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Saturday, April 6, 2013
Friday, April 5, 2013
Tuesday, April 2, 2013
Biological Genomic Diversity in Food
Preventive Health Care
Numerous studies show that proper nutrition and intake of proteins, carbohydrates, fats, vitamins, minerals and trace elements are essential to normal health. The human gastrointestinal tract harbors a universe of microbial life required to maintain normal bowel function. It functions in symbiosis with the remainder of our body systems. It is small wonder our systems are thrown out of balance by antibiotics.
As time evolves, A crisis is looming: To feed our growing population, we’ll need to double food production. Yet crop yields aren’t increasing fast enough, and climate change and new diseases threaten the limited varieties we’ve come to depend on for food. Luckily we still have the seeds and breeds to ensure our future food supply—but we must take steps to save them.
Like the animal world the plant world evolves and some species become endangered or extinct as a result of normal evolution or from the effects of herbicides, genetically modified crops and organisms.
The animal kingdom also evolves slowly as do human beings. Genetic changes are occurring in all species, some beneficial and others aversive or even fatal or species extinction.
Prevention has become important, our healthcare needs have rapidly accelerated our ability to finance our health system.
Differing populations may require unique approaches to food intake.
Today’s ecosystem offers a different crop from hundreds of years ago.
Much of this change may have an unmeasured effect on health and disease which has yet to be studied or understood.
The Food Ark and The Seed Savers Exchange
Six miles outside the town of Decorah, Iowa, an 890-acre stretch of rolling fields and woods called Heritage Farm is letting its crops go to seed. It seems counterintuitive, but then everything about this farm stands in stark contrast to the surrounding acres of neatly rowed corn and soybean fields that typify modern agriculture. Heritage Farm is devoted to collecting rather than growing seeds. It is home to the Seed Savers Exchange, one of the largest nongovernment-owned seed banks in the United States.
In 1975 Diane Ott Whealy was bequeathed the seedlings of two heirloom plant varieties that her great grandfather had brought to America from Bavaria in 1870: Grandpa Ott's morning glory and his German Pink tomato. Wanting to preserve such unique varieties, Diane and her husband, Kent, decided to establish a place where people could store and trade the seeds of their own past. The exchange now has more than 13,000 members and keeps in its walk-in coolers, freezers, and root cellars the seeds of many thousands of heirloom varieties. The farm grows a glorious profusion of select vegetables, herbs, and flowers around an old red barn that is covered in Grandpa Ott's stunningly deep purple morning glory blossoms.
There are many examples of the reduction in biological diversity fueled by the modification of native species into high yield, low disease plants and animals, to the exclusion of more natively robust crops. The increased need for more food due to exploding human population fuels this negative effect of ‘technology’. It may also fuel new diseases or nutritionally deficient foods.
Food varieties extinction is happening all over the world—and it's happening fast. In the United States an estimated 90 percent of our historic fruit and vegetable varieties have vanished. Of the 7,000 apple varieties that were grown in the 1800s, fewer than a hundred remain. In the Philippines thousands of varieties of rice once thrived; now only up to a hundred are grown there. In China 90 percent of the wheat varieties cultivated just a century ago have disappeared. Experts estimate that we have lost more than half of the world's food varieties over the past century. As for the 8,000 known livestock breeds, 1,600 are endangered or already extinct.
This is not occurring in an isolated manner, and must have a secondary effect on all living organisms.
Svalbard Global Seed Depository
The Svalbard Global Seed Vault (Norwegian: Svalbard global frøhvelv) is a secure seedbank located on the Norwegian island of Spitsbergen near the town of Longyearbyen in the remote Arctic Svalbard archipelago, about 1,300 kilometers' (810 mi) from the North Pole.[4] It was started by conservationist Cary Fowler in association with the Consultative Group on International Agricultural Research (CGIAR),[5] and functions to preserve a wide variety of plant seeds in an underground cavern. The seeds are duplicate samples, or "spare" copies, of seeds held in gene banks worldwide. The seed vault is an attempt to provide insurance against the loss of seeds in gene banks, as well as a refuge for seeds in the case of large-scale regional or global crises. The seed vault is managed under terms spelled out in a tripartite agreement between the Norwegian government, the Global Crop Diversity Trust (GCDT) and the Nordic Genetic Resource Center (NordGen).[6]
Rather than considering this facility a “Doomsday Resource”, perhaps it will function to restore biological diversity when the time comes as our natural health deteriorates from deficiencies.
The Porcinification of Patient Centered Medicine
There are many issues which seriously inhibit the goal of patient centered medicine. Despite the well intentioned advocacy by many patients whose healthcare is negatively affected by a disease centric system, and because of a reimbursement system that now predominates, progress toward PCMC will continue to be slow.
Patient centered care and the family physician’s brain was the topic by Paul Grundy .
Paul Grundy is IBM’s Director of Healthcare, Technology and Strategic Initiatives for IBM’s Global Well Being Services and Health Benefits. He has led the development of the Patient-Centered Primary Care Collaborative, which is leading the way to create a more efficient and responsive healthcare system
Richard Young, MD in a post on KevinMD heard Paul Grundy speak recently at the annual meeting of the North American Primary Care Research Group, which is the largest and most influential organization for primary care research. Others sitting at his table said they’d heard him before and that his presentation that day was typical of others they’d heard. One oddity of his talk was that he showed a model of the Patient Centered Medical Home (PCMH) full of the usual boxes and arrows. It included phrases such as care coordination,electronic medical records, and disease management. However there was no mention about family physicians or primary care physicians in the process.
All sorts of models have been projected and written about.
Matt Adamson in another post on KevinMD postulates an
Optimization of the new PCMH neighborhood.
There are a number of care models now being explored to improve the manner in which healthcare can be delivered. Let’s take a quick look at a few of the well known options:
Accountable Care Organization (ACO): The ACO model has the ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory (outpatient) and inpatient hospital care and possibly post acute care. Further, ACOs have the capability to plan budgets and resources and are of sufficient size to support comprehensive, valid and reliable performance measurement. The ACO model is one of the latest designs for managing healthcare costs, especially Medicare costs, and is gaining traction among policymakers desperate to control costs and boost quality in healthcare.
All of this is dependent upon more basic structure, some of which is sorely lacking at present in our system.
Patient Centered Medical Home (PCMH) Neighbor:
The American College of Physicians (ACP) believes that the effectiveness of the PCMH care model is dependent on the cooperation of the many subspecialists, specialists and other healthcare entities (e.g., hospitals, nursing homes), also called “PCMH Neighbors,” to achieve the goal of integrated, coordinated care throughout the healthcare system. The ACP states that the success of the PCMH model depends on the availability of a “hospitable and high-performing medical neighborhood” that aligns their processes with the critical elements of the PCMH.
America is a technophilic society, it makes perfect sense that gadgets such as electronic medical records (EMRs) would appeal to Dr. Grundy and others. However, the evidence that primary care provides better health at a lower cost than multi-ologist care predates all the new gizmos. All the American studies listed in the Starfield analyses didn’t rely on EMRs to achieve their results. Quad Graphics, a large printing company in Wisconsin, has 18 years of data showing its commitment to primary care has resulted in 30% lower costs than other large employers in its region over the entire time span.
The research on the effectiveness of EMRs is spotty at best. They don’t consistently improve quality, safety, or prevention. About the only care delivery factor they have been consistently shown to improve is they make handwriting errors on prescriptions go away.
I was dismayed that the inherent patient-centeredness of my question didn’t resonate. My question wasn’t just about my needs. When I talk to non-medical people they have the same frustration about their doctors’ visits. We live in a Wal-Mart culture not a go-to-the-market-every-day culture. Americans want to save up a list of needs then go to the market and have them all met in one visit. There are studies documenting that Americans make fewer visits to primary care physicians than other countries. In Britain, the general rule is the consultation only lasts 10 minutes. If more issues need to be addressed, the patient is expected to make another visit. Most Americans would rather not make another trip.
The E/M rules are way too complicated, but in a nutshell, after I address two issues with my patient the rest of the visit I’m giving away my services. If you’ve ever visited a primary care physician for your migraines and high blood pressure, then was annoyed that he insisted you make another appointment to talk about a rash that just appeared, now you know why he did that. If he addressed the rash on the first day he was paid nothing; if he addressed the rash on a different day he was paid the full fee.
Even if the PCP found a way to address more than one issue he would be barred from billing for the additional service on the same date. And many patients take time off from work, and travel a significant distance to be seen. The reimbursement system penalizes PCPs that are ‘holistic’ or comprehensive. In fact under some circumstances it could be considered fraudulent for attempting to deliver patient centric health care.
So, despite protestations that we are attempting to provide patient centric care it becomes an oxymoron in itself.
There are lots of other ways the national bigotry against family medicine, as reflected in the E/M rules, disincentives family physicians from taking complete care of their patients. I’ll cover more of that in a future post.
Patients, keep your hopes high, do not become discouraged. We have a lot of work to ‘undo’ reimbursement systems that were not in existence 20 years ago.
The good news is that we now have an extended diagnostic code…ICD10. the bad news is that we have an extended diagnostic code ….ICD10.
Will we be successful in modifying reimbursement models down to the daily operations of a hospital, clinic or physician’s office ?
What Dr. Grundy doesn’t seem to understand is that the most important component of any patient-centered solution to our healthcare system is a family physician’s brain. (Sorry general internists and pediatricians. The evidence for better outcomes at a lower cost is much stronger for family physicians/European GPs than your fields.) Family physicians bring to the patient encounter a unique set of skills and approaches to patient care that lead to efficient patient-centered care. An EMR by itself doesn’t add much. I want to be the comprehensive convenient family physician for my patients and I’d like to provide lots of services in one visit. My friends and neighbors tell me that’s what they want too.
And that brings me to a better title for the pronouncements (HOGWASH) of those proposing patient centered medicine. You need to get the ducks in order to produce these results.
Monday, April 1, 2013
Friday, March 29, 2013
Ben Carson M.D.
Medicine’s new rock star is a quiet but outspoken Pediatric Neurosurgeon, the Head of the Pediatric Neurosurgery Department at John Hopkins University School of Medicine in Baltimore, Maryland. He received the Presidential Medal of Freedom in June 2008 the highest civilian award in the United States. It recognizes those individuals who have made "an especially meritorious contribution to the security or national interests of the United States, world peace, cultural or other significant public or private endeavors
Carson’s ratings have skyrocketed since his keynote speech at the National Press Club’s annual event. Sitting at the dais with Barak Obama at this right, Carson set a high benchmark for values and morality. Obama who considers himself a benchmark for social justice seemed dazed and unable to respond.
America ! Ben Carson has your attention, so listen carefully. The attacks on Carson have begun, with PC statements about ‘gays’ which Carson apologized about.
The best way to divert attention from the message and/or messenger is to introduce chaos with a totally irrelevant complaint. Carson’s message is one every American, politician and decision maker needs to keep in his mind (and heart) while they go about their business.
Although famous in a relatively small subspecialty of medicine, Carson was not well known to the general public. His academic and surgical skills have taught many neurosurgeons to accomplish what once seemed impossible.1
Thus far he has been accused of being disrespectful to the leader of the free world, using derogatory remarks about gays. Soon there will be accusations of infidelity, pedophilia (he does operate on children). Of course none of which are true.
Did I tell you that he was born into a poor black family ? Images of his hard working mother standing watch over him and his brother insisting they read each night. Ben’s life could have gone in the opposite direction.
Carson is at the age of retirement from his medical practice, however we will be hearing a lot more from him about social issues. I recommend everyone read his biography, and the other books he has written on his Amazon Page .
Carson has the ability to carve out the essential forces at work in society which have become over-riding and interfering with proper decision making which threaten the fabric of American ideals.
We now live in a ‘comfort zone’ where decisions are based upon the profit, either in money or influence, rather than the true value of a decision.
Ben Carson MD is one of the true voices of American Medicine, he deserves all our support regardless of your mode of practice, solo, group, integrated health system.
His essential message to us all is to maintain our integrity of beliefs and insist they be met by our health system.
His not so shocking message is not that surprising to any of us at all. The shocker is that he makes it so plain that maybe even a President could understand it. President Obama has made no comment, thus far.
The Republicans seem anxious to appropriate him for their own selfish purpose. I advise Ben to stay independent.
Tuesday, March 26, 2013
The ‘INBOX"’ for the Health Train Express
My morning routine opens with GMAIL, followed by my Google notifications, often they duplicate each other since I have my preferences set to notify me via email of notifications. (I know it seems redundant, but it helps somewhat to organize priority notifications.
Next is reviewing Google Reader (in the process of syncing with Feedly and Old Reader. as well as Newsblur). At first the news about Google Reader going to the happy hunting ground was devastating, however we have adjusted accordingly with some unexpected positive consequences for all.
At this point I am reading my inmail subscriptions to several internet medical newsletters, including California Healthline and iHealthbeat, both publications of the California Health Care Foundation. (a non-profit organization) There is some redundancy in their reporting but not always. There are also a variety of subscriptions, such as the Medicare News Report, Inside Health Policy and a number of health care related social media sites filtered by hashtags on twitter. The only thing I will miss in Google Reader is it’s tight integration with Google + and Gmail overall.
My next stop is on my #hcsm twitter feed (I use tweetdeck as well to follow the following # tags, #hitsm #aca #mhealth. Each week I review meetings that are being held. I can usually find their #tag at Symplur (the Hashtag Directory) I belong to several groups on Linkedin in the HIT and healthcare group as well.
There’s more, however I have drifted away from health related issues..
Technorati Tags: google reader,feedly,old reader,newsblur,hashtags,#hitsm,#aca #hcsm,#mhealth,symplur,linkedin,hit
Monday, March 25, 2013
Health Train Special Edition
Thanks to the “Galen Institute” Health Train Express is privy to this information, which falls under the FOIA. (Freedom of Information Act)
In order to qualify and seek eligibility information regarding how to become insured under the terms of the Affordable Care Act (Obamacare), you will be able to go online and file.
Appication(s)
Health Benefit Exchange. HBE EZ form
Health Benefit Exchange. HBE Long form
The Red Tape Tower: The pièce de résistance at the moment is the Red Tape Tower (#RedTapeTower) showing all 20,000 pages of the ObamaCare regulations that had been issued as of March 8. The tower was a star at CPAC, and Senate Minority Leader Mitch McConnell received hoots and applause when it was rolled out for so graphically visualizing the incredible burden this law is placing on the health sector and economy. National Review tells the story and has the photo.
The Patient Protection and Affordability Act has grown from an adorable 2,700-page binder full of rules and kickbacks into a towering 7-foot-3-inch, 300-pound behemoth totaling more than 20,000 pages of byzantine mandates and regulations.
The “red-tape tower” has been making its way around Washington, D.C
The NPR article and photos are making the rounds on social media, including twitter #redtapetower and Facebook
Promises we cannot keep !
For those who like charts and pictures
My thanks to Grace-Marie-Turner and the Galen Institute
Technorati Tags: health benefits exchange,red tape tower,foia,galen institute,health train expeess,obamacare
Don’t Leave Home Without Me
Op-ed: Gary M. Levin M.D.
The Health Train Express is leaving the station and perhaps the tracks with many physicians not onboard. This despite health providers never ending pleas to delay the departure.
Many have not boarded because the train really does not know where it is going, nor what the actual fare will be, nor it’s destination. (Sound familiar?) It should, because that is what the Accountable Care Act offers. Despite the goal of taking everyone to some destination, and providing ‘free tickets or deeply discounted fares, there is much reluctance to believe or trust the conductors or the barons of the train industry.
For some, the ACA is good news and virtually guarrantees employment for nurse practitioners, physician assistants, and many physician extenders.
There is a serious disconnect between providers, hospitals and payers, not just in reimbursement needs, but in overall organizational liason. Every hospital and provider seems to be on it’s own track, and the patient comes in dead last. Hence the badly needed patient-centric approach.
Why not ? It’s complicated.
As far as electronic records are concerned it is far more complex than the ubiquitous ATM (long used as a comparison between banking and medicine). The advocates were wrong.
Saturday, March 23, 2013
FDA and Mobile Health Apps
The Sprawling leviathon Food and Drug Administration Complex is struggling to keep up with drug review, and is now facing additional challenge of mobile health regulations in the face of [Governmental Sequestration.] [Washington Post Opinions]
Sprawling leviathon Food and Drug Administration Complex struggling to keep up with drug review, now facing additional challenge of mobile health regulations in the face of Governmental Sequestration.
Three days of congressional hearing with the FDA concluded with discussions about the FDA’s role in monitoring and producing guidelines for mhealtlh applications. There were no specific guidelines, nor binding regulations forthcoming at this time.
iHealthbeat reported this yesterday, along with other topics.
Lag of Long Term Facilities in HER adoption
HIMSS Hot Topics:
HIMSS13: Mostashari Says Data & Incentives Matter
HIMSS13: Federal Officials Stress Commitment to Health IT
HIMSS13: Sequester Will Affect Medicare EHR Pay, ONC Budget
11 Experts on Health IT Progress, Frustrations and Hopes for 2013
The meeting at HIMSS 2013 produced an intense focused forum for discussions about the progress of digitizing health information. Most leaders in HIT were present, and many vendors were present on the meeting floor.
Unable to attend in person Digital Health Space monitored several live twitter streams, and also video live streams. Microsoft’s health division and Dell Systems sponsored an evening meeting for a roundtable discussion of some high points of the meeting.
Hashtags from Dell's HIMSS Meeting:
You can follow the tweets via the hashtag #DoMoreHIT or the participating tweeps in the conversation: @drandylitt, @ahier, @egpierro, @techguy, @lsaldanamd, @cthielst,@2healthguru, @jloveloc, @norabelcher, @boltyboy, @shahidnshah and @healthcarewen.
Implementation of HIT is turning out to be a “Big Bang”, an issue which challenges our ability to get our hands around it.
Presenters indicated how costly the effort has become, estimating that about $ 25 billion USD is the annual HIT budget at present, just to maintain current systems. At the same time most indicated that this offered employment security for many people at that meeting. In the midst of the economic crisis it is not yet apparent what or if any of the HIT federal incentives will suffer. Health now provides employment for a large segment of the U.S. Economy and reductions in health expenditures may be felt in the unemployment rates.
The topic of ‘BIG DATA” emerged as to how it would enter into the equation. Attendees at the Dell sponsored forum were sure Big Data would play a major role. The theory is that analysis of this forthcoming tool will improve outcomes and reduce costs. The Kaiser model seems to bear that out, but it will take immense effort to convert the rest of American Health Care. Other countries in Asia, and Europe are significantly ahead of the United States.
Big Data was vaguely defined. It was unclear if analytic systems were really in place to understand it, although it was mentioned that some large integrated systems such as Kaiser were already utilizing “Big Data”. Most participants agreed that most hospitals and providers were not at all prepared for “Big Data”, that a large challenge is to educate 800.000 providers, and several thousand hospitals.
What organizations can encompass this ? State, county, Public Health, Health Information Exchanges. The ‘baby” is still in the womb….what will emerge is still unknown.
Finally the topic of personalized medicine was discussed, in connection with advances in genomics. Exponential decreases in the cost of analyzing one genome have occurred due to immense increases in computer power. We will be discussing personalized medicine and genomic in one of our next blog posts.
At times there are more questions than answers, a good sign of interest in solving our health challenges.
The choices for organizational hierarchy changes, rapidly expand in number and perhaps we need an IBM Watson to analyze our organizational structures of health care to prepare a diagnosis and then a treatment plan for our health system ills. How about several second opinions before the operation?
Thursday, March 21, 2013
First Amendment Extends to Health
2004 Democratic Convention Freedom of Speech Zone.
We physician bloggers and social media gurus have a tremendous responsibility as we take risks reaching out to our patients, legislators, insurers, and other pundits when we express our honest opinions.
Ben Brown wrote in his blog a well written and graphic appraisal about the ‘Deceptive Income of Physicians”. There are over 800 comments, 95% in agreement, 3% opposed and 2% saying it’s true but we should not ‘complain’ because we are “so lucky” and fortunate. I disagree.
In fact I posted a reply, “Physician Privilege” which drew some critical comments from some very highly respected “authorities” on health systems. The reply to me was at the same time, right, and wrong. Wrong because they felt I diminished my stature by my anger and frustration at what has happened to our privileged and beloved profession., and the fact that the wheels are coming off the bus, along with the rest of our society. We all have a right to express our thoughts, good, bad or indifferent. Disagreements can occur among agreeable people. Legally it’s protected by the First Amendment (Freedom of speech).
There is passion on both sides of this ‘fence’. The fence established a boundary, both protecting each from the other, and a barrier to understanding and agreements. Perhaps this is human nature.
Tuesday, March 19, 2013
Heavy Weight in the Mobile Health Zone
Several years ago Google Health was developing a personal health record. It failed to attract much interest due to consumer apathy and lack of interoperability with electronic medical records and an inability to download information from the clinic EMR.
About the same time, Microsoft developed Microsoft Health Vault. It has languished in a torpor and now that Microsoft has entered the mhealth zone, with ‘Surface”, “Windows Phone” and Windows 8 Microsoft. These are all based upon Windows 8 GUI, which features large icons, a simple main menu and touch screen functionality.
The early edition of Microsoft Health Vault was tied to the desktop or laptop until very recently.
Microsoft has correctly read the marketplace, albeit very late. They finally came to the table with Windows 8RT, and Windows 8 Professional as well as a well designed tablet, Surface.
Microsoft also recognized the exit from desktop and fixed locations. The transition to mobile should empower and engage patients to get their healthcare from where they are, at work, in the car, or even outside.
Health Vault in the past several years has attracted many to the platform, laboratories, pharmacies, health and wellness, remote monitoring and more.
What can you do with HealthVault?
Microsoft HealthVault is a free web-based platform that enables patients to collect, store, and share their health information, without charge.
Prepare for an emergency
Use HealthVault to make your most important health info available
Browse the App Directory
Browse the Device Directory
Pulmonary Flo-meter Pulse Oximeter
Examples:
There are now several hundred mobile and remote sensing devices which interface directly with Microsoft’s Health Vault. There is easy access to information and the ability to purchase apps and devices. All of this is designed to be patient-centric and user friendly, HIPAA compliant and requires authentication for secure transmission of data.
Microsoft Health Vault SDK provides a software developers toolkit for developing applications.
HealthVault-connected apps are websites, computer software, and mobile apps that can help you get more out of—and put more into—HealthVault.
You can choose apps to help you stay motivated, analyze trends, and receive education and recommendations to keep you at your best. And it is designed for the rapidly growing niche of mobile applications, available almost anywhere.
It is a welcome addition to the PHR market.
The most interesting part is the list of devices for remote monitoring and health and wellness .
Microsoft even has social media engagement for many of their products.
Empowering Patients
Health Vault in Action
If you’re like most people you just don’t want to sit there and enter your health records into a personal health records..Well, now there is a cure for that as well. Unival PHR is a service for obtaining your records from wherever they may be.
yourPHR, part of the yourHealth suite of services, offers three solutions for getting your medical information into HealthVault. Choose one or all of the following:
- Full data conversion of your medical records by a trained, experienced nurse abstractor
- Direct import of organized, scanned documents
- An online interface to complete specific aspects of your personal health record such as demographics, insurance information, etc.
Sunday, March 17, 2013
The Problem with ACO’s
The most efficient means of using ACOs is to employ physicians by a hospital. Kaiser get’s around this because Southern California Permanente is a foundation which employs the doctors and Kaiser Hospital contracts with that medical group. That is because hospitals were previously forbidden to hire physicians. Time and trends have altered that formula, however legally hospitals are banned from controlling physicians due to a conflict of interest. I believe it should still be the same, and it may be that in certain regions ACOs may fall under anti-trust regulation.
Many physicians have ‘rolled over’ and succumbed to threat of insolvency, brutal administrative loads, the threat of malpractice, long hours and irregular call schedule.
Social media is playing a larger role with open communications which are transparent and reveal how dissatisfied physicians have become with the system, the dysfunctional way the accountable care act is attempting to correct increased costs, and improve outcomes. The addition of electronic records, while having some merits has added to expense, decreased efficiency, and has converted a highly skilled physician who usually generates at least $ 200.00/ hour in gross revenue (before overhead and tax burden) into a clerk (hire for 12.00/hour), The wise thing to do is pay a clerk $96.00 dollars/day + adjunctive costs such as health insurance, overhead for workman’s compensation, liability, vacation time, etc. It is often said that an employees salary is double by ancillary cost. Using that formula that clerk would cost about $180.00 per diem. However each time you hire an additional employee it adds to the complexity of the human equation, absenteeism and more.
Add to all the above the mandate for outcomes, reduced readmissions, and demand for analytic data pushes the balance toward ACOs
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