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Journal of the Academy of Hospital Administration

Telemedicine for Improving Health Care Services in Developing Countries

Author(s): A.U.Jai Ganesh*, U.S. Rao*

Vol. 14, No. 1 (2002-01 - 2002-06)

Abstract:

Telemedicine uses telecommunications to deliver health care, often over great distances, with the possibility of cost savings particularly in remote and rural areas. It is a multi-disciplinary undertaking requiring expertise from telecommunications, health care and information technology sectors. There has been significant interest in the possibilities of using telemedicine to overcome some of the difficulties in providing health care in remote and rural areas of developing countries. Most of the telemedicine experience to date has been in the industrialized world. It is apparent that the first requirement of developing countries is for more information about telemedicine, what it is, and how it might be able to help to solve some of the shortages in medical and health care services.

This paper gives a broad outline of objectives of telemedicine end its evolution over the years, surveys telemedicine experience around the world, the technologies involved, standards, emerging trends in the development of telemedicine services, benefits of telemedicine and challenges to overcome. It also proposes a broad model for implementing telemedicine services in developing countries to improve healthcare services in geographically dispersed villages with limited financial and human resources.

Introduction

The state of health of a population is a direct determinant of development. Access to better health services reduces poverty and increases productivity. Investment in health is a prerequisite to economic and social progress. Developing countries face various problems in the provision of medical services and health care, including funds, expertise and resources. To meet this challenge, governments and private health care providers must make use of existing resources and the benefits of modern technology.

For countries with limited medical expertise and resources, telecommunication services have the potential to provide a solution to some of these problems. Telemedicine has he potential to improve both the quality and the access to health care regardless of the geography. It enables medical and health care expertise to be accessed from under served locations.

Telemedicine offers solutions for emergency medical assistance, long-distance consultation, administration and logistics, supervision and quality assurance and education and training for health care professionals and providers. In the industrialized world there has been a rapidly growing interest in telemedicine as a means of easing the pressure of health care on national budgets. Some of the technologies and experiences of industrialized countries could help developing countries in their desire to provide improved health care and primary health care in particular.

Telemedicine needs to be implemented carefully and managed well. The impact of telemedicine on health care structures can be significant. In this respect, telemedicine can be seen as a tool to reorganize or to build up new health care structures. However, there are also concerns about liability, confidentiality and other policy and regulatory issues. Hence the adoption of sound policies and strategic plans that guarantee the provision of high quality, sustained and integrated health care services to the population are the challenges faced by most developing countries.

Health care services have become increasingly team based, involving multiple care providers from different specialties. Contemporary medicine requires coordinating the services of multiple physicians (including specialists) from the same or different institutions to address a patient's health care problems and needs. The increasing awareness about the health and development of advanced telecommunication means and information technology has given rise to telemedicine that allows healthcare when patient and doctor are long distances away from each other. This procedure allows for maximum utilization of limited resources. Telemedicine has the potential to overcome problems commonly found in conventional face-to-face service arrangements, including difficulty in meeting service-time criticality without loss of care quality and continuity, inadequate information exchange, and time-space service constraints. The pressure for timely response for service needs is paramount1.

Definition

The definition adopted by an international consultation group convened by the WHO in Geneva in December 1997 to draft a health telematics policy for the WHO is as follows:

Telemedicine is the delivery of health-care services, where distance is a critical factor, by health-care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, and for the continuing education of health-care providers as well as research and evaluation, all in the interest of advancing the health of individuals and their communities.

The Objectives of Telemedicine

One of the basic ideas of telemedicine can be expressed by the saying: "Move the information, not the patient". When a patient needs to consult a specialist, information about the patient could be obtained locally and exchanged through a network to a specialist. In many situations this can replace transporting the patient or the specialist to a given location. This exchange of information and expertise for medical diagnosing and treatment is a basic concept of telemedicine.

Evolution of Telemedicine

Telemedicine literally means medicine practiced at a distance. It is not new and has been practiced since antiquity, using primitive communication technologies. Simple devices such as bells, flags and signs were used for this purpose in the past. This included the convention of making lepers ring bells to warn others not to come near. Ships carrying the plague flew yellow flags to indicate their ship was in quarantine and to keep other ships away. These are early examples of transmitting health information at a distance. As advances in the telecommunication technologies have occurred, the medical use of these technologies has followed.

Landmark Events in the history of Telemedicine

  • 1844: Transfer of medical information using public telegraph.
  • 1876: Alexander Graham Bell"s invention of the telephone.
  • 1897: A telephone was used to diagnose a child with croup and the case was reported in the medical journal Lancet.
  • 1906: The first Electro Cardio Graphic (ECG) transmission by phone.
  • 1923: Sahlgrens University hospital in Gothenburg, Sweden offered medical advice to fleets of trade ships by using Morse code.
  • 1927: The first experimental television transmission was undertaken.
  • 1949 The Jean-Talon hospital in Montreal used a television to perform X-ray data transmissions.
  • The initial idea behind telemedicine was, and is, to overcome the barriers of time and distance. From its inception, the emphasis has been on diagnosis. Since diagnosis usually requires visual information, one needs a device that enables the physician to "SCC" the patient. Among the early telemedicine efforts was the research and development work into telemetry undertaken by the National Aeronautics and Space Administration (NASA) in the USA. Scientists at NASA demonstrated successfully that physicians on earth could monitor the physiological functions of an astronaut.
  • 1957: The first interactive video link between the Nebraska Psychiatric Institute in Omaha and the Norfolk State Hospital 118 km's. away established by Dr. Cecil Wittson.
  • 1961: The first radio telemetry for monitoring patients in an intensive care unit was described in the journal of Anesthesiology
  • 1965: Live transmission of a open heart surgery performed by Dr. Michael Ellis DeBakey of Methodist Hospital. Houston, Texas in the United States to the audience attending a World Health Organization meeting in Geneva, Switzerland using Comsat"s Early Bird satellite.
  • 1967:Physicians provide services for airline passengers at Boston"s Logan International airport clinic with an electronic link from the airport to Massachusetts General Hospital (MGH).
  • 1972 to 1975: The department of health education and welfare, NASA, Lockheed, and the Indian Health Service combine to provide health care, to the Papago Indian Reservation in Arizona known as the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC).
  • 1989:NASA established a Space Bridge to Armenia to extend medical consultations for the victims of a massive earthquake in the Soviet Republic of Armenia.
  • 7th September 2001: The first complete long distance surgery performed by a doctor stationed thousands of kilometers away from the patient. The surgical team in New York sent high-speed signals to robots operating on the patient in France.

Technologies involved in telemedicine

Developing countries can benefit from using information technology and telecommunications networks to improve health care in remote and rural areas. Although advanced telemedicine applications may require a sophisticated and expensive telecommunications infrastructure, some solutions require only a basic infrastructure to provide health-care services to remote areas.

The two types of technologies, most commonly used today, are:

  • Store and Forward: In this text, audio, static and video images can be captured, stored and then forwarded to another location for review and/or consultation by a physician. This technology is less expensive and well suited for non-emergency situations in radiology, pathology and dermatology.
  • IATV (Two-way Interactive TV): In emergency medical situations such as a trauma service, video-conferencing equipment at both ends allows real time or near real time consultation. The key feature of telemedicine equipment which distinguishes it from simple video conferencing units is the use of peripheral devices: electronic versions of examination tools such as stethoscopes which allow the distant cardiologist to listen to the heart-beat of the patient.

Services such as specialist-assisted surgery or psychiatric consultations usually require live video. If live, real-time transfer of information is not required, such as in radiology and pathology, the use of store-and-forward technology can be more convenient and much more cost-effective.

Standards

Standards represent universally accepted agreements on how to implement technologies, allowing interconnection and communication between devices manufactured by different companies. Health Level Seven (HL 7) is the standard for electronic exchange of health data (clinical orders, billing information, patient admission, discharge, transfer and registration information). The Digital Imaging and Communication in Medicine (DICOM) standard defines common formats for data generated by imaging equipment and routine actions that can be performed on images, specifies how messages about the data and the processing actins can be exchanged.

Telemedicine in the INternational Scenario

As such, telemedicine is not a new phenomenon and work in this field has been going on since last 30 years. A number of telemedicine projects are being undertaken by NASA, the US universities, Australia, Europe, International Space University (ISU) Strasbourg, France and various other organizations and countries.

Telemedicine may in fact have a more profound impact on developing countries than on developed ones. Satellite stations in Uzbekistan, wireless connections in Cambodia, and microwave transmission in Kosova have shown that the low bandwidth Internet can reach into remote areas, some of them with troubled political situations and uncertain economic environments. The Internet-email, websites, chatlines, multimedia presentations, and occasional opportunities for synchronous communication via Internet phones and video conferencing provide an opportunity for medical education and medical care, not to mention collegial support2. Another example of the value of the Internet was the implementation of educational web servers in Kosovo, established with satellite links only months after the conflict abated. The installation of an Internet server allowed the local physicians to gain access to literature and websites, which replaced their 10-year-old collection of journals. Email has advantages in poor countries. SatelLife, a Boston based charitable organization provides e-mail access in 140 countries using a low earth orbit satellite and phone lines serving over 10,000 health workers3. An ongoing project to support doctors in Bangladesh by the Swinfen Trust, a medical charity has proved the use of e-mail is clinically useful and cost effective4.

Projects in other countries

Many countries are making headway in the field of telemedicine.

  • Imphone - is a research program at the Department of Radiology, University of Pisa, looking at the application of advanced informatics in medicine.
  • TeleSCAN project on cancer is being carried out at the Netherlands Cancer Institute. It is designed to demonstrate the benefits and possibilities of multimedia telematics to the European oncologist's in order to assist in the uptake of IT as an effective tool, both for clinicians and the staff.
  • Yale Telemedicine Center, Connecticut provides clinical consultation to various universities and medical institutions.
  • Israel has formed Telemedicine and Telecare Development Centre based at Ben Gurion University of the Negev and at Soroka Medical Centre Beer Sheva.
  • Japan is at the edge of a major push into telemedicine. The number of active programs in Japan jumped from 49 in 1995 to 98 in 1996 and to 148 in 1997.
  • Tripler Army Medical Center's Internet Tumour our Board, a web-based telemedicine project has let to better care for remote cancer patients and better communication among military medical specialists throughout the Pacific islands.

Telemedicine in the Indian Scenario

In India, there are many remote areas, which lack basic health care facilities, and patients have to travel for miles before they can be treated at any hospital/health care centre. With 80% of India"s population living in rural areas and 80% of the medical community living in cities, there is an imbalance in health care reaching people. So much so that in new millennium, 11% of the world"s population (residing in rural areas) remains devoid of quality health care. Hence, it becomes very essential that telemedicine be introduced and implemented in the country.

  • Apollo Hospital group has set up a 50-bed telemedicine center at Aragonda village (Andhra Pradesh, South India). It has also set up freestanding centers at Guwahati and Kolkata. These centers are equipped with facilities like CT- scan, X-ray, ECG and integrated laboratory and are linked to Apollo's specialized hospitals at Hyderabad, Chennai, and Delhi for seeking referral services, second opinion, post-acute care, interpretation services and health education. The hospital group has also a web portal, Apollo Life that allows patients to interact with doctors via the web, upload all their diagnostics and reports on the net.
  • Escorts Heart Institute and Research Centre (EHIRC), Delhi through its Escorts Heart Alert Service (EHAS), Utilizes telemedicine in establishing prompt contact with patients in distress. The EHAS subscribers can record their ECG's at the time of discomfort through the cardiac beeper provided and transmit them through a telephone to the "heart alert centre". These tele-ECG"s can be monitored 24-hours at the dedicated center and fully equipped mobile cardiac care units from the centre can be rushed to provide intensive care to the patients before they brought to the hospital for medical investigation.
  • Telemedicine project by Bharat Electronics Limited (BEL's) links a General Hospital in Chennai with a government rural hospital in Wallajah about 100 km away.
  • Telemedicine project by NIC (National Informatics Centre), Ministry of Information Technology aims at providing health-related information resources, decision support tools and data at the time and place of need by health care providers across the country.
  • Cardiovascular Technology Institute (CVTI), Hyderabad in association with Defence organisations has successfully tested an indigenous telemedicine field unit capable of transmitting, all the clinical data including MRI, CT Scan and even X-rays to a doctor of one"s choice through computer and telephone. The facility also offers two-way audio and video communication for real interaction helping doctors in seeking either expert or second opinion related to a case particularly for working in the remote corners of the country.
  • Technology Development Program for Telemedicine by The Ministry of Information Technology aims to link three premier medical institutions All India Institute of Medical Sciences, New Delhi; the Post graduate Institute (PGI), Chandigarh; and the Sanjay Gandhi Medical Institute at Lucknow for realizing tele-diagnosis, tele-consultancy and tele-education.

Emerging Trends

Just as any field of endeavour adapts to changes in the technologies upon which it depends, the filed of telemedicine is affected by emerging telecommunication and information technologies.

Electronic Patient Record (EPR)

One of the most important trends is the mover toward a universal electronic patient record. It could be defined as electronically stored health information about any individual uniquely identified by an identifier. This entails capturing, storing, retrieving, transmitting and manipulating patient-specific health care-related data, including clinical, administrative and biographical data. An example for such virtual patient records is the TeleMed Project at Los Alamos National Laboratory in New Mexico.

Smart Cards

Smart cards can provide basic medical information, such as lists of drug sensitivities; current conditions being treated, the name and phone number of a patient's doctor and other information vital in an emergency. Smart cards can also carry vital medical history and details about insurance coverage. For example, complex services such as remote diagnostics and health-related decision-making can be integrated efficiently with a Smart Card's patient record to provide added treatment alternatives to improve the overall quality of health services5.

Electronic House call

Researchers at the medical college of Georgia and the Georgia Institute of Technology have developed an "electronic house call" prototype enabling patients to have virtual checkups in their homes. This can be a solution for patients suffering from congenital heart diseases and other chronic health diseases that require frequent care and regular checkups.

Telesurgery

Another important trend is the move toward telesurgery.- A provision of surgical care over a distance, with direct, real-time visualization of the operative field through Telepresence Surgery to transmit the surgeons actions at a surgical workstation to the operative site at the remote surgical unit, with haptic (force feedback) input to transmit to the surgeon the tactile environment of the operative field. Telerobotics using a robotic arm, and telementoring where an experienced surgeon acts as a preceptor for a remote inexperienced surgeon by observing the surgeon via interactive video. The use of telepresence surgery will enable specialists to operate or assist an operation in a remote location6. Similar to simulation programmers in aviation, computer-based training in a virtual environment with visual and force feedback surgical trainers, which allow real-time simulation of dexterous endoscopic instruments, will ultimately change the tradition of surgical education7.

Benefits of Telemedicine

Everyone benefits from telemedicine from the patient to the community, as well as the physician team. Benefits can be classified according to the target group:

Benefits to patients

Includes faster diagnosis and treatment; reduction of additional examinations; seamless care; avoidance of the inconvenience of traveling to another hospital or physician; easier scientific and statistical analysis; better management of the populations" health by governments.

Benefits to clinicians: new opportunities to consult experts, broader base for decision making, avoidance of the inconvenience of traveling, improved image quality and the opportunity to manipulate images. Increased collegial support to medical personnel working in remote and isolated areas (Continuing Medical Education), resulting in improved teaching and learning possibilities and opportunities, access to virtual medical libraries and increased job satisfaction.

Benefits to Hospital

Includes reduced risk of images getting lost, faster and more precise diagnosis and treatment, better communication between sites, transport sites, transport savings, more efficient use of equipment.

Challenges to Overcome

In spite of the support for the benefits of telemedicine and its exciting global expansion, major barriers continue to prevent its widespread use. Several issues are cited as major obstacles and they include infrastructure constraints, lack of clear cut insurance reimbursement policy, licensure of providers, liability, confidentiality, lack of rigorous patient outcome and cost benefit data.

Telemedicine has a number of challenges to overcome before it can be integrated into the overall fabric of health care. They are:

(1) Infrastructure

Telecommunications: Telecommunications constitute an essential link in any telemedicine application. Telemedicine therefore demands a high degree of telecommunications network security, a high level of efficiency and adequate transmission capacity.

Medical technologies: In a modern health service, providing diagnosis, treatment and care depends on the quality of both the biomedical equipment and professional expertise. Developing countries are inevitably short of both equipment and well-trained experts.

(2) Quality of transmission

Accuracy of diagnosis is dependent on the clarity of images and data. If the quality of transmission is poor or incomplete, the physician must be prepared to decline diagnosis and treatment to avoid malpractice liability.

(3) Hardware and Software Compatibility

Telemedicine systems and services require that users have compatible hardware at both ends of the communications link, which reduces inter-operability and the benefits of access to different sources of telemedicine expertise.

(4) Costs

Much of the equipment used in telemedicine is still expensive (although costs are coming down) and network costs can be significant. Though declining transmission costs and advances in digitization and compression has made telemedicine applications more affordable, rural consultations are not frequent and it may be difficult to operate telemedicine systems cost effectively. At the same time high volumes of usage may not be possible in the initial phase of any telemedicine projects.

(5) Dispersion of Liability

If a local doctor or paramedic treating a patient contacts a telemedicine service and sends X-ray images for interpretation, who bears the responsibility toward the patient? Is it the local doctor or the specialist a thousand kilometers away? Although many telemedicine interactions are already crossing state and national boundaries, legal precedents for remote liability and licensing have not yet been established in the courts. When a telemedicine consultation crosses state lines, does the provider have to be licensed in one state, the other, or both?

(6) Privacy and confidentiality

Remote consultations involve the transfer of medical data that are sensitive, confidential and private electronically from one location to another. Sensitivity information, which can be associated with a patients"s identity, must not fall into the hands of unauthorized persons. Ensuring privacy of patient information sent across public networks where it may be "seen", intentionally or otherwise, is another issue to be addressed to avoid public disclosure of private facts.

(7) Acceptance

The success of telemedicine depends upon how users-patients, doctors, hospitals and governments accept it. But patients and doctors who are accustomed to personal visits may be reluctant to alter the traditional methods of health care. Like many people, some physicians may resist the use of a new technology, which they do not understand. If telemedicine is to have any significant and safe impact in developing or other countries, global agencies such as the World Health Organization need to encourage and accumulate studies on its local impact, while also seeking a global framework to ensure its safety and ethics8.

(8)Reimbursement

Since no difference is made between a conventional consultation and a teleconsultation, secondary consultations cannot easily be reimbursed and investment and telecommunication costs cannot easily be amortized. Also there are few insurance providers who will cover the risks associated with telemedicine consultations.

The Suggested Model

Developing countries are inevitably short of high-level hospital infrastructures. The geographical distribution of existing hospitals and health services is far from ideal; usually they are limited to urban centres at country or district level. Referral hospitals with competent medical specialists and state of the art medical technology, such as scanners and other sophisticated diagnostic equipment are non-existent, or where they do exist are at best confined to a single metropolis.

There is a growing recognition in many countries of the importance of placing, greater priority on the provision of primary health care as a way of minimizing the cost of direct medical care. The implementation of telematics in primary health care has lagged behind the application of telematics to the hospital environment for a number of reasons. One reason is the lack of investment in primary health care. Another important reason is the unstructured and dispersed nature of primary health care. As the policy to shift more health care from secondary to primary care is implemented and demographic changes begin to have an impact, increasing demands are being placed on primary health-care services. The need for coordination of health-care services for individual patients is a major consequence and the application of telematics in this area has the potential to improve both the quality and efficiency of health care.

Integration is the key to effective delivery of care. There cannot be high-technology hospitals in every part of a developing country, and with telemedicine links, there need not be. Instead a stratified system can be used, with telemedicine and conventional links between the various levels of the health services, so that the PHC's refer the difficult cases to district-level hospitals which in turn can refer patients to more specialized centres (secondary or tertiary care centers) if necessary.

Under these circumstances the suggested Model (Fig 1) can help developing countries to improve health care facilities through telemedicine by being an electronic umbilical cord that professionally links metropolitan and rural health care providers.

Figure 1

Fig 1: Suggested Model

OBJECTIVES

  1. To enable advancements in medicine and specialty care to reach remote areas where medical facilities are non-existent.
  2. To enable the medical expertise to reach people who cannot afford the high costs involved in specialty care.
  3. To implement the national "Health for All" policy on the basis of WHO's principles: accessibility, continuity and comprehensiveness of primary health care.
  4. To increase health awareness and bring about education and training of health professionals in remote areas.

This model is based on hub-and-spoke concept. This concept was originally developed for air services so that they could service a large area with the help of small regional/local air services for short haul flights while the large distance flight routes were serviced by large national/international carriers.

Network Architecture

In this model, each Primary Health Centre (PHC) with basic telephone connection (POTS or ISDN) is connected to a dedicated telemedicine cell in the district hospital. This district hospital is in turn linked to other district hospitals through ISDN lines or any other available high bandwidth links. The district level hospital is in turn connected to a dedicated telemedicine cell in a super specialty hospital through broadband links (satellite links or fiber optic lines). This super specialty hospital is in turn linked to other super specialty hospitals, medical universities and libraries and national level health coordinating centre through broadband links.

Primary Health Centre

  • Is a facility providing primary care.
  • Requires transfer of low volume data
  • Has low cost infrastructure.

Telecommunication Infrastructure

  • A telephone link
  • An Internet connection
  • A Pentium PC with web camera or digital camera
  • A modem
  • A printer
  • An Uninterrupted Power Supply (UPS)

Medical Infrastructure

  • A digital stethoscope.
  • A trans-telephonic electrocardiograph.
  • Basic diagnostic kits.
  • A registered medical practitioner or a qualified health nurse or a paramedic trained to handle the equipment and facilitate teleconsultation with the telemedicine cell in the district hospital.

District Hospital

  • Has a dedicated cell with medical practitioners and specialists for attending to call from PHC's.
  • Has a mobile unit that can be dispatched to villages in case of emergencies and to areas not having PHC's.
  • Has access to national medical universities and libraries.
  • Is linked to super specialty hospitals through broadband links.
  • Link to PHC's. through web based links.
  • Has X-Ray machines, diagnostic labs and even CT and MRI.
  • Has a team of medical personnel to provide expert opinion to PHC's.
  • Has a team to advise rural health workers in PHC's. about vaccination, nutrition etc.
  • Provides training through continuous medical education.
  • Provides guidelines and treatment advice during epidemics.

Super specialty hospitals

  • Has an expert team of specialists to provide opinions guidelines and diagnosis to district level telemedicine cells.
  • Has access to other tertiary medical centres, medical research institutes and a national level health-coordinating centre.
  • Has sophisticated medical equipments and capable of super specialty care.

Conclusion

Telemedicine promises to provide significantly improved and cost effective access to quality health care. The revolution in information technology and telecommunication technology has resulted in evolution of effective teleconsultation methods. Initially considered simply an enabling technology for increasing the access to health care in under served regions, telemedicine is seeing a greater recognition of its applicability to the entire health care delivery system. Telemedicine might not only allow physicians and other health care workers to take better care of patients, but also provide with tools to allow them to take a much more active and effective role in taking care of themselves. In short telemedicine can place medical and health resources where they need to be - near the patient.

References (cited in the text)

  1. Sheng Olivia R Liu, Paul Jen-Hua Hu, Chih-Ping Wei and Pai-Chun Ma, "Organizational Management of Telemedicine Technology: Conquering Time and Space Boundaries in Healthcare Services", IEEE Transactions on Engineering Management, 1999, 46(3),265-71.
  2. Cooke FJ, Holmes A, "E-mail consultations in international health" The Lancet, 2000, 356, 138.
  3. Fraser, Hamish SF and St John D McGrath, "Information technology and telemedicine in sub-Saharan Africa", British Medical Journal, 2000, 321, 465-6.
  4. Wooton R, "Telemedicine: Recent advances" British Medical Journal. 2001, 323, 557-60.
  5. Chan Alvin TS, Jiannong Cao, Henry Chan and Gilber Young, "Web-Enabled Framework For Smart Card Application in Health Services", Communications of the ACM, 2001, 44, (9), 77-82.
  6. Bowersox JC, PR Cordts, AJ LaPorta, "Use of an intuitive telemanuplilator system for remote trauma surgery: An experimental study" Journal of American College of Surgeons, 1998, 186: 615-621.
  7. Kuehnapfel, UG and B Neisius, "CAD based graphical computer simulation in endoscopic surgery",
    Endoscopic Surgical Allied Technology, 1993, 1:181-3.
  8. Rigby, Michael, "Impact of telemedicine must be defined in developing countries" British Medical Journal, 2002, 324:47.

* Sri Sathya Sai Institute of Higher Learning (Deemed University),
Prashanthi Nilayam. Ananthapur Dist. A. P.
Email: [email protected],
[email protected]

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