About the Authors:
Abderahman Rejeb is a doctoral student and researcher at Széchenyi István University. His research interests include technology applications, supply chain management, logistics, marketing, and tourism.
John G. Keogh is a strategist, C-level advisor and academic researcher with 30 years of executive leadership roles as Director, VP and SVP in global Supply Chain Management, Information Technology, Technology Consulting and global Supply Chain Standards. He advises the public and private sectors worldwide and is a regular subject matter expert on TV and Radio. Mr. Keogh holds a PG diploma and an MBA in Management and an MSc in Business and Management Research. He is a doctoral researcher at Henley Business School, University of Reading.
Horst Treiblmaier is a Professor in International Management at MODUL University Vienna, Austria. He received a Ph.D. in Management Information Systems from WU Vienna and worked as a Visiting Professor at Purdue University, University of California, Los Angeles (UCLA), University of British Columbia (UBC), and the University of Technology in Sydney (UTS). His research interests include the economic and business implications of blockchain.
|Citation: Rejeb, A., Keogh, J. G. and Treiblmaier, H. (2019) “The Impact of Blockchain on Medical Tourism”, WeB2019 Workshop on e-Business, December 14, Munich, Germany.|
Medical tourism has witnessed significant growth over the last decade. By combining healthcare services with tourism and hospitality, this nascent sector creates a new tourist class with access to affordable healthcare services. Information technology is an essential factor, which can enable the growth of medical tourism. Technology enables the search process for information about the available services, costs, hospitality, tourism and post-treatment options. However, these technologies are primarily legacy systems and lack interoperability. Several questions arise, including the ability of the potential patient-tourist to verify crucial factors such as the quality of care and the credentials of the medical professionals and medical facilities. Moreover, questions arise regarding patient-doctor trust, procedure and risk transparency‚ medical record privacy and other health-related hazards in specific procedures. In this conceptual paper, we investigate the potential benefits of Blockchain technology to address some of the open questions in medical tourism. We conclude that Blockchain technology can benefit medical tourism, and we lay the foundation for future research.
Keywords: Medical Tourism‚ Blockchain Technology‚ Trust & Transparency‚ Privacy‚ Efficiency
Over the past two decades, medical tourism has grown in prominence, appeal and acceptance as consumers seek faster and cheaper medical interventions. Drivers of this development include the high costs of private medical insurance, low reimbursement rates for specific procedures, lack of local expertise, and long wait times in public healthcare. The scope of medical tourism ranges from minor dental procedures to cosmetic surgery and significant interventions such as an organ transplant. Medical tourism positively contributes to economic growth in adjoining sectors, including tourism, transportation, pharmaceutical industry, and hospitality. The magnitude of medical tourism is reflected in the fast-growing number of medical tourists estimated to be 20-24 million cross-border patients worldwide (Patients Beyond Borders, 2019). This steadily growing niche market is intended to meet travelers’ needs for quality care with affordable medical interventions and treatments, as well as the provision of highly specialized healthcare facilities. The number of countries which are developing their medical tourism markets has increased, and their services are expanding with competitive pricing (Behrmann & Smith, 2010). Moreover, the globalization of medical tourism is aided by higher disposable incomes, technology transfer and growing competition in this lucrative segment. Additionally, the globalization of the ‘sharing economy’ lowers costs for local transportation (e.g., Uber) and provides an alternative, cost-effective accommodation options (e.g., Airbnb) (Tsai, Song, & Wong, 2009).
The introduction of new technologies in travel and tourism introduces new consumer-centric tools. Research in the tourism field underlines the impact of technology and contributes to the continuous development of strategies to increase the satisfaction of medical travellers. For example, information technology has been a critical factor in providing foreign medical tourists with easy access to information about the treatments and interventions that private hospitals in Thailand and India can offer (Levebvre & Bochatan, 2002). Moreover, there are several information systems that can be profitably integrated into the medical tourism industry, such as point-of-sale (POS) systems for cosmetic services (Cosmetisuite, 2019), electronic health records systems (EHR) (Rezaei-Hachesu et al., 2017), and destination management organisations (DMOs) websites (Qi, Law, & Buhalis, 2008). Blockchain has become a promising technology for driving large-scale societal and economic change. Blockchain is defined as a “digital, decentralized, and distributed ledger in which transactions are logged and added in chronological order with the goal of creating permanent and tamperproof records” (Treiblmaier, 2018, p. 574). The heightened popularity of blockchain stems from its ability to create a trustworthy network where value can be exchanged between peers. The technology has extensive, industry-spanning possibilities for applications (Fosso Wamba et al., 2019; Rejeb, Sűle, & Keogh, 2018). Blockchain technology has received increasing attention from academic researchers and industry practitioners who aim to solve persistent problems in many areas. Even though the impact of blockchain on tourism has been identified as an important research topic that can trigger essential transformations (Önder & Treiblmaier, 2018), the nascent area of medical tourism still lacks rigorous research. With the rapid digitization of healthcare, the introduction of blockchain technology is expected to have significant implications on healthcare delivery services for medical tourists. For example, medical tourism providers face the challenge of convincing potential customers of the quality of medical care centres and the safety of health outcomes (Connell, 2006). In this conceptual paper, we discuss how blockchain technology can enable patient travelers to gain in-depth knowledge and enhanced trust in medical tourism destinations. In doing so, we lay the foundation for future theoretical and empirical research.
Definitions and Drivers of Medical Tourism
Goodrich & Goodrich (1987) describe medical tourism as a plan to co-promote healthcare and tourism services. As such, the health-conscious consumer becomes both a tourist and a patient in order to obtain either preventative healthcare assessments or healthcare treatments such as cosmetic, dental or even invasive surgical interventions. According to Carrera & Bridges (2006), medical tourism is the systematic planning, maintaining and restoring one’s physical and mental health condition. The search for medical services is, therefore, the primary motivator for medical tourists’ travel decisions. More broadly, the final decisions made by aspirational medical tourists is influenced by their online search for trusted, safe, timely and cost-effective healthcare options and services.
The primary drivers for searching for alternative healthcare and medical intervention options are affordability, accessibility and availability. In many countries, particularly those located in developed regions in the world, public healthcare often provides essential services while private medical insurance coverage carries a high cost and may penalize those with pre-existing medical conditions. Research from Canada shows that public healthcare often has extended wait times for interventions which can significantly impact patients’ health and wellbeing (Patrick & Puterman, 2008). Research on women’s attitudes toward cosmetic surgery in Australia reveals that peer pressure, media exposure and global views on appearance ideals are drivers for undergoing such treatment while social acceptance of cosmetic surgery functions as an enabler (Sharp, Tiggemann, & Mattiske, 2014). Social pressure and universal ideals of beauty can create an obsession with physical appearance. In turn, this leads to elective, minimally invasive procedures (e.g., remorseful tattoo removal, microdermabrasion) or more invasive cosmetic procedures on the face and neck (e.g., rhinoplasty, otoplasty, blepharoplasty, mentoplasty, rhytidectomy) and body (e.g., abdominoplasty, brachioplasty, mammoplasty) and specific male and female genitalia enhancements (Sharp et al., 2014). In this ‘vanity’ category of elective cosmetic surgery, the medical tourist may prefer to be away from their social and work networks during the recovery which may include wearing bandages for several weeks or include significant swelling and discomfort. Additionally, medical tourism may include patients with an ‘acquired defect’ resulting from various types of trauma (e.g., accident deformity or burn) or from cancer. Furthermore, patients may have a congenital disability, such as a cleft lip, cleft palate or other physical deformities. Finally, another market segment includes gender reassignment or correction surgeries.
Medical tourists also take into consideration the affordability of international travel, how favorable the currency exchange rates are and the increasing sophistication of medical care in some developing countries (Swain & Sahu, 2008). Since the technological gap has been narrowed globally, the affordability of medical care has become a decisive factor for shifting the patterns and flows of medical travellers. Additionally, several medical destinations are responsive to the evolving needs of the ‘tourist-patient’ for affordable medical treatments, allowing them to gain a cost advantage and a competitive position in the global market. As a case in point, spinal surgery could cost a patient about $70,000 in the United States. However, the same medical intervention, coupled with a five-day stay in a private recovery room, costs $4,700 in a recognized hospital in Thailand (Smith, 2012). The significantly lower costs are applicable to a growing array of healthcare services provided throughout Central Europe and Asia (Bostan et al., 2016).
Accessibility and Availability
Two important drivers of medical tourism are the accessibility and availability (including wait times) of specific healthcare services in patients’ home countries. More specifically, the undertaking of medical travel is either due to the absence of the required medical services in the patients’ home country or to their non-availability at a certain point in time. Furthermore, medical tourism might be an option when treatment procedures are delayed due to long waiting times, priority listings, and the paucity of organs necessary for transplant operations. Dawn & Pal (2011) highlight that the majority of medical tourists from industrialized regions such as the United Kingdom, Japan, the United States, and Canada receive their treatments abroad because of the long waiting times for medical consultations and interventions. Similarly, the capacity of the Japanese healthcare system to handle the medical demands of the country’s ever-growing elderly population drives medical tourism. For instance, many Japanese firms send their employees to neighbouring countries for yearly medical checkups. Medical tourism, such as this showcases the importance of organ transplant tourism, which saves thousands of lives every year.
The Potentials of Blockchain Technology in Medical Tourism
Blockchain technology has numerous characteristics such as immutability, transparency and enhanced security which can significantly impact business processes as well as whole industries (Treiblmaier, 2019). In this paper, we primarily focus on those characteristics which can impact the medical tourism industry. In Figure 1, we summarize four essential areas of focus, namely, disintermediation, trust and transparency, digitization and interoperability and privacy. We will elaborate on these in the sections below.
Figure 1. The Impact of Blockchain on Medical Tourism
Increasing demand for medical tourism has paved the way for healthcare intermediaries to become facilitators between international patients and medical service providers (Connell, 2006). Intermediaries provide a wide array of value-added services for this new class of tourist-patient. The emergence of intermediaries is mainly due to medical tourists’ lack of technical knowledge and their inability to assess the quality, suitability, and benefits of a medical-tourism destination (Legido-Quigley et al., 2008). As such, potential patients experience significant information asymmetry about the specific healthcare facilities and rely on intermediaries to answer queries and arrange their travel and hospitality. The activities carried out by intermediaries include the matching of patients with appropriate medical care providers. It may extend to arranging specific travel procedures (e.g., specialized equipment, prescription drugs permits, or nurse-assisted travel care), as well as the arrangement of visas, flights, accommodations, treatments, and post-operative care during recuperation (Lunt & Carrera, 2010).
Traditional travel agencies maintain a dominant position in the medical tourism industry which can lead to opportunistic behavior. The role of medical tourism intermediaries has led to a paternalistic model of relationships, rather than the establishment of close connections between medical institutions and their patients (Lunt, Hardey, & Mannion, 2010). Medical tourism packages offered by these entities are often delivered at inflated prices which are marked up from the actual costs of the healthcare service providers. Moreover, medical intermediaries are very likely to restrict available options due to their affiliation with specific medical providers to whom they exclusively send their patients (Herrick, 2007). Being specialized in a particular target market or service, intermediaries might refer patients to inappropriate medical providers with additional mark-ups and high referral fees. More troubling, these medical tourism intermediaries are unlikely to be held legally accountable for any failures, since they are not healthcare providers themselves (Connell, 2011). Blockchain technology can significantly lessen the asymmetric power of medical tourism intermediaries. For example, blockchain technology can enable medical tourists to engage in direct, interactive communication with foreign healthcare service providers. In doing so, they can objectively verify their qualifications, certifications and procedural costs. This can lead to the elimination of unnecessary costs and reduce patient dependence on exclusive arrangements through intermediaries to arrange all aspects of their medical travel and tourism. Additionally, streamlining the medical tourism infrastructure by removing, or lessening the power of non-value adding intermediaries will benefit the credibility of the sector (Raman & Varshney, 2017). The technology, therefore, holds an untapped potential to unlock new value, since it reduces information asymmetry by enhancing the transparency of information and knowledge about medical facilities. Hence, the use of blockchain technology can address several issues by either enabling a fully disintermediated approach or enhancing aspects of the intermediation where medical travel agents are incentivized to specialize and offer superior value-added services to their potential customers (Ehrbeck, Guevara, & Mango, 2008).
Enhancing Trust and Transparency
Sirdeshmuhk, Singh, & Berry (2002) define trust as the expectation held by the consumer that the service provider is dependable and can be relied upon to deliver its promises. In the context of medical tourism, this implies that the (mostly foreign) health service provider is reliable, that their medical professionals are competent, and that the entire medical institution is highly adept at improving the health of their overseas patients. The proliferation of informative medical tourism websites creates greater awareness of healthcare services. Rather than consulting with a medical tourism agency or contacting a healthcare facility directly, medical tourists favour online methods to quickly obtain and assess information on healthcare services and prices (Greenspan, 2004). The use of ICTs supports the patient-tourist in their decision-making process and may assist them in negotiating medical packages. Medical tourism businesses strive to attract customers through new marketing channels, media coverage and social media platforms such as YouTube, Facebook and Twitter.
ICTs are essential enablers of medical tourism, especially in the initial phase of information search and medical facility selection. According to Connell (2006), the biggest hurdle that medical tourism providers have to face is the challenge to persuade potential patients about their qualifications and the quality of pre, and post-procedure services as well as overall patient safety. Medical facilities signal their qualifications through various online and offline channels with the goal of reducing information asymmetry between them and the potential patient. Potential patients are signal receivers but do not have the expertise or necessary tools to verify these ‘unobservable’ qualifications from the medical facility (Connelly et al., 2011). If qualifications cannot be verified, a potential patient lacks trust in the medical providers’ signals of their unobservable features such as quality of care and skill levels of specialists. Blockchain technology can be used to link the qualification claims of health facilities to their various certification bodies and authorities. In this regard, blockchain technology facilitates the verification process of credentials, including certifications and qualifications of the facilities, doctors or specialists, and the authentication of online reviews. The latter is useful because potential patients often feel uncertain about post-procedural outcomes or unfulfilled expectations.
The reliability of online health information is often questionable, and individuals are, therefore, cautious when seeking medical information online (Lunt et al., 2010). Moreover, most medical websites aim to influence cognitive, affective, and behavioural dimensions of consumers (Manaf et al., 2013) while ignoring their real needs. Some websites may entice customers to purchase medical travel packages which may include a high-risk procedure and are carried out in non-accredited health institutions by untrained professionals (Lee & Fernando, 2015).
With all of these challenges in mind, the medical tourism industry is primed to become a principal beneficiary of blockchain technology. In line with Pilkington (2017), the use of blockchain in medical tourism can enhance patient trust and information transparency. Using blockchain technology allows potential medical tourists to make reasonable and well-informed decisions. In the planning stage, prospective medical tourists can use blockchain-enabled systems to optimize their search for medical tourism services by receiving detailed, authentic, and verified information about medical tourism institutions. This includes verified curriculum vitae of healthcare staff, institutions’ accreditations, and service or procedure certifications. The benefits of this approach are twofold: first, travellers’ confidence will be strengthened before they enter the unknown medical system. Second, medical tourism providers can build brand equity for their customers from the beginning and sustain a consistent brand image (DeMicco, 2017). The integration of blockchains in the medical tourism industry can help to provide credible and in-depth medical and non-medical information. Blockchain-enabled systems can also assist medical tourists in making a more informed decision, regardless of their socio-economic, cultural, or linguistic backgrounds (Lee, 2007).
Enhancing Digitization and Interoperability
The operational mechanism of health-related systems has several significant limitations. EHRs are still scattered over different healthcare systems and ‘siloed’ in nature (Galen et al., 2018). This results in inaccessibility problems and inconsistency of medical information. Similarly, the lack of integration of EHR management systems (Wang & Huang, 2012) binds medical patients with specific foreign health service providers. This implies that if medical tourists want to terminate their involvement with a particular foreign healthcare provider, then they would not be able to transfer their medical information to their new provider, as they lack access to the records system. As a consequence, interoperability, security, and privacy issues resulting from the online exchange of health-related records should not be overlooked as being part of the medical tourism experience.
By empowering a patient-centric model of information handling, blockchain technology can provide a holistic and comprehensive assessment of an individual’s health. This can be achieved through active tracing of patients’ entire medical history, sophisticated record management of health documents, and increased control of data access. A medical tourism ecosystem based on blockchain technology allows overseas patients to maintain an increased level of control over their health data and to take an active role in ensuring communication between their overseas healthcare providers and their local physicians (Alleman et al., 2011). As a result, blockchain can address important interoperability issues inherited from existing health information technology systems, thus enabling medical tourists, foreign healthcare providers, and other stakeholders to have a borderless, timely, and secure exchange of health data (Linn & Koo, 2016). Furthermore, blockchain can significantly improve the quality of healthcare service delivery to medical tourists. Through the use of cryptocurrencies, medical tourists can settle payments quickly and securely while minimizing transaction costs (Önder & Treiblmaier, 2018).
As medical tourists return home, delays and discontinuities in the patients’ continuum of care may occur due to a lack of access and interoperability to their overseas health records. Moreover, there is a higher risk of errors in diagnoses if the patient’s full medical records are not available. Furthermore, recommended treatments may include drugs which are not available in their home countries. Blockchain technology can create an effective solution to the enduring problem of fragmentation in medical records, and alignment of prescribed medications to those which are approved and readily available in their home countries. Importantly, blockchain architecture also guarantees that patients have secure access and control over their encrypted health records. Importantly, blockchains immutability feature ensures that patients are unable to change, remove, or add any health-related information to these records. Therefore, patients’ medical records on a blockchain are secured, encrypted and have authentication mechanisms which preserve the integrity of medical information. These capabilities have already caught the attention of policymakers who consider the technology as an enabler for health tourism (Pilkington, 2017).
Alleviating Privacy Concerns
One integral component of medical tourism is patient privacy. Medical tourism patients often entrust their sensitive records to untrusted healthcare providers or intermediaries (Connell, 2006). A survey among American medical tourists showed that ‘privacy and confidentiality of treatment’ was the second most crucial element they considered, behind treatment costs (Singh, 2013). In an Asia-Pacific study on wellness tourism, privacy was identified as a crucial factor for higher-paying guests (Kucukusta & Guillet, 2014). As far as the sensitivity of their medical records is concerned, some tourist-patients feel more confident when they know that their privacy will be protected, regardless of the geographic remoteness of their medical tourism destination. However, this ‘remoteness’ might only appease patients’ privacy concerns because confidentiality problems still exist that can run counter to the expectations of medical tourists. In addition, some prospective medical tourists might have doubts about a foreign country’s readiness to enforce appropriate privacy policies and protect private medical information. This distrust is aggravated by the use of modern ICTs in medical tourism. Previous research by Laric & Pitta (2009) suggests that technological advances and digitization of medical information tend to intensify, rather than alleviate, patients’ privacy concerns. While these technologies have significantly facilitated the recall of information on medical procedures and details, they have also opened up a new arena for privacy intrusions. Wagle (2013) provided evidence that websites regularly display patient information in the form of testimonials and photographs, along with the type of treatment administered. Even though this information serves as a marketing tool for foreign healthcare service providers, there is a strong likelihood that their use is without the tourist patients’ knowledge and consent (Culnan & Armstrong, 1999).
Destinations which promote surrogacy—a medical tourism subset referring to the gestation of a baby by one mother for another (Panitch, 2013)—have implemented practices that exacerbate privacy issues. For example, the US state of Georgia facilitates procedures of surrogacy by exhibiting a database of surrogate mothers with photographs—a practice that typifies a very pronounced act of privacy violation in many countries (Connell, 2011). Moreover, according to Angst & Agarwal (2009), the tension between technology and confidentiality amplifies the reluctance of some patients to use electronic health record systems (EHR). The possible reasons for this are that patients fear that their data will be divulged, leaked, or stolen, and that they could fall victim to identity theft (Brown, 2012). Therefore, the privacy risks arising from existing computerized hospital systems, medical databases, and EHRs pave the way for privacy violations in medical tourism.
Blockchain technology can be viewed as a ‘privacy-by-design’ solution for the many privacy issues resulting from the digitization of medical information (Benchoufi & Ravaud, 2017). As such, privacy and data protection mechanisms are embedded in the blockchain system from the inception of the system’s design, rather than being an add-on feature. The confluence of decentralization and distributedness embodied in blockchain technology allows the patient-tourist to have more control over their personal medical information. With control and ownership, the medical traveller’s privacy concerns tend to ease because they have full knowledge of the flow and use of their private information (Milne, 2000). Also, foreign health entities will be able to communicate privacy-enhancing features and thus show a strong commitment to protecting the confidentiality of overseas patient-tourists, which, in turn, makes patients feel more confident, relaxed, and even potentially willing to disclose their private information. It should be noted that the potential information transparency of blockchain technology, enabled by shared data access, does not necessarily entail the goal of privacy. Cryptographic identity schemes offer secure confidentiality through anonymity or pseudonymity and the unlinkability of transactions. The built-in privacy of blockchain allows patients to be self-sovereign over their sensitive information, which could be shared partly or wholly, temporarily or permanently, and restrictedly or unrestrictedly (Lenz, 2019). For instance, the use of private blockchains in medical tourism entails that the patient-tourist information and data will be controlled by a permissioned mechanism that assigns different access rights to foreign medical entities. The privacy of medical tourists will no longer be an issue even after receiving a medical service because their control is long-lasting.
Conclusion and Future Research
The desire to prolong the quality of life, restore health and find an enjoyable leisure experience boosts the global development of medical tourism. This nascent industry segment fostering international travel by patients seeking medical treatment is booming. Medical tourists’ needs range from non-invasive rejuvenation to risky and invasive interventions for serious medical conditions that often require complex surgeries (Connell, 2011). This multi-disciplinary service segment is triggered by a set of push factors that urge people to engage in a medical travel experience. This has led to the possibility of accessing highly regarded health institutions, medical professionals, sophisticated technologies and quality treatments. Moreover, these services and procedures are often viewed as being more affordable, accessible and available than the comparable treatments in the patients’ home nation. Medical tourism is also appealing for those seeking to accommodate their recuperation in comfortable physical surroundings located in luxurious and distant therapeutic venues, as well as to participate in entertaining activities (e.g. sightseeing, food, cultural visits) during their stay. Despite the vital role of medical tourism in responding to many patients’ critical and sensitive needs, uncertainty still permeates every part of the medical travel process. At the planning stage, tourist patients often consult medical travel intermediaries who offer aid in preparing and arranging patients’ itineraries. Intermediaries often facilitate the linking of medical tourism destinations to their prospective clients. Such intermediaries are not necessarily subject to external evaluation or accreditation, and many employ brokers who will connect medical tourists with the international hospital networks that they seek (Connell, 2006). As a result, there are some unreliable, poor-quality medical products and services being marketed via the Internet (e.g., ill-considered and harmful cosmetic surgeries, ineffective treatments and ethically questionable organ transplantations). Furthermore, existing ICT systems in healthcare lack jurisdictional interoperability. As a result, there is a need to foster the growth of a more transparent and trusted health tourism segment. Healthcare providers and institutions need to re-engineer their care processes and reap the full benefits of health information technologies (Kellermann & Jones, 2013). Importantly, privacy and security issues resulting from the digitization of medical records should not be overlooked while engaging in a medical travel experience.
In this paper, we have responded to the significant challenges facing medical tourism by comprehensively elaborating on the possibilities of blockchain technology. Blockchain can solve several entrenched problems within the field of medical tourism. Disintermediation enabled by blockchain technology can fundamentally reshuffle power relationships among key players of the medical tourism industry by elevating the sense of autonomy experienced by tourist patients and lessening the reliance of patients on powerful intermediaries. Moreover, the ‘trust-by-design’ and transparency-enhancing features of blockchain technology allow prospective tourist patients to make informed decisions in the selection of their medical destinations. In facing the fragmentation and inefficiencies of health tourism systems, blockchain is a workable solution for improving and securing the flow of medical information and data between foreign health service providers and travelling patients. Information inconsistencies and interruptions in the healthcare continuum resulting from tourist patient’s mobility can be avoided, since blockchain reflects a permanent availability of their procedural interventions, transactions and overall medical history. Tourist patients can also benefit from blockchain’s ‘privacy-by-design’ architecture because of its ability to bestow a solid sense of discretion and confidence that their personal information will be protected. This conceptual paper contributes to the current body of knowledge regarding the possibilities of blockchain technology in the medical tourism industry and builds a better understanding of how emerging technological developments can be a viable solution for a number of problems in medical tourism. Further research is needed to rigorously investigate the impact of blockchain technology and to create a solid theory-based foundation. Blockchain technology is under constant development and its potential to integrate with other technological advancements such as big data analytics, artificial intelligence (AI), machine learning (ML) and the Internet of Things (IoT) is vast but insufficiently understood. Further academic research is therefore called upon to contribute to the understanding of the positive and negative implications of blockchain and related technologies in the field of medical tourism.
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