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Over the last couple of weeks I have been running across various success and failure stories of EMR implementation in various settings, ranging from small practices to large hospital wide implementations. 

The number one factor in a successful EMR implementation from all the read reports have been due to physician/surgeon buy in.  Makes sense, after all these are end users of the applications and if you don't have anyone on the provider side vying for a successful workflow adaptation, there is no reason to implement an EMR.  Also, if you have an M.D. as your champion, won't the rest of the staff have to buy in for fear of replacement of someone who will?  I know in other occupations, what the boss says, goes.  The true is same in healthcare, no?

The next seemingly most important factor is the ability to customize the application in a way that will best benefit the providers.  This is absolutely a main component in the success factor of an EMR in my opinion.  Vendors have to do what they can to include everything in their system that a practice, clinic or hospital may use.

In a hospital system, this problem is very clear.  A hospital system has to be a nightmare to the specialists who use it.  Why would a provider want to sift through literally thousands of medications when they typically only prescribe certain ones for their patients.  This is where careful planning and delegating comes in.  The customer needs to understand that the hospital system is meant to meet the needs of all providers in the entire system.  It is recommended that each specialty department within the community appoint select staff to create a list of "Favorites" within the medications, procedures, diagnosis, orders etc. tabs.  This way, time will be saved when completing a patient visit.

In a smaller setting, I have to recommend going with a specialty specific vendor.  In doing this, the provider will have a more robust system specifically catered to their needs and will not include any additional data fields that they will never have a need for.  The specialty specific vendors are also more likely to already have certain reporting tools already preloaded in the system to generate specialty specific and relative reports, such as those required for Centers of Excellence.  Exemplo Medical (  is one such company that develops specialty specific software.  For example, Exemplo's application for Breast Cancer, eMD for Breast Centers, is an application designed in conjunction with Breast Surgeons and staff that only shows pertinent workflows that a typical Breast Center or Practice may use.  The workflow includes specific data fields for patient visits, orders, medications, procedures and so on.  They even have a specific report that automatically generates a NQMBC report that is easily submitted to the National Consortium of Breast Centers for their COE compliance.

Of all the success stories these two themes: provider buy in and customization seem to be at the top of the list and perhaps the easiest to attain.  Some may disagree with that statement of being "easy to attain" however if a provider has been given a clearly painted picture of the benefits of EMR implementation, then it should be a no brainer on their end.  As for the customization...providers do your homework, there are wonderful systems out there that you will be amazed to find how easily adaptable they are to any practice.


Two studies were published in the Archives of Internal Medicine this past Monday showing "The risk of cancer associated with popular CT scans appears to be greater than previously believed".

I originally read this article in the WSJ and they included a nifty graph showing the increase in CT scans over the years (1993-2006, and included projected 2007 numbers). I can't say I was shocked. Obviously there will be an increase, population increases year over year.

As expected, the American College of Radiology (ACR), released their own statement in response to the recent studies. The ACR statement was wonderfully put together and basically stated that if an imaging center abides by the standards put forth, then there should be no increased risk as the benefit of the scan outweighs the risk. Seems like common sense to me.

This is where I believe that patients need to take more responsibility for their own health by asking questions instead of just going along with whatever their physician says. After all, when you break it down, its a business that strives to make a profit. I am not putting down all clinicians who perform CTs, I am putting down the clinicians who abuse the system to make the money to pay for their fancy state-of-the-art equipment. Those machines come with a hefty price tag and the ROI must be met somehow. Some clinicians go about it the right way, others don't unfortunately. They are human after all.

Now for the other issue with this...clinicians have to protect themselves. If a patient comes in complaining of a mild condition that a CT may show, its up to the doc to determine the severity of the situation. This is a very fine line due to the liability involved. Unfortunately we live in a world of money hungry individuals who are willing to sue if their coffee if too hot. This is where the relationship of the physician and patient comes into play. There has to be a level of understanding and trust for the situation at hand.

Personally, I have a wonderful relationship with my GP and others specialists that I see because I feel comfortable with them. If you don't feel comfortable asking the hard questions with your provider, maybe its time to look into a different one. Good ones are out there, more good than bad fortunately for us. But it is up to us to sift through the population to find one that fits best. Unfortunately for doctors now a days, it is getting harder and harder to make money and that is unfortunate because I believe that some of the "good" docs may be susceptible to becoming more focused on business side rather than patient care, which I can't say I don't necessarily blame them, they have bills to pay too, big ones like student loans, salaries, mandatory EMR adoption etc.

Now for my cynical comment....I wonder which diagnostic test or treatment or whatever will be next to take some heat in order to cut healthcare costs? Keep in mind this is at the expense of the public who desperately wants change, but I have to ask, at what price? So far it has been more about money than human lives.


The National Consortium of Breast Centers (NCBC) has just released their position statement regarding the recent mammography guideline changes:

“The National Consortium of Breast Center's Board of Trustees has given their consent to the following position statement reflecting their stand on the issue of mammographic screening, in response to the recommendations made by the US Preventive Services Task Force.

National Consortium of Breast Centers, Inc.

Position Statement regarding the Mammography Screening Recommendations of the United States Preventive Services Task Force (USPSTF)

The National Consortium of Breast Centers (NCBC), the largest national organization devoted to the inter-disciplinary care of breast disease, requests the USPSTF rescind their new position on mammography screening.

The U.S. Preventive Services Task Force (USPSTF) published a paper detailing model estimates of potential benefits and harms to women screened for breast cancer with mammography.1 They provided an updated USPSTF recommendation statement on screening for breast cancer for the general population that alters currently accepted guidelines for women over 40 years old.2

The NCBC opposes the new guidelines as written. We cite specific evidence that screening mammography leads to early detection which leads to improved survival.3 In every country starting population screening, mortality declines coincide with onset of screening, not systemic therapy. These USPSTF models are not based on sound data, namely different denominators in the “harms” vs. “benefits” groups leading to invalid comparisons. Recent data from randomized controlled trials reveal significant mortality reductions evident approximately five years after screening programs were initiated. The reductions in age-adjusted, disease specific mortality (30-40%) since 1990 define screening program benefits not seen in the prior six decades. In the United States, these mortality declines continue at a rate of approximately 2% per year. 4 This mortality improvement counts as a remarkable public health achievement.

In addition, the USPSTF panel (comprised almost exclusively of primary care physicians) did not include breast imaging specialists nor was it represented by any of the multiple other specialists who collaborate to optimize patient outcomes. These specialists include pathologists, surgeons, medical oncologists, radiation oncologists, reconstructive surgeons, technologists, geneticists, nurse navigators, educators and others.

The NCBC does not understand the assumptions used by the USPSTF to value human life. We note the cited literature was selective and failed to acknowledge equally powerful and credible peer-reviewed literature, which supports currently accepted breast cancer screening guidelines.

We would also like to note that quality of life has a significant value, not just survival. It is well established that if we discontinue mammography for women in their 40’s, the cancers eventually detected will be larger, more likely need more aggressive surgery, more likely need chemotherapy and more likely lead to other significant socio-economic concerns.

The NCBC requests input into future guideline development and vows to work with government, scientists and industry to keep the process transparent and keep the focus on the patient. We recommend further efforts target screening, risk assessment, education and awareness regarding the implications of positive and negative screening findings. Funding for further research is imperative and supported by the controversy these articles have generated.

Finally, we note the USPSTF article states, “whether it will be practical or acceptable to change the existing U.S. practice of annual screening cannot be addressed by our models.”1 The NCBC agrees with this comment and finds their screening guideline suggestions unacceptable. The NCBC believes many women’s lives will be placed at risk if current screening guidelines are altered. We respectfully request the Task Force rescind their position on this specific women’s healthcare screening policy.

# # # #

About NCBC: The National Consortium of Breast Centers (NCBC) is the largest national organization devoted to the inter-disciplinary care of breast disease. In keeping with our mission, to promote excellence in breast care through a network of diverse professionals dedicated to the active exchange of ideas and resources including: 1) To serve as an informational resource and to provide support services to those rendering care to people with breast disease through educational programs, newsletters, a national directory, and patient forums; 2) To encourage professionals to concentrate and specialize in activities related to breast disease; 3) To encourage the development of programs and centers that address breast disease and promote breast health; 4) To facilitate collaborative research opportunities on issues of breast health; and 5) To develop a set of core measures to define, improve and sustain quality standards in comprehensive breast programs and centers.


1. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 738-747.

2. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 716-726.

3. Tabar L, Vitak B, Chen HT et al. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 2001; 91: 1724-1731.

4. American Cancer Society, Breast Cancer Facts and Figures, 2009-2010.

All content and design © 2009 by the National Consortium of Breast Centers, Inc.”

As mentioned in the recent post, "Scrapping the Barrel to Support Health Reform", it seems like the current Health care reform plan is costing the nation a trillion dollars yet is taking away money from preventative care of deadly diseases, mainly its been cancer that has been hit the hardest.

The optimist in me at first said that with these changes, maybe techniques and other medical procedures will be forced to improve based on this change. I still believe this will be the case, but does one outweigh the other? The best approach would be to do both of course. Maintain the guidelines that have been proven effective through various published trials, and allocate ARRA funds to increase R&D of new treatments or improved quality of current techniques. Who knows, there may be money left over from the HITECH stimulus funds by ARRA if physicians are unable to collect the 44k in order adopt EMR.

Once improved procedures allow for a change in the guidelines, then the change is warranted. If not, guidelines should not be altered.

The National Consortium of Breast Centers (NCBC) is currently the largest national organization devoted to the care of Breast Disease. Through their quality measures program, the National Quality Measures for Breast Centers (NQMBC), breast care centers have the opportunity to collect and standardized data to the NCBC in hopes to improve clinical care of Breast Cancer Patients.


As usual, its been a busy few weeks in the Health IT world and things continue to get shaken up with many recent announcements.

In a press release on 10/22/2009 the Certification Committee for Health Information Technology (CCHIT) announced that they are seeking candidates to serve as Trustees and Commissioners.

Another press release on 11/13/2009, announced that CCHIT's well known Chair, Mark Leavitt will be retiring in March of next year after 5 years of service.

Once the first press release came through on my feed, I thought it was only a matter of time before this happened. Changes need to be made by the CCHIT to gain acceptance by many skeptics. Then I received the second feed, an interesting decision made by Dr. Leavitt to announce his retirement, especially since the CCHIT has been under major scrutiny lately for being the sole certifier of EMR systems and carrying a rather large price tag, so large in fact that most of the smaller vendors are unable to afford the certification. I'm just not sure if leaving his organization now, especially announcing it, was the greatest business decision for the CCHIT.

The CCHIT has also been accused by it's critics for catering to the larger EMR vendors that also conveniently sit on their Board of Trustees and Commissioners.

I find it quite coincidental that after undergoing such a large amount of scrutiny for favoritism that the CCHIT is now holding interviews to replace some of it's Board Members. I know that you are probably thinking, damned if you do damned if you don't. Thats not where I'm headed. I want to give kudos to the CCHIT and Dr. Leavitt for their accomplishments in the past years as well as the realization, or wake up call, that changes need to be made their board, specifically the board member ratio, which I'm sure will be affected. The positions are open to members of physician practices and hospitals, payers, health care consumers, vendors, safety net providers, public health agencies, quality improvement organizations, clinical researchers, standards development and informatics experts and government agencies. I would imagine that the vendor to healthcare provider ratio will be severely affected.

As for Dr. Leavitt leaving, personally I don't think this is the greatest time the CCHIT during this critical time, especially when the certification business is open for business according to Health and Human Services. Who know's, maybe its a career move...he would be a perfect candidate to head up a start-up certifying company.

That brings me to my next topic, the Drummond Group may prove to be a worthy alternative. They had their own press release on 11/02/2009 that they will submit to become a certifying body. I haven't heard of any progress, but if anyone out there has heard anything, please let me know. For those of us who are new to the Drummond Group, they are a company specializing in interoperability testing. Rik Drummond, CEO of Drummond Group was quoted in the press release saying, "Drummond Group has been supporting Fortune 500 industries and government by certifying the transfer, identity and cybersecurity of their internet information flow over the last ten years. We have also done testing for the CDC, DEA and GSA. Certification of EHR is a natural extension of our testing program, and we believe we can provide great value for the medical community. We look forward to the publishing of the ONC requirements in the days ahead so we can get started."

There seems to be a lot of progress within the Certification realm. My only other questions and worries are targeted towards getting everything in place in time for physicians to get their reimbursements.


What a past couple of days in the Healthcare realm. First of all, the Health Reform bill passed in the House with a price tag of $1 trillion. The money has to come from somewhere and it seems like it is coming down to the preventative care of women as for now. In other releases, separated by one day each, new guidelines came out for mammograms and pap smears. Another release just came out regarding a 5% tax on non-elective plastic surgery procedures.

I have to wonder who is influencing these recently altered guidelines and their research findings. I have my opinions on can be manipulated to prove a desired point. I have to assume this is what is going on in these recent releases regarding the preventative care for serious cancers that specifically target women. For the past year I have heard more news to promote preventative care than ever before. Why? Because it saves lives and yes money too. So now, why are they changing these guidelines that promote a higher level preventative cancer? Has anyone thought that the numbers may be down because of the preventative measures that have been in place?

With a $1 trillion price tag, one has to wonder is its to free up funds to pass this bill. Unfortunately, these changes are going to be just the beginning I believe.

As for the elective plastic surgery procedures, in 2008 it was reported that $10.3 billion was spent on these procedures. People choose to get certain procedures to benefit their quality of life in some way, which can ultimately change certain mental conditions such as depression and anxiety which both play an enormous factor in the progression of other serious health factors. Not everyone who elects to get plastic surgery are the typical "trophy wife" getting a different nose every 5 years, its also those people that have little money to pay for a procedure to correct something that may have been caused by an accident for example. Now, these people who have to spend thousands of dollars, that may have had to scrape it together, are expected to spend 5% more. Is that fair to the little girl who was in a car accident and suffered injuries to her face that left her scarred for life without plastic surgery? This is just an example, but it is also a reality of how people are going to be affected by this health care reform push.

I believe something has to change in Healthcare, but at what cost? Certainly not time, after all the current administration is rushing this thing out without the proper time to think of how it will actually pan out in the future.

Its going to be an interesting couple of years to say the least.


Since the inception of ARRA, there has been mixed emotions of whether or not throwing money at a situation will benefit the struggling incumbent health care system. Having only worked in Healthcare IT for a limited amount of time I believe I can shed some light on the subject from an outsider's perspective rather than a biased, perhaps jaded, insider's view.

First lets talk some basics. Approx $19.2 bill in incentives available to physicians who adopt a certified, meaningful use EMR system. This breaks down to around $44k/provider on up to $64k/provider depending on Medicaid/Medicare patient ratio (the more CMS customers, the higher stimulus awarded). Incentives start this 2010 and penalties start 2015.

The main debates have been lying in the "certified" and "meaningful use" or simply "MU" realms. Let's first talk about certification. The only certifying body to date is the CCHIT which was spawned off of HIMSS and even has a former HIMSS member as its leader. For those of you that are new to this area, the Certifying Commission on Health Information Technology (CCHIT) is a non-profit group based out of Chicago, near HIMSS HQ, that is comprised of different executives who have vested interest in the large EMR vendors...because they run and/or work for them. That is all I will rant about for this post on the CCHIT.

The next big issue, which needs to be radically simplified is MU. Every practice and specialty are different. Meaningful use may vary from specialty to specialty. This needs to be a simplistic model, not a complicated matrix that was originally released, for everyone to understand. There also has to be a lot of gray area as well in this definition to allow for proper payment if a practice is able to show that they use MU.

These 2 criteria, certification and MU, have yet to be decided on. Deadlines are set, but as we all know and have experienced, they may be moved again.

So back to the original question in the title, has the stimulus money caused a boom for HIT or has it been a bust thus far?

Certain areas of the HIT market has seen an increase due to the stimulus funds for HIT for sure, but on the same note, many HIT vendors have seen a lull in sales. Why, when there is at least 44k on the table and adoption needs to happen quickly in order to qualify for the 1st and biggest stimulus handout.

The stimulus money has put providers on a bit of a "wait and see" mentality. There are far too many providers who do not see the value of EMR. Should this stimulus money have been allocated differently? Should more money have went to education and research rather than purchase and implementation?

EMR is not a thing of the future. It is a technology that has been around and in use for over a decade. They have time over time proven effective, efficient and reliable. I am not going to go into detail because the case studies are out there. The only problems that I have seen are due to bad matches between vendor and customer, not the idea or technology itself.

Look at our world now, smartphones that allow us to answer emails while out of the office, telecommuting from home to save on overhead costs etc. Technology will continue to improve upon quality. Be it quality of care or quality of life.

EMR is a way to do both. The incentive from ARRA is there yes, but treat it as a bonus for adopting a new way of patient care and reporting to improve the overall quality of care and patient health for futures to come by adopting and embracing a sound technology that you may, or may not, get some extra cash from.


Appropriate IT



A colleague of mine came up with this brilliant distillation of wisdom:

It is possible to force a project plan to match reality but impossible to force reality to match a project plan. So why is it the latter is attempted more then the former?

S. Yetter


My DSL has been flakey for a couple of weeks. Today, it finally went out for good. The administrative web app on our 2Wire router said the DSL signal was kaput. So began my experience with AT&T High-Speed Home Network support.

The first person to answer my call is Macy. I’m using her real name because everyone should know it. Especially her supervisor. Macy hung up on me because I couldn’t understand her accent. To her credit, before hanging up on me, she tried to communicate by talking REAL LOUD.

I called again hoping to get Macy as I had a few things to say but Joy answered the call instead. Joy asked me some questions and made me unplug the entire deal and move it to another phone jack. She put me on hold a lot while she multi-tasked with other support calls. Joy didn’t seem terribly enthusiastic about the whole affair. Most of the time I thought we had lost contact but after while she’d come back on the call. Eventually, Joy escalated the call to Ron after she was unable to figure out the problem. Even after I had to move the whole deal to another phone jack. Did I mention that I have (had) all of my cables neatly tied and tucked away?

Ron was from California and asked me all of the same questions Joy had. He was unable to find the ticket in the system. He announced that he had some diagnostic tools and could see that the signal in our house was intermittent (tools and progress!). Then he announced that our 3mb downstream should have never worked because we were too far away from the hub (sigh. so much for progress). I was about ready to write off the entire organization but Ron was very personable and seemed very interested in helping me out. I told him we’ve had this setup for three years with no problems except in the last couple of weeks. Somewhere, something has changed. Ron asked me about every phone we had in the house and if they were all attached to filters and expressed surprise that Joy hadn’t asked this earlier. I couldn’t remember so I did reconnaissance. Basement, first level and upstairs. And there it was: Jaime’s new cordless phone. Unfiltered. Got that about two weeks ago. I unplugged it and Ron announced that the signal to the house turned strong and steady.

This two-hour ordeal really reinforced in my mind what it takes for successful support:

  1. People
    We need more Rons and no Macys.

  2. Systems
    Accurate, accessible ticket information saves time for everyone. Additionally, Ron had access to diagnostic tools that Joy apparently did not. Finally, while high productivity is a key goal, multi-tasking to the point of ineptidude is not an effective component of a solid productivity system.

  3. Process
    Ron fell back to a first level diagnostic process that started at square one. Having and using such processes is the only way to efficiently diagnose and solve issues.


The Premise of Covey's, The Speed of Trust, is that when there is trust in any business or human transaction, the transaction takes less time and thus, costs less.

Think of any transaction, whether it be buying something or talking with your boss. If there is trust, things move along quickly. If there is no trust, we get bogged down in analysis and take extra time checking things out. Trust is the lubricant for effective human transactions. Increased friction is the result of lack of trust.

Typical of Covey materials is the framing of principles around values and specific behaviors, an approach adapted by Ministry Health Care for our Patient Promise.

Trust is a key element of effective leadership. I highly recommend this one. It's an easy listen, only 75 minutes (executive summary version from


In the aftermath of a virus or malware outbreak, we typically beat up on our Client Technology and Data Center folks or even our security software vendor and demand answers, “How could you let this through? Why didn’t our technology block this threat? Where was your vigilance?” Frankly, the question we really want to ask is:

“Who’s the nincompoop that clicked on the malware that kicked this catastrophe off?”

Virus and malware outbreaks typically cause us to revisit our usage of Windows local administrative rights. In a nutshell, local admin rights serve double duty as a requirement for certain, critical applications as well as the scourge of IT Support.

One approach to keep malware from attacking a device is to “lock it down”, that is, to remove local admin rights so that the user can’t install anything on it. This approach has its advantages because it protects users from the negative consequences of their own actions. This is similar to web filtering where we keep users away from harmful sites. Standard tools in the IT Security arsenal, right?

The problem I have with employing blocking technologies as the sole deterent is that we do two things:
1) We imply a lack of trust whereby we further are viewed as “big brother”.
2) We create a nanny security environment where users assume no responsibility for their actions (for what they click on).

While blocking technologies are important and necessary, I strongly believe we need to cultivate another, farther-reaching approach: personal responsibility and consequences. Before you call me naïve, consider this: Is it better to instruct our teenagers about the dangers of alcohol consumption or should we prominently lock the liquor cabinet and call it a day? Clearly the healthier and more sustainable answer is the former. (Having said that, there are certainly times when we may have to resort to the latter!)

I propose educating users on what they can and cannot install. We don’t want them installing games and we don’t need them to help us update their virus scanners. In fact, we don’t want them to install anything without the consent of the Service Desk. If, after this simple education, a user decides to install something, we will impose simple consequences. If it takes 30 minutes for a technician to remove Google Earth, then the user will forfeit 30 minutes from their paid-time-off (PTO) account. If they click on something that requires a 2-hour reimaging and reconfiguration of their device, they forfeit 2 hours from their PTO account.

In essence, we need to employ a two-prong approach: blocking technologies AND user responsibility and consquences.

In Jurassic Park, John Hammond tells Dennis Nedry that he doesn’t blame people for their mistakes, but he does ask that they pay for them. I agree and believe that this stance would vastly cut down on the number of illicit software installations, with blocking technologies providing the final cover.


Our Lady of Victory Hospital (OLVH) routinely posts the best employee culture scores in the Ministry Health Care system. I'm often asked how it is that OLVH consistently rates so high. We're certainly not perfect nor perfectly consistent across all departments but I see OLVH's cultural strengths as follows:

Leadership by Example

OLVH leaders are "working managers". I think that makes the layer between managers and staff less pronounced. Whether it's our DON working ED shifts or the Rehabiliation Director going to the prison to provide therapy, the leaders at OLVH have their sleeves rolled up just like the staff does. I believe that fosters more of a "we're all in this together" environment.


Values and culture activities are treated seriously and sincerely by our leadership. These initiatives are always followed by serious and sincere action. Employees can smell disingenuous lip service a mile away.

Connection with Staff: Honesty and Openness

From a senior leadership level, the hospital President does a great job of keeping everyone appraised of what is happening, even if the news is negative. There are few, if any, secrets. Discordance is hard to hide in a small environment so it's typically dealt with quickly resulting in less time to fester (certainly there is variability in performance here but overall this is a strength at OLVH). Conversely, good works and good staff are more visible to all. The President's weekly email is a great example of how she openly connects with staff to relay good news, bad news and give sincere kudos and encouragement to specific individuals.

Focus, Accountability and Follow-through

There is a strong current of accountability here complete with follow-through and closure of initiatives. Thus, things get done. This leads to the sense of accomplishment as well as confidence that what we focus on will be accomplished.


All of the above lead to a higher sense of trust among leaders and staff and trust is probably the main ingredient of commitment.


This is the time of year when I field a lot of questions about point-and-shoot digital cameras for gifts or for capturing pictures of kids and grandkids during the holidays. Luckily, a very highly respected digital camera review site,, is coming out with a series of reviews of cameras within various classes. Each class review will select the best cameras in their respective classes.

Their first review is of the budget camera class and includes cameras under $150. According to the review, the two best cameras in the group are (with Amazon links) the Sony DSCW120 at approx. $130 and the Panasonic LZ8 at approx $117.

Remember, this first review is of budget cameras so the winners will provide good quality photos yet may or may not have all of the features you desire. Read the reviews carefully as DPReview does a good job of specifying the pros and cons of each class of camera as well as for the individual cameras themselves. I'm actually quite amazed that both the Sony and the Panasonic above have Image Stabilization and large viewing screens. Clearly, high-end camera technology is working it's way down to the budget models!

If you're interested in digital camera buying this Christmas, check back at the DPReview site for more information and more reviews as they become available.


(BTW- Don't judge a camera based on the number of megapixels it has. All new cameras have enough megapixels to produce large prints.)
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