 1.12-1.48; P<.001). Use of EHRs was not associated with burnout in adjusted models controlling for CPOE and other factors. CONCLUSION: In this large national study, physicians' satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.