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VA Quality Care Electronic Medical Records EMR Case Management Conte

2503 -
2503 -    ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS 5 0000. ref SDS 4 0000.
250502 -
250503 -
250504 -
250505 -
250507 -  ..
2506 -
2507 -
2508 - Progress
2509 -
250901 - Research on 091113 shows the VA has been recognized in recent years
250902 - for outstanding medical care.  Many articles cite VA reliance on
250903 - computerized medical records for improving quality care. ref SDS 5
250904 - LS6G
250906 -  ..
250907 - Additional research today on the Internet finds...
250909 -         ..
250910 -    3.  IEEEXPLORE Digital Library
250911 -
250912 -        System Sciences (HICSS), 2010 43rd Hawaii International
250913 -        Conference on
250915 -         ..
250916 -        Issue Date: 5-8 Jan. 2010
250917 -        On page(s): 1 - 9
250918 -        Location: Honolulu, HI
250919 -        ISSN: 1530-1605
250920 -        Print ISBN: 978-1-4244-5509-6
250921 -        INSPEC Accession Number: 11205965
250922 -        Digital Object Identifier: 10.1109/HICSS.2010.145
250923 -        Date of Current Version: 11 March 2010
250924 -         ..
250925 -        Developing an EMR Simulator to Assess Users' Perception of
250926 -        Document Quality
250927 -
250928 -        Date of Current Version: 11 March 2010
250929 -
250930 -              http://ieeexplore.ieee.org/Xplore/login.jsp?url=http%3A%2F%2Fieeexplore.ieee.org%2Fiel5%2F5428222%2F5428274%2F05428389.pdf%3Farnumber%3D5428389&authDecision=-203
250932 -  ..
250933 - The paper presents difficulty implementing VA's information management
250934 - system, ref SDS 5 W45P, and also benefits of the system for making
250935 - sense of complex data. ref SDS 5 XG38
250937 -  ..
250938 - Paper Developing EMR Simulator... continues...
250939 -
250940 -        Efthimis N Efthimiadia, PhD,....... efthimis@u.washington.edu
250941 -        Kenric W Hammond, MD............... kenric.hammond@va.gov
250942 -        Ryan Laundry
250943 -        Stephen M Thielke, MD
250945 -         ..
250946 -        Information School, University of Washington, Seattle, WA
250948 -         ..
250949 -        VA Pugetn Sound Health Care System, Tacoma and Seattle, WA
250950 -
250952 -         ..
250953 -        Abstract
250955 -         ..
250956 -        Simulators are used in research and training because they
250957 -        provide a realistic and safe environment for participants.  In
250958 -        the course of conducting a comprehensive study of patient care
250959 -        documentation in electronic medical record (EMR) systems we
250960 -        found that use of a simulated EMR system could address logistic
250961 -        and conceptual barriers encountered in deploying a research
250962 -        instrument to assess user perceptions of patient care document
250963 -        quality.  Designed for use by practitioners, nurses, and
250964 -        administrators at four VA hospital sites, the web-based EMR
250965 -        simulator presents clinical documents as they appear in VA's
250966 -        CPRS production EMR, and administers a document quality
250967 -        assessment questionnaire.  The EMR simulator was developed to
250968 -        overcome the contradiction of studying computerized documents
250969 -        with a paper instrument, to permit self-administration at
250970 -        multiple sites and to manage data collection.  This paper
250971 -        discusses the motivation to evaluate EMR document quality,
250972 -        development of the quality questionnaire, and how the design of
250973 -        the simulator evolved and was pilot tested.
250974 -
250975 -        1.  Introduction
250976 -
250977 -            Adoptoin of electronic medical records (EMRs) is at the
250978 -            center of national health care reform strategy.  The EMR
250979 -            furnishes health care personnel with patient data captured
250980 -            by health care information systems (HCIS).  Its primary
250981 -            function is to support health care decision-making by
250982 -            serving as teh point of contact between human minds and
250983 -            teh compels data stored in a HCIS.  It provides a "viewing
250984 -            window" for information access and a "transaction window"
250985 -            for conducting health care business.  The EMR interface
250986 -            should present the "right" amount of information to users.
250987 -            Otherwise there is risk of information overload and
250988 -            "overlook" of important information that could lead to
250989 -            degradation of decision quality{1}.
250991 -             ..
250992 -            Decision-making is a central cognitive activity for EMR
250993 -            users.  Many aspects of physician decision-making (e.g.,
250994 -            problem formulation, diagnosis, and choice of therapy and
250995 -            tests) have been described from a formal logical
250996 -            perspective {2}.  Also important, for physicians, nurses
250997 -            and administrative staff alike, is naturalistic
250998 -            decision-making {2}, and emerging area of cognitive study
250999 -            which recognizes that expert decisions are frequently based
251000 -            on pattern recognition and situation awareness rather than
251001 -            formal logic.  Both modes of decisoin making can be
251002 -            supported by th EMR,  Rule-based decision making requires
251003 -            "facts" from the EMR:  labs, demographics, studies and
251004 -            events.  Naturalistic decison making relies on decisions
251005 -            cued by patterns of facts, many of which are expressed in
251006 -            the narrative text that is written by the clinicians,
251007 -            doctors or nurses, during patient care and found in notes,
251008 -            reports and summaries in the EMR.  In both cases, decision
251009 -            making based on an electronic patient chart becomes
251010 -            increasingly complex as the volume of data in the HCIS
251011 -            increases {4}.  Data display strategies that work
251012 -            reasonably well with sparse data may fail when data is
251013 -            abundant.  Coping with the growth of data in successfully
251014 -            implemented EMR systems is an emerging cognitive challenge
251015 -            for EMR users.
251017 -             ..
251018 -            We use the term computerized patient care documentation
251019 -            (CPD) to refer to the free text progress notes,
251020 -            consultation reports and summaries that reside in the
251021 -            electronic medical record.  Free text narrative is signed
251022 -            by an author and is an official legal document.
251023 -            Categorical, numeric and image data (e.g., coded diagnoses,
251024 -            lab reports, prescriptions, appointments, bills and x-rays)
251025 -            are excluded.  CPD is an important but problematic EMR
251026 -            information resource:  while it can vividly and succinctly
251027 -            tell a patient's "story", clinical text in contrast to
251028 -            published text is often hurriedly created, highly variable,
251029 -            unedited, unstructured and voluminous.  This poses a
251030 -            significant challenge to the health care worker whose
251031 -            decisions depend on an effective interpretation and
251032 -            response to CPD text.  Preliinary investigations of the US
251033 -            Department of Veterans Affairs' (VA's) computerized patient
251034 -            record system (CPRS) have revealed important quality
251035 -            concerns that organizations adopting EMRs will face when
251036 -            they fully implement electronic documentation.  These
251037 -            include the "copy and paste" phenomenon, poor formatting,
251038 -            clutter, and propagation of inaccuracy {5-7}.  Each of
251039 -            these can negatively impact safety and human performance.
251041 -             ..
251042 -            To date, most studies of the impact of documetnation on
251043 -            work activity in an EMR have relied on observations and
251044 -            self-report.  Paper-based study methods fail toreplicate
251045 -            the computer experience, and practical and ethical
251046 -            considerations (privacy, safety, time and cost) limit
251047 -            controlled experimentation in production EMR systems.
251049 -             ..
251050 -            Given realistic data and EMR interfaces studies involving
251051 -            EMR documetn review could be conducted without disrupting
251052 -            operations.  Because simulators provide a realistic and
251053 -            safe environment for participants, they are useful in
251054 -            research and training.  The desire for a flexible,
251055 -            non-disruptive experimental approach motivated the effort
251056 -            to develop a simulated EMR testing platform capable of
251057 -            presenting real patient data, and equipping it with
251058 -            measurement tools such as questionaires, exercises and
251059 -            timers.  Also desirable was a method that could be applied
251060 -            at muliple research sites, scheduled at staff convenience,
251061 -            and conducted in the workplace.  These considerations
251062 -            shaped the decison to build a web-based system that could
251063 -            eventually permit large scale interface testing involveing
251064 -            many users at hundreds of worksites in the VA health care
251065 -            network.
251067 -             ..
251068 -            This paper focuses on design issues surround the
251069 -            developmetn of the simulator.  First we present the
251070 -            conceptual foundations and the motivation for the
251071 -            simulator.  Then in section 2, we provide background
251072 -            information regarding CPRS, the VA's EMR and in section 3
251073 -            describe the large study that the simulator supports.  In
251074 -            section 4 we present the design methodology, and in section
251075 -            5 provide a descriptive technical overview of the
251076 -            simulator.  Discussion of the pilot tests and concluding
251077 -            remarks follow.
251079 -             ..
251080 -            1.1 Conceptual Foundations and Motivation
251082 -             ..
251083 -            This work is part of a larger VA Health Services Research
251084 -            and Development effort to better understand and improve EMR
251085 -            documentation:  identifying problems, sources of problems
251086 -            and possible solutions from the EMR user's perspective.  As
251087 -            part of theoverall goal of understanding threats to
251088 -            accuracy and efficient processing of documetn-based
251089 -            informatoin in health care, it was felt necessary to defin,
251090 -            quantify and validate a concept of "information value" in
251091 -            clinical documents.  Recognizing that CpD is not the
251092 -            exclusive providne of any single work role in a health care
251093 -            system, we chose a user-centered approach, and conducted
251094 -            focus group interviews of practitioners, administrators and
251095 -            nurses to understand their experience with the CPD system
251096 -            and to elicit user-oriented concepts of document quality
251097 -            from a multi-role perspective.  Using this information we
251098 -            developed and refined a document quality questionaire.
251099 -            Then, we developed a simulated EMR system to present the
251100 -            questionaire.  The research process is summarized by the
251101 -            following steps:
251102 -
251103 -            ......
251105 -                 ..
251106 -            2.  Background
251107 -
251108 -                1.  CPRS 0 the VA's successful EMR
251109 -
251110 -                    The VA's EMR development effort began in 1977 {9}.
251111 -                    In 2982, the VA nationally adopted a system that
251112 -                    supported administrative, lab, and pharmacy
251113 -                    operations and had some basic EMR functions.  In
251114 -                    1977, the system implemented a graphical user
251115 -                    interface.  The on-screen presentation of the CPRS
251116 -                    was deliberately fashioned to resembel a
251117 -                    traditional chart, with tabbed sections for labs,
251118 -                    orders, notes, consults, etc.  VA hospitals started
251119 -                    becoming "paperless" in 1999.  By 2002 all 162 VA
251120 -                    hospitals were paperless and the system was
251121 -                    networked, permitting remote access to data between
251122 -                    all VA facilities.
251124 -                     ..
251125 -                    The graphical CPRS interface improved access to a
251126 -                    wide range of patient information {10} and
251127 -                    databases accrued from clinical operations both
251128 -                    provide a rich resource for research and drive the
251129 -                    VA's quality improvmeent {11-13}.  VA's CpRS is
251130 -                    promoted as a model for other health care
251131 -                    organizations {14}, but CPRS users have also
251132 -                    experienced unwelcome consequences of its success,
251133 -                    notably information volume overload and input
251134 -                    burden.
251136 -                     ..
251137 -                2.  Beginning around the year 2000 and counterbalancing
251138 -                    projections that new technology would save lives
251139 -                    and money {15,16} several investigators described
251140 -                    unforseen adverse consequences of introducing
251141 -                    health care information systems (HCIS) and EMRs.
251142 -                    These included increases in errors seen with
251143 -                    introduction of the HCIS {17-19}, problems with
251144 -                    documentation {5,6,20,21}, and even outright
251145 -                    rejection of the EMR by clinicians {22,23}.  A
251146 -                    growing realization arose that existing information
251147 -                    systems fail to accomodate teh "complex
251148 -                    socio-technical systems" of health care.
251150 -                     ..
251151 -                    A recent report to the National Research Council
251152 -                    (NCR) commissioned by the National Library of
251153 -                    Medicine makes a similar critique.  Its authors,
251154 -                    informatics experts who surveyed eight leading HCIS
251155 -                    systems, concludde that these systems {24}:
251156 -
251157 -                    1.  appear designed largely to automate tasks or
251158 -                        business processes
251160 -                         ..
251161 -                    2.  are designed in ways that simply mimic existing
251162 -                        paper-based forms
251164 -                         ..
251165 -                    3.  provide little support for the cognitive tasks
251166 -                        of clincians or the workflow of the people who
251167 -                        must actually use the system.
251169 -                         ..
251170 -                    4.  do not utilize human-computer interaction (HCI)
251171 -                        principles, leading to poor designs that can
251173 -                         ..
251174 -                        increase the chance of error
251175 -                        add to work load
251176 -                        compound frustrations completing tasks
251177 -                        cause new forms of error difficult to detect
251179 -                 ..
251180 -                The NCR report also described insufficient support for
251181 -                clinical cognition as a key challenge in present day
251182 -                EMR systems {24}.
251184 -                 ..
251185 -            3.  Prior work
251186 -
251187 -                Our ongoing research project, VA Health Services
251188 -                Research and Development project IIR 05-019, studies
251189 -                the CPRS documetation system and how VA employees work
251190 -                with it.  As part of this study, we conducted 14
251191 -                scripted focus groups at four VA sites, interviewing
251192 -                129 VA practitioners, nurses and administrative
251193 -                personnel in 2007 and 2008.  CPRS users gave examples
251194 -                of the challenge they faced when navigating and working
251195 -                in the large "information space" of clinical
251196 -                documentation.  A recurring theme was the EMR's
251197 -                inabiity to present document information in ways that
251198 -                were a good "cognitive fit" with tasks.  Too often, the
251199 -                information user's needed to complete their work was
251200 -                scattered in different screens, or so combined with
251201 -                irrelevant information that users were slowed down and
251202 -                frustrated.  Participants said they knew that the
251203 -                information they needed was present in the HCIS, but
251204 -                were stymied when it was hard to find or when access to
251205 -                information needed to complete a transaction was
251206 -                blocked.  Other frequent themes included:  poor support
251207 -                for communication between memebers of the care team;
251208 -                distress and irritation when copy-and-paste (which
251209 -                users also stated they were driven to use by time
251210 -                pressure) impeded use of the written record; and
251211 -                suboptimal support for the infomration needs of ward
251212 -                nurses. {25,26}.  Themes from focus groups were
251213 -                distilled to four major categories:  (1) irrelevant and
251214 -                redundant textual data, (2) difficulty with copied and
251215 -                pasted test, (3) awkward navigation and (4) poor fit
251216 -                with inpatient work.
251218 -                    ..
251219 -                   [On 100911 0800 VA credited for improving speed of
251220 -                   access to computer records; discussed "Knowledge
251221 -                   Management loop" that redundancy and ignoring the
251222 -                   record collapses productivity and vitiates care
251223 -                   because health care professionals do not have
251224 -                   command and control of the record on patient
251225 -                   history, ref SDS 6 OL50, citing case study of work
251226 -                   at VA today on 091021. ref SDS 2 FB5N
251228 -                 ..
251229 -                The focus interviews revealed that VA users experienced
251230 -                many benefits from CPRS.  They cited CPRS as a reason
251231 -                they liked working at the VA.  They valued computerized
251232 -                documentation because narrative helped "make sense" of
251233 -                other data in the EMR.  Because users reported
251234 -                furstrations, stress and time pressure in their work
251235 -                with CPRS, we anticipated their support in efforts to
251236 -                improve the system's efficiency.
251238 -                 ..
251239 -                Accordingly, we undertook to investigate document
251240 -                review, and activity common to all users studied, and
251241 -                in this instance, examined the impact of documetns
251242 -                containing greater or lesser amounts of boilerplate and
251243 -                inserted data (factors frequently cited by our subjects
251244 -                as contributing to document "clutter").  Future studies
251245 -                will explore specific enhancement strategies to
251246 -                overcome other identified barriers.  Use of a simulator
251247 -                will permit experimental evaluation in realistic work
251248 -                contexts.
251249 -
251251 -         ..
251252 -    4.  Gooznews.com
251253 -
251254 -        The VA -- Best Care Anywhere (an update)
251255 -        by GoozNews ~ 28 May 2010 12:05pm
251256 -
251257 -              http://www.gooznews.com/node/3360
251258 -
251259 -        1.  Journalist Phil Longman at the New American Foundation
251260 -            recently updated his book "Best Care Anywhere," which
251261 -            documents the 1990s rejuvenation of the Veterans
251262 -            Administration's health care system.  Between editions, the
251263 -            wars in Iraq and Afghanistan placed strains on the VA not
251264 -            seen since Vietnam.  Here's his thoughts on the current
251265 -            state of the system, and the lessons its transformation
251266 -            holds for other delivery systems in the U.S.
251268 -             ..
251269 -        2.  How does contact with the VA healthcare system compare in
251270 -            terms of medical outcomes for its patients?  How about in
251271 -            other measures of quality?
251273 -             ..
251274 -        3.  In study after study published in peer-reviewed journals,
251275 -            the VA beats other health care providers on virtually every
251276 -            measure of quality.  These include patient safety,
251277 -            adherence to the protocols of evidence medicine,
251278 -            integration of care, cost-effectiveness, and patient
251279 -            satisfaction.  The VA is also on the leading edge of
251280 -            medical research, due to its close affiliation with the
251281 -            nation's leading medical schools, where many VA doctors
251282 -            have faculty positions.  The VA has its problems, but
251283 -            compared to those found elsewhere in the U.S. health care
251284 -            system, it offers "Best Care Anywhere."
251286 -             ..
251287 -        4.  How has the VA managed to create such a successful model
251288 -            when government bureaucracy, political pressures and
251289 -            limited funding would seem to make it impossible?
251291 -             ..
251292 -        5.  During the 1990s, VA health care underwent a quality
251293 -            revolution.  It was started by frontline doctors and nurses
251294 -            who simply wanted to do right by America's veterans.  It
251295 -            was later propelled by the enlightened and charismatic
251296 -            leadership of Dr. Ken Kizer, who took control of the
251297 -            Veterans Health Administration under President Clinton.
251298 -            The key to making it all work was the VA's near life-long
251299 -            relationship with its patients, which means it has
251300 -            incentives as an institution for investing in prevention,
251301 -            disease management, and other protocols that keep patients
251302 -            well-incentives that are sadly lacking elsewhere in the
251303 -            U.S. health care system.
251305 -             ..
251306 -        6.  The VA's medical records are entirely computerized.  Why
251307 -            hasn't the private sector been able to do the same?  What
251308 -            are the effects?
251310 -             ..
251311 -        7.  As the VA has shown, digital medicine, when properly
251312 -            implemented, vastly improves the quality of medicine.
251313 -            That's great for the VA, whose institutional incentives are
251314 -            aligned with those of its patients. But elsewhere in the
251315 -            U.S. health care system, the business case for quality is
251316 -            weak or doesn't exist.  Improved quality means that fewer
251317 -            patients get sick, and that when they do they experience
251318 -            fewer complications.  This is very costly to hospitals and
251319 -            doctors who earn their money by performing procedures, as
251320 -            opposed to keeping people well.  Why invest it electronic
251321 -            medical records if its means that ultimately you'll have
251322 -            fewer heart attack patients to bill, or will earn less from
251323 -            treating diabetic patients because you have properly
251324 -            managed their disease?
251326 -             ..
251327 -        8.  Health care reform passed without creating a public care
251328 -            option, a loss many progressives feel dooms the bill to
251329 -            failure. Is that the case?
251331 -             ..
251332 -        9.  The Bill does concern itself primarily with expanding
251333 -            insurance coverage, and not directly with reform of the
251334 -            actual practice of medicine.  But it also contains
251335 -            provisions, which few people know about, that could provide
251336 -            the ground work for something like a civilian VA health
251337 -            system.  Whether this actually happens depends heavily on
251338 -            people at the local and state level taking advantage of the
251339 -            opportunity the bill gives them.  It's kind of like getting
251340 -            just the toy you want for Christmas, only it says on the
251341 -            box "some assembly required."
251343 -             ..
251344 -       10.  What are the prospects for that happening, and is the
251345 -            funding adequate?
251347 -             ..
251348 -       11.  There is at least $12 billion available for anyone who
251349 -            wants to set up what the bill calls an "Accountable Health
251350 -            Care Organization." That means an organization that is
251351 -            willing to accept getting paid for keeping its patients
251352 -            well, and that is willing to adapt and integrate health
251353 -            care information technologies of the kind the VA has
251354 -            pioneered.  The barriers to entry are remarkably low.  The
251355 -            VA's software, for example, is free to any health care
251356 -            provider who wants to use it, because was written by VA
251357 -            doctors on government time.  It's also "open source," which
251358 -            means that health care providers outside the VA can modify
251359 -            it to meet their particular needs.
251361 -             ..
251362 -       12.  Would a civilian VA mean more and bigger government?
251364 -             ..
251365 -       13.  For those who are concerned about the growth of government,
251366 -            and I am one, the most important single objective is to
251367 -            control the cost of health care, which is driving up
251368 -            spending at all levels of government.  The more Americans
251369 -            have access to the VA model of care, the lower health care
251370 -            costs will be, while at the same time health care quality
251371 -            will improve.  Done right, the widespread adoption of the
251372 -            VA model of care could free up enough resources to pay for
251373 -            tax cuts, or to start making serious down payments on our
251374 -            national debt.
251376 -             ..
251377 -       14.  What effect would such a system have on health insurance
251378 -            costs for American businesses and families?
251380 -             ..
251381 -       15.  It's estimated that one-third of all health care spending
251382 -            outside VA goes for over-treatment, such as redundant
251383 -            testing and unnecessary surgery.  Because the VA model
251384 -            gives doctors no financial incentive to perform operations
251385 -            people don't need, and empowers them with the information
251386 -            technology to keep track of test results and coordinate
251387 -            care, it's widespread adoption could well cut health care
251388 -            spending by a third. Insurance premiums would fall
251389 -            commensurately.
251391 -             ..
251392 -       16.  Would such a healthcare system mean that doctors and
251393 -            patients would lose the freedom to decide which treatments
251394 -            and medications they wanted to use?
251396 -             ..
251397 -       17.  Most Americans have very little choice of doctors right
251398 -            now.  Just try finding a primary care physician who is
251399 -            still taking patients.  Every VA patient has a primary care
251400 -            physician who coordinates their care among specialists.
251401 -            Unlike most other health care providers, the VA does
251402 -            extensive research on what works and doesn't in medicine,
251403 -            including by using the outcomes data available from its own
251404 -            electronic medical records.  This, ironically, provides its
251405 -            patients with insurance against one of the leading health
251406 -            hazards in the United States, which is being subjected to
251407 -            unnecessary treatment.  Of course, no one is compelled to
251408 -            receive their care from the VA, nor would anyone be
251409 -            compelled to join a health care plan that adopted its model
251410 -            if it didn't fit their preferences.
251412 -             ..
251413 -       18.  What can the average citizen do to make VA quality medical
251414 -            care available for themselves and their communities?
251416 -             ..
251417 -       19.  Start by talking to veterans about the care they receive
251418 -            from the VA.  It's rare to fine a vet who has been treated
251419 -            there recently who isn't a big fan.  Then start questioning
251420 -            your health care providers about why they can't deliver the
251421 -            same quality of care. People all over the world, including
251422 -            the people in Uganda, enjoy the benefits of electronic
251423 -            medical records, but few in the U.S. do.  Demand to know
251424 -            why your doc is still using 19th century information
251425 -            technology. Finally, be open to the many people both in and
251426 -            outside U.S. medicine who are calling for wholesale reform
251427 -            of the delivery system, even if what they say at first
251428 -            seems counterintuitive or contrary to conventional wisdom.
251430 -             ..
251431 -       20.  How did you get interested in the VA and what did you think
251432 -            you would find out when you began your research?
251434 -             ..
251435 -       21.  Several years ago, Fortune magazine asked me find out who
251436 -            was providing the most innovative and effective health care
251437 -            in the U.S.  Having lost my first wife, Robin, to breast
251438 -            cancer, and having seen much of the dysfunction of the U.S.
251439 -            health care system up close during that ordeal, I was eager
251440 -            to take the assignment.  No one was ever more surprised
251441 -            than me to find that that the long troubled VA had become
251442 -            the bright star of American Medicine.  What would you like
251443 -            to see the American health care system look like in 20
251444 -            years?
251446 -             ..
251447 -       22.  If all goes right, we will have a health care system in
251448 -            which the interests of patients and providers and aligned,
251449 -            as they are in the VA.  Both individuals and policy makers
251450 -            will pay much more attention to prevention, and to the
251451 -            environmental and behavioral factors that play by far the
251452 -            greatest role in determining our health and longevity.  We
251453 -            will also come to understand that many of the procedures
251454 -            performed by today's profit-maximizing surgeons and other
251455 -            specialists have no scientific basis and, worse, cause much
251456 -            needless death and suffering. And we will wonder why it
251457 -            took us so long to open minds to these truths.
251458 -
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251460 -
251461 -
251462 -
251463 -
251464 -
251465 -
251466 -
2515 -