Telehealth in the US for patients with end-stage kidney disease: its utilization and impact on social, economic and health outcomes

Introduction

Background

Centers for Medicare and Medicaid Services (CMS) administers Medicare, the largest healthcare insurance coverage in the United States (US), and works with states to regulate Medicaid, thereby having a major influence on telehealth activity (1). While most major regulatory changes require a statutory change by Congress, CMS can adjust within existing regulatory frameworks.

On October 30, 1972, the United States Congress passed legislation authorizing the end-stage renal disease program (ESRD) under Medicare. Section 299I of Public Law 92-603 extended Medicare coverage to Americans if they had stage five chronic kidney disease (CKD) and were otherwise qualified under Medicare’s work history requirements regardless of age (2).

Rationale and knowledge gap

The history of telehealth in the US can be understood by tracking its activity before, during, and after the coronavirus disease of 2019 (COVID-19) pandemic public health emergency (PHE).

Objective

This report will focus on telehealth for end-stage kidney disease (ESKD) patients and review the potential impacts of telehealth on users (patients, clinicians, and staff), health, and economic outcomes in kidney disease care. This review will be informative for patients, practitioners, providers, and industry by providing ESKD telehealth operational and regulatory frameworks in the US. Table 1 provides definitions for terms used in telehealth.

Global telehealth experiences

Early global experiences in ESKD telehealth

We will first review global experiences in patients with ESKD to provide a comparative perspective to US experiences. Clinicians explored telehealth by using technology to support dialysis therapies as early as 2000 (3-5). In the peritoneal dialysis (PD) space, Nakamoto et al. in Japan showed reduced visits to the outpatient clinic and demonstrated successful real-time data collection by using automated PD cyclers and cellular telephone-based platforms to remotely monitor cycler data and patient biometric data (5,6). While in Spain, Gallar et al. showed shorter tele-consultation time and lower mean hospitalization rates, albeit at a slightly higher cost when using alternate-month telemedicine and hospital consultations (4). In Italy and Spain, installation of Integrated Service Data Networks lines, modems, microphones, and cameras allowed two-way communication (3,7). In India, Nayak et al. used technology for remote patient monitoring in rural areas and educational support (8,9). In Germany, telecare improved the quality of life for patients on PD (10).

In the in-center hemodialysis space, remote patient monitoring and/or video conferencing were performed between a central or University hospital and satellite dialysis units in Canada (11-14) and Norway (15), which allowed hemodialysis to occur in rural areas that could not support a full-time nephrologist.

Later global experiences in ESKD telehealth

Further advances in technology resulted in expanding telehealth in the late 2010s, and it has accelerated since 2020. The global penetration of telehealth in home dialysis depends on the country’s health insurance coverage and legal framework, as seen in the European Union (16). International telehealth experiences outpaced US experiences in telemedicine.

In Italy, video dialysis (VD) was used initially to prevent dropout in prevalent PD patients by guiding them in performing dialysis (VD-Caregiver). Later VD was extended to the clinical follow-up of critical patients (VD-Clinical), problems relating to transportation to the center (VD-Transport), and training or retraining of patients (VD-Training) (17-19). These VD efforts resulted in a flexible, effective, safe, and valued tool that can be used to recruit and maintain patients on home PD modalities (19).

Telehealth in the US

Pre-COVID-19 pandemic public health

Early barriers to telehealth

In the US, CMS defines an originating site as the location where a patient receives physician or practitioner services through telehealth (20). Prior to 2019, the originating site for patients receiving home dialysis was restricted to certain geographic locations and clinical settings (see Figure 1). Medicare beneficiaries receiving home dialysis were eligible for telehealth services only if these services were furnished from either an originating site located in a county outside of a metropolitan statistical area or in a rural health professional shortage area located in a rural census tract. Moreover, the originating sites were limited to rural health clinics, federally qualified health centers, the offices of physicians or practitioners, hospitals and critical access hospitals (CAHs), hospital-based or CAH-based renal dialysis centers, skilled nursing facilities, and community mental health centers. Specifically noted was that non-hospital-based dialysis facilities and the patient’s home were not eligible originating sites (20).

Figure 1 US telehealth timeline according to CMS regulations, with an emphasis on the end-stage kidney disease population. Telehealth timeline with a focus on the end-stage kidney disease population, delineating originating and distant sites, geographic restriction and HIPAA compliant platform requirements. CAH, critical access hospitals; CMS, Centers for Medicare and Medicaid Services; FQHC, federally qualified health centers; HIPAA, Health Insurance Portability and Accountability Act; PHE, public health emergency; TBD, to be determined; US, United States.

A distant site refers to the location from which a physician or practitioner provides telehealth services (20). Distant site practitioners are defined as providers who furnish and receive payment for covered telehealth services. These practitioners are limited to physicians, nurse practitioners, physician assistants, clinical nurse specialists, clinical psychologists, social workers, registered dietitians or nutrition professionals, nurse midwives, and certified registered nurse anesthetists (20). The practitioners’ location was limited to their office or hospital, places where medical practice was conducted.

As a condition of payment, telehealth services require the use of interactive audio and video telecommunication technology that allows real-time communication between the practitioner at the distant site and the beneficiary at the originating site. Due to these strict regulations, although there may have been interest in telehealth there was little activity in the US.

Early US experiences

Telehealth was assessed for feasibility and efficacy in populations not covered or restricted by CMS regulations

(I) CKD

A few studies were conducted in special US populations with CKD to assess feasibility and efficacy (21-23). Ishani et al. randomized patients with CKD from a few Veterans Affair Health Care Systems in Minnesota to telehealth and interprofessional care management vs. to usual care. They found that telehealth was feasible and that there was no statistically significant difference between the telehealth-based intervention and usual care on composite health outcomes of death, hospitalization, emergency department visits, or admission to skilled nursing facilities (21). Ladino et al. performed a retrospective study to evaluate the effect of telehealth in veterans in the Miami Veterans Affairs Healthcare System between 2013 and 2015 and found an improvement in blood pressure readings and stabilization of kidney function in patients with CKD residing in underserved areas (22). Narva et al. delivered telehealth effectively and efficiently to rural high-risk communities using a collaborative and integrated model of care with the distant site consisting of a nephrologist based at the National Institutes of Health in Bethesda, Maryland to the originating site at the Zuni Comprehensive Health Center in western New Mexico over a 9-year period (23). Despite barriers and challenges, this model implemented nephrology care that otherwise would not be easily accessible, not as a clinical research trial, but as a demonstration that telemedicine can be a durable approach to deliver nephrology consultation to a high-risk rural population over an extended period of time.

(II) Remote monitoring

Additionally, in the US, there was interest in and use of remote monitoring of home dialysis therapies to collect data in real-time and to improve oversight and care. We provide examples from PD and home hemodialysis (HHD).

Chand and Bednarz used a home dialysis modem connected to the home telephone line to allow PD treatment data from a cycler to be transmitted daily to the dialysis unit, uploaded to the patient’s electronic medical record and reviewed by the patient’s PD nurse and/or pediatric nephrologist and adjustments were made accordingly (24).

PD cyclers from two major manufacturers with global presence (Baxter in Deerfield Illinois, and Fresenius Medical Care in Waltham Massachusetts) support remote patient monitoring for PD in the US (25). Perceived and realized benefits of remote patient monitoring in PD, described in studies conducted in US, Italy, Colombia, Turkey, and China include (I) improved clinical outcomes (26-33); (II) improved treatment adherence (29); (III) improved blood pressure control (34); (IV) improved patient quality of life due to more PD-free time, and remaining in contact with health care providers (27,29,31,35,36); (V) a more cost-effective treatment due to a reduction in emergency department visits, hospitalization rate and hospital length of stay (26,27,29,30,31,33,37,38); and (VI) decreased technique failure (28,30).

Similarly, benefits were noted in remote patient monitoring undergoing HHD. Patients using Nx2me Connected Health, a telehealth platform that enables ongoing assessment of HHD, experienced a lower risk of all-cause attrition, lower risk of technique failure, and higher likelihood of HHD training graduation (39).

(III) Pediatric population

Clinicians have used advances in technology to collect data in real-time, improve communication, and provide better oversight and care to patients in the US on home dialysis therapies in pediatrics as reported in 2017. Using an iPad for video-conferencing in a pediatric population on PD resulted in fewer cancelled appointments, allowed other caregivers to participate in video conferencing, reduced the cost of travel and time for family members to accompany their child to the clinic, and decreased school and work absences for patients and their families (40).

Telehealth used in populations covered by CMS

(I) Advocates for telehealth

Advocates tried to break down the barriers to telehealth by citing its virtues of increasing access to care, improving quality of life, decreasing hospitalization rate, decreasing emergency department visits, obtaining biometric data in real-time and reducing the cost of care (31-41). Notably, organizations and industry also advocated for changes. The American Society of Nephrology and the US Food and Drug Administration (FDA) established a public-private partnership, Kidney Health Initiative (KHI) in 2012, to advance scientific understanding of kidney health and to foster the development of therapies for kidney disease (42). The KHI convened a multidisciplinary workgroup in 2015 to increase the acceptance of home dialysis and improve outcomes and patient satisfaction while potentially decreasing costs. The workgroup identified barriers imposed by payer and government (federal and state) regulation with telehealth procedures, obtained the viewpoints of the various stakeholders in this process (patients, caregivers, clinicians, payers, dialysis organizations, and government regulators) and outlined potential benefits that telehealth may provide (43). Advocates highlighted how remote therapy management, provided by advances in PD cyclers technology, collected medical information and transmitted it to healthcare providers for patient management (44).

In a Center for Medicare and Medicaid Innovation demonstration project to advance remote monitoring, daily remote biometric monitoring of weight among PD patients was associated with fewer hospitalization events, fewer days of hospitalization, while monitoring of blood pressure was associated with increased days of hospitalization and increased odds of hospitalization. The overall visit claim payment amounts increased slightly in the outpatient setting and decreased in the inpatient setting, resulting in no significant difference in the overall cost of care (37).

From the patient perspective, patients had heard of telemedicine and were prepared to use it when surveyed from a PD clinic, and both in-center and HHD settings (45,46). The majority of patients knew how to access the internet and had access to a smartphone.

(II) CMS coverage for home dialysis—a major breakthrough in regulation

Congress approved the Bipartisan Budget Act of 2018, which contains key elements of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, expanding telehealth to home dialysis patients (47). Several key features based on statute within HR 1892—Bipartisan Budget Act of 2018, Sec 50302 should be noted. For the first time, telehealth could be conducted from the patient’s home or dialysis facilities as an originating site and without geographic restrictions. Therefore, starting January 1, 2019, ESKD patients receiving HHD or PD could be eligible for telemedicine encounters. The approved distant site practitioners (i.e., physicians, nurse practitioners, physician assistants, clinical social workers and registered dietitians) and locations remained the same as under CMS regulations. There were, however, some additional stipulations (see Figure 1).

• Home dialysis patients must receive face-to-face assessments monthly for the first three months of home dialysis and at least once every 3 months thereafter.
• The patient must be the one to choose the telemedicine modality.
• A facility fee cannot be charged if the patient’s home is the site of the visit.
• The telehealth encounter requires an interactive, two-way HIPAA-compliant, communication, using a real-time audio and video connection between the clinician at a distant site and the patient at the originating site.

Many patients were not aware of the Bipartisan Act (48). As stipulated by the statute, the patient chooses a telemedicine encounter, not the clinician. It is obvious that patients who are unaware of the legislation will not ask for a telemedicine visit. The burden of educating the ESKD home dialysis population of this legislation fell on the interdisciplinary team. For these reasons, the adoption of telemedicine was sluggish at the beginning. Yet, both patients and healthcare providers regarded this regulation as a major breakthrough for patient’s quality of life and convenience.

(III) Challenges to telehealth in home dialysis remained

After the passage of the Bipartisan Budget Act of 2018, supporters developed guidance on how to operationalize telemedicine for home dialysis patients. Supporters highlighted telehealth’s potential to increase home dialysis penetration, decrease transportation cost and time to the dialysis unit, improve staff supervision of biometric remote monitoring data, and provide better access to health care providers (49,50). Yet challenges in adopting telemedicine included access to reliable internet services and devices, inability to perform a hands-on physical examination by the clinician, and changes in staff workflow and facilities’ inability to collect the facility fee (49,50). The staff must devise a feasible plan for patients to obtain monthly lab work and receive injectables. The staff also needed to devote adequate time to review data obtained from remote patient monitoring to observe for any deviations or unhealthy patterns (49,51).

The challenges contribute to health disparities and highlight the impact that digital literacy, internet access, and geography have on health outcomes. However, advocates point out the potential economic impact of telemedicine via reduced hospitalization rates and emergency department visits, decreased length of hospital stay, and home dialysis growth (52).

Prior to deploying telehealth, the dialysis unit has to build an infrastructure to operationalize telehealth to meet additional requirements (49). Both the originating and distant sites need access to the internet with appropriate bandwidth to accommodate transferring the volume of information per unit of time. Both parties need appropriate devices such as cell phones, tablets, or computers. Software and hardware have to comply with Health Insurance Portability and Accountability Act (HIPAA) requirements. Certain technologies require FDA clearance. In addition, the clinician needs to be licensed in the state of the originating site and, in some cases, the state of the distant site as well.

During the COVID-19 pandemic PHE

PHE waivers

Due to the impact of the COVID-19 pandemic, a PHE was declared in the US on January 31, 2020. CMS subsequently used its emergency waiver and other regulatory authorities to allow providers a way to deliver more services to patients via telehealth (53,54).

Many telehealth regulations were relaxed under waivers from CMS. The patient’s home and the dialysis unit were considered approved originating sites (see Figure 1). The clinician’s home was considered an approved distant site. Physicians could provide telehealth services to new and established Medicare patients. Patients were required to provide consent for telehealth services. Clinicians were reimbursed for both audio-only and audio-video conferencing encounters. However, the ESKD monthly capitation payment (MCP) for outpatient dialysis services still required an audio-video conferencing encounter. Non-HIPAA compliant platforms were temporarily permitted. Additionally, some states recognized out-of-state licenses for clinicians with an active state license to practice medicine.

The federal government increased funding for telehealth initiatives by passing the Coronavirus Aid, Relief, and Economic Security (CARES) Act ($2 trillion), which included $200 million for the Federal Communications Commission to expand telehealth services across the country (55). Specifically, health care providers can apply these funds toward medical devices and telecommunications equipment to enable remote care as part of the COVID-19 Telehealth Program (55). Additionally, the Universal Service Fund, administered by the Federal Communications Commission, provided $100 million to subsidize internet connectivity for health care providers (56). These funds helped recognize a role for telehealth in response to the short-term pandemic as well as long-term provision of health care in the United States. The PHE waivers literally opened the floodgates for telemedicine for ESKD patients.

Clinical experiences and outcomes

During the COVID-19 pandemic, home dialysis was encouraged to support social distancing (51,57,58). Home dialysis among incident patients achieved the highest penetration in 2021 at 13.4% compared to 2020 with 13.2% and 2011 with 7.5% (59). Similarly, home dialysis among prevalent patients increased from 13.7% in 2020 to 14.1% in 2021, compared to 9.7% in 2011 (59).

Early use of telehealth in home dialysis occurred in New York City, the epicenter of the COVID-19 pandemic in the US (60,61). The COVID-19 pandemic PHE waivers that relaxed telehealth regulations spurred the use of telehealth in dialysis for both in-home and in-center patients as the need was present. Stakeholders had the desire to conduct virtual encounters, and they had access to the internet and devices (62,63).

Pediatricians also supported the adoption of telehealth services during COVID-19 pandemic. In 175 completed surveys from providers and caregivers from 27 out of 53 Standardizing Care to Improve Outcomes in Pediatric ESKD Collaborative centers, reported benefits of telehealth included no travel, visits take less time, easier to care for other children, more comfortable for patient, and no time off from work. However, provider challenges were the inadequate/lack of physical exam, inability to visit with the patient/family in person, and inadequate/lack of PD catheter exit site examination (64). In particular, evaluation of pediatric patients’ physical, mental, and sexual growth to mark milestones is challenging during virtual visits.

For the first time, telemedicine was conducted with the in-center dialysis unit as the originating site. Generally, a dialysis unit staff member (i.e., dietitian, social worker, nurse, or technician) became the clinical presenter. The clinical presenter would establish an audio-video conference on a desired platform with the clinician using common devices such as smartphones, tablets, or laptop computers. The clinician could obtain hemodialysis treatment data in real time from the patient’s electronic health record. The clinician would document patient findings with remote access to the electronic medical record.

Two publications obtained the patient’s perspective on telemedicine encounters during the COVID-19 pandemic while receiving in-center hemodialysis (65,66). In one study, the surveyed patients reported a positive experience (ranking 8 out of 10 on a Likert scale where 10 was extremely satisfied) (65). Specifically, 90% of the respondents reported spending enough time with their physician during the virtual visit. Despite the close proximity to the next dialysis patient and a staff member and the use of the dialysis unit’s internet service, patients did not have major concerns regarding internet security (85%) or privacy (85%). Since the dialysis unit staff members arranged for the video-conferencing visit, patients did not commonly encounter technical issues (92%) and they all had access to the internet and devices irrespective of social determinants of health or technology literacy. Most patients felt that the lack of a physical examination didn’t hamper the clinician’s ability to treat them (65%) (65). In the second publication, the investigators conducted semi-structured interviews with 32 patients from underserved populations (i.e., older, less educated, unemployed, persons of color) who received in-center hemodialysis and used telemedicine with their nephrologist during the COVID-19 pandemic PHE (66). The following common themes were reported by the interviewees: (I) the patients adapted to telemedicine with familiarity and confidence over time, overcoming and resolving technical difficulties, and relying on staff for communication; (II) the patients acknowledged that the physicians were more available, especially responding immediately to urgent medical needs; (III) the patients experienced peace of mind as the virtual visits addressed their needs adequately; (IV) the patients felt safe against infections by limiting COVID-19 exposures; (V) the patients reported strained communication and physical interactions, namely that they were unable to reapproach physicians about a forgotten issue or lack of a physical examination; and (VI) patients reported that privacy was maintained (66). The patient perspective was overall positive but clearly leaves opportunities for innovation and improvement.

Based on US Medicare claims data between March 1, 2020 and June 30, 2021, US Medicare beneficiaries receiving in-center hemodialysis experienced a peak in reported telemedicine use (9% of patient-months) in April 2020 and declined to 2% of patient-months by June 2021 (67). Telemedicine use varied geographically, with increased use in areas that were remote and socioeconomically disadvantaged. Telemedicine was also used in areas with higher incidence of COVID-19. Telemedicine use was more likely in a facility with more staff and varied by facility ownership type (67). The authors highlighted several limitations to analyzing claims data to assess telemedicine usage. For example, although the claim was coded for a telemedicine visit, the actual number of visits that were conducted virtually in that particular month remains unknown (i.e., 1, 2, 3, or more). The proper use of a telemedicine code depends on the physician’s knowledge, and its application by the person entering the billing code represents another possible limitation.

During the COVID-19 pandemic, clinicians needed to practice social distancing to protect themselves and their dialysis patients from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure since their main care-burden was hospitalized patients with COVID. Since clinicians using telehealth didn’t need to travel to the dialysis unit to see their patients, they saved travel time and costs. Telehealth has always limited clinicians’ ability to perform a physical examination; however, since the dialysis unit cares for patients with repeated visits, it could be cost-effective for the dialysis unit to invest in a digital stethoscope to allow clinicians the ability to listen to the chest, abdomen and arterio-venous access. In this fashion, medical issues can be resolved as an outpatient rather than referring the patient to the emergency department or admitting them to the hospital. In this case, the dialysis unit would lose revenue from missed treatments.

Remote patient monitoring continues to play an active role in home dialysis as a means to providing better patient oversight and to document home therapy. Among providers surveyed in the US and Canada, 91% of those that responded reported having access to a remote monitoring platform, while only 31% reported having a standardized protocol for data monitoring. Nurses reported reviewing the data multiple times per week, while physicians reported viewing the data only during regular/monthly visits (68).

Limitations

The literature on telehealth usage and outcomes has been based on observational data. As such, selection and practice biases are introduced. To understand the impact of telehealth on patients with kidney disease, a randomized, double-blinded, placebo-controlled study will need to be conducted to determine efficacy, hospitalization and emergency department visit rates, hospital length of stay, and cost savings.

In addition, the quality of the video-conferencing encounters has not been described or studied. Quality is not limited to the fidelity and latency of the sound and image, but should include whether the clinician gains enough information to provide care and the patient receives appropriate care.

Telehealth has been advocated to support home dialysis growth. A large part of telehealth for home dialysis patients includes remote monitoring. At present, there are limited data on how to systematically assess the large volume of data that staff members and clinicians may receive. However, new advances in artificial intelligence may allow for more effective and efficient monitoring of enormous amounts of data to alert clinicians to deviations from set parameters.

Post COVID-19 pandemic PHE

Although the COVID-19 PHE in the US ended on May 11, 2023, certain telemedicine waivers and exceptions were extended to December 31, 2024 (69). Specifically related to patients with kidney disease, this section allows beneficiaries to continue to receive telehealth services at any originating site, regardless of type (e.g., the beneficiary’s home or dialysis unit) or geographic location. Additionally, the section provides funds for FY2023 for CMS to conduct a study on program integrity relating to all Medicare telehealth services, including the effects of telehealth utilization.

At the time of this writing, a bill that would extend Medicare telehealth flexibilities awaits approval from Congress in late 2024 (70). The legislation would extend a number of Medicare flexibilities like removing geographic restrictions, expanding which providers can offer virtual services and allowing for audio-only telehealth care through the end of 2026 (70). Advancements in telehealth and remote patient monitoring (RPM) technologies would allow patients to receive care and transmit health information to their doctors from home. A Congressional report in 2024 showed that 25% of adults utilized telehealth, while 91% of patients utilizing telehealth had a favorable experience and 78% were likely to complete a medical appointment via telehealth again (71).

Although several federal laws have been introduced to make aspects of telehealth waivers permanent, the fate of telehealth with the hemodialysis unit as an originating site after December 31, 2024 remains unaddressed (72,73). This uncertainty challenges healthcare providers and industry to make investments in improving telehealth, enabling workflows and technologies.

Conclusions

Over the last decade, US telemedicine experiences started as experiments in populations who were not CMS beneficiaries. Advocates for telemedicine rallied for legislative changes. The Bipartisan Budget Act of 2018 opened an opportunity for home dialysis patients to receive telemedicine encounters with home as the originating site after an initial three-monthly visits to establish care, then one in-person visit per quarter. This legislation was considered by many as a major breakthrough for ESKD patients. The PHE waivers in response to the COVID-19 pandemic relaxed many CMS regulations that had stifled telehealth in the US. For the first time, home and the dialysis unit were originating sites and without geographic restrictions. The PHE telehealth waivers helped to reduce the impact of SARS-CoV-2 infection on ESKD patients. Telehealth was proven feasible at a larger scale. Evaluation of its usage, patient satisfaction, and outcomes have shown benefits and challenges using observational methods. The infrastructure for telehealth remains in place, but health care providers will not make further investments in virtual care unless Congress permanently extends telehealth benefits. Only then will it be possible to conduct additional studies to evaluate long term safety, efficacy, and cost savings from telehealth in patients with kidney disease.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-61/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-61/coif). S.Q.L. is the member of American Society of Nephrology Quality Committee and of Medical Review Board of Quality Insights related to end-stage kidney disease. N.S. received grants from Qualcomm Wireless Reach and Johns Hopkins University/Sibley for Digital Literacy Coaching, and royalty from Oxford University Press for book edited, Practical Guide to Emergency Telehealth. K.F.E. reports receiving grant from NIH, personal fees for consulting and advisory services with Acumen LLC, Outset Medical, and Fresenius Medical Care, and honorarium from Dialysis Clinic, Inc. K.F.E. has a leadership role for American Society of Nephrology Quality Committee. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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