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| VistA to community health centers' special needs. | | VistA to community health centers' special needs. |
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| '''From: Hardhats Listserve:'''
| | ==From Hardhats Listserve:== |
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| Here are some recurrent questions us nontechies have about VistA: | | Here are some recurrent questions us nontechies have about VistA: |
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| [[2) What is the fundamental difference between a relational database and a hierarchical database and how does that effect the end-user? (Should we even care? If so why?)]] | | [[2) What is the fundamental difference between a relational database and a hierarchical database and how does that effect the end-user? (Should we even care? If so why?)]] |
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| '''3) How hard is it for non-Mumps IT personnel to learn Mumps/VistA and are there enough experienced VistA programmers (or former VistA programmers) to consult or be hired to non-VA projects?'''
| | [[3) How hard is it for non-Mumps IT personnel to learn Mumps/VistA and are there enough experienced VistA programmers (or former VistA programmers) to consult or be hired to non-VA projects?]] |
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| Learning MUMPS is as simple as learning BASIC. Learning about all
| | [[4) What other concerns should we have regarding adopting VistA?]] |
| the utilities and capabilities of the common services in VistA is
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| a years long process. And learning the functionality and setup
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| for the clinical and administrative functions in VistA would
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| probably take several life-times. Are there enough experienced
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| programmers and application consultants? So far I believe you'll
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| currently pay more for a Java programmer.
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| I am a physician and have taught myself M. It is a very simple
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| language. I consider it to be a scripting language. But it gets
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| the job done, and has run hospitals safely for decades.
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| There are many people on the list that would like work as
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| programmers, so I don't think there will be any limitation there.
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| And when CMS releases VistAOffice, there should be even more
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| interest and consultants available.
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| [[Rick Marshall]] replies: | | [[5) Are any Community Health Centers currently utilizing VistA?]] |
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| It is easy to learn Standard MUMPS, but impossible to master VistA.
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| Like the art of medicine itself, VistA is complex beyond human
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| comprehension--no, I am not kidding or exaggerating--and no one person
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| will ever know it all anymore. I have been programming with VistA for
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| twenty-one years; there are a couple areas of the code I know better
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| than anyone, several I know as well as the other experts, and a dozen or
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| so I know reasonably well--out of 80-120 software packages, depending on
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| where you draw the lines. Most of VistA I know by its patterns and
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| common structures, and maybe a few basic architectural features per
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| package, but for most of VistA I am the wrong person to go to. There
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| are whole packages I know only by name, whose purpose I can only guess
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| at. So it is with all the VistA gurus. None of us pretends to know it
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| all or even most of it. We work together as a community, sharing out
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| the vast scope of work that is VistA among ourselves.
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| To address your central concern, our tradition is to grow our own new
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| Standard MUMPS and VistA programmers from among its users, because we
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| have discovered it is far easier to teach a nurse to program than to
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| teach a programmer to practice medicine; the nurse has already mastered
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| the difficult part. It takes mere minutes to start writing Standard
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| MUMPS code, as with any programming system worth discussing, but a day
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| or two to introduce the basics, a week or two to introduce them fully,
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| and a month or two to become fully comfortable with the programming
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| system. It takes experienced programmers longer to learn Standard
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| MUMPS, because it is not like most other programming systems, and they
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| spend years whining about it instead of buckling down and coming to
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| grips with it on its own terms. Learning Standard MUMPS is like taking
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| small steps over very deep crevices; it is easy but unnerving for some.
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| Learning to program with VistA takes longer, and should happen in two
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| phases. First the programmer needs to learn our programming standards
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| and conventions and common calls. Then the programmer needs to pick a
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| package and focus on it for a long time, moving from simple assignments
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| to more complex ones. It is best if the student began as a user of that
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| package, then graduated to being an application coordinator (a kind of
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| super-user) for it, before learning to program with it. Becoming an
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| expert user of any reasonably sophisticated VistA package takes years.
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| Once an application coordinator starts training to become an information
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| manager, starts working on supporting and extending a package at a site,
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| every year they keep at it improves their skills with the package
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| measurably. Those who have worked with a package for ten years or more
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| are easy to tell apart from those who have only been doing it a few years.
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| There is a lot more I could tell you about the expertise lifecycle, how
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| it is structured, where to find VistA experts and how to grow your own,
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| but I am trying to keep this postscript "short."
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| '''4) What other concerns should we have regarding adopting VistA?'''
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| Expect a long learning curve. Get help.
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| I think a factor here is how much you want to put into the system.
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| It is not turn key at this point, although there are installers
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| who can do the work for you. It is not going to have all the
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| bells and whistles that commercial EMR's want you to pay for.
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| It is not currently integrated with a billing system or a system
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| for appointments.
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| [[Matthew King]] adds:
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| On the other hand, a lot of the bell and whistles that seem to
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| exist in many commercial products are actually rudimentary or even
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| vaporware. VistA isn't as pretty, but is very functional, with
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| easily modified clinical and preventive care reminders,support for
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| disease management, advanced drug interaction checks and lexion
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| support. The CPRS module supports drag and drop template building.
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| This makes custom templates a snap, something you pay dearly for
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| in many commerical products. The experts say 1/3 of medical errors
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| can be reduced by intelligent software design. Since the VA
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| product exists for patients, not profits, it is designed for
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| clinical functionality and patient safety, so that is where it
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| shines. Most commercial products have recently added EHRs as an
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| afterthought in an emerging market. The bells and whistles look
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| slick, but don't necessarily add to patient safety.
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| [[Rick Marshall]] replies:
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| Above all, it is a serious commitment. It is free as in freedom, not
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| free beer. It will save lives, not time. You cannot do this alone; you
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| may think you can, but sooner or later you will run aground without
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| help. To succeed with VistA you need the community in ways you cannot
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| imagine, but the good news is they will welcome and help you, and it
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| will not be long before you can return the favor. The big hurdle with
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| VistA is that anyone used to making medical informatics decisions has
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| learned how to prepare for defeat, to choose vendors on the basis of how
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| deep their pockets are (so you can sue them when the project collapses
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| in failure) instead of on the basis of their expertise and customer
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| service, to choose based on marketing flair and reputation. VistA is
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| the real deal, and for that very reason may be difficult to recognize as
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| such by customers who have learned only how to choose among flashy
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| failures. VistA requires the "customer" to become a partner, a
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| collaborator, words that have all but lost their meaning in the modern
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| marketplace; when you become fully engaged with the VistA lifecycle, you
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| will come to understand that if VistA is broken it is your fault as much
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| as ours, that it is your responsibility to hold the developers and the
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| software to a high enough standard to meet your needs. Unlike with most
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| commercial software products, you will rewarded instead of punished for
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| engaging in the critique, review, and even development of VistA.
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| There is an endless amount to learn about it, and it is under continuous
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| development, continuously patched, continuously changing, as it must
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| be. The static details of VistA are less important than the living
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| process by which its users drive development through their continuous
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| stream of suggestions and complaints. You will not and cannot
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| appreciate how true that is until after you have been involved with
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| VistA for years. The secret to its success is no secret, not specific
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| features, nor the technology used. It is the dynamic, hyperactive
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| software lifecycle that engages the creativity of tens of thousands of
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| users to mold the software over and over so that the longer you wait the
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| better it gets, as opposed to most software which is static by design,
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| updated at best occasionally, and obsolesces with time.
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| That inversion of the norm, emphasizing change instead of stasis, is a
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| repudiation of the core beliefs of the software industry and much of
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| academia, and as such you must expect to hear an endless stream of
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| irrelevant complaints lodged against VistA, usually by those who have
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| not used it. From those who do use VistA, you will generally find an
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| endless stream of relevant complaints together with strong loyalty.
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| Like any experienced VistA professional, I can and will criticize VistA
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| up one side and down the other for hours on end. We like it in part
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| because we know its faults, and so we try to prioritize the work most
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| important to us; when the lifecycle is healthy, if something is broken
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| it's because we think it's more important for the developers to work on
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| something else first. Those who fully engage in the VistA lifecycle
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| know VistA's flaws far more intimately than its critics, but they know
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| its strengths, too, and they can point to features in the software that
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| they personally first brought to the attention of the VistA development
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| community. In a way most software will never be, VistA really does
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| belong to its users, and they know it.
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| So when I echo other writers in saying VistA is free as in freedom, I
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| mean as in the responsibility that comes with true freedom, the
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| expectation to interact with it as an adult, taking responsibility for
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| what we need from it, and helping to chart our own future. To be blunt,
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| many people do not want that, prefer the simplicity of having limited
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| choices imposed upon them by someone more powerful, to recreate the
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| false security of childhood. Others do not mind the responsibility, but
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| cannot spare the time to learn a fully featured medical informatics
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| system, not even just the few parts of the few packages they would use
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| in their medical roles. In general, we find the truth about VistA
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| properly screens our potential clients; the right people respond well to
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| the challenge and possibilities of VistA, and enrich the community and
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| its software when they engage with us.
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| PPS: If I sound opinionated in the above, it is because experience has
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| made me so. For the first half of my career with VistA, I thought it
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| was probably nothing special, that every hospital system must have
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| something comparable. My disgust with the state of the art and
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| appreciation for VistA has accumulated over the years through a series
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| of disillusioning exposures to how most medical software works--or
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| doesn't. I do not know if there is even one feature in VistA that it
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| does better than any other system, but no other system seems to be able
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| to combine them all into such an integrated architecture driven by such
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| a potentially responsive software lifecycle. The experience of patients
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| in New Orleans in the wake of Hurricane Katrina would seem to be the
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| latest dramatic illustration. I have gradually arrived at the
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| surprising conclusion that my friends and I are working on something
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| unusually cool. Who knew?
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