Testimony Before the

Subcommittee on Healthcare and Technology

Committee on Small Business
U.S. House of Representatives

Helping Providers Adopt and Meaningfully Use

Health Information Technology
Statement of
Farzad Mostashari, M.D., Sc.M.
National Coordinator,
Office of the National Coordinator for Health IT
U.S. Department of Health and Human Services

June 2, 2011
 Good morning Chairwoman Ellmers, Ranking Member Richmond and distinguished

members of the Subcommittee. I am Farzad Mostashari, National Coordinator for Health

Information Technology at the Department of Health and Human Services. Thank you for

giving me the opportunity to appear before you today to talk about what we are doing to support

the deployment and meaningful use of electronic health records (EHRs) and other types of health

information technology (health IT), especially among small physician practices and hospitals.

I know from personal experience both the importance and challenges of using better

information to improve individual and population health. I began my career in health IT as

assistant commissioner for the New York City Department of Public Health and Mental Hygiene.

As head of the Primary Care Information Project, we reached out to primary care

practices that serve Medicaid patients, and signed agreements with over 1,700 providers in small

practices, community health centers, and hospital outpatient departments to establish electronic

health records systems. In New York City’s three most underserved communities, over 53

percent of small practices participated in this city program. In a little more than one year, more

than 1,000 providers in over 150 of these independent medical practices started live use of EHR

systems with a 99 percent implementation success rate.

The project provided critical boots on the ground to implementation, and provided post-

implementation technical assistance, around effective use of EHR to protect patient privacy, and

improve practice efficiency, safety and quality of care. Thanks to the authorities provided by

Congress in the American Recovery and Reinvestment Act of 2009 (ARRA), the Office of the

National Coordinator for HIT, was able to draw on successful elements of the Primary Care

Information Project as it developed the Regional Extension Center (REC) program. The REC

program is a nation-wide initiative that is charged with helping 100,000 providers, especially

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small and primary care practices, plan for and achieve meaningful use of EHR systems, trouble

shoot problems along the way, and sustain use of those systems over time to improve patient care

and outcomes.

My experience has been that providers in these kinds of small practices, as well as those

in smaller hospitals, are aware of the benefits of health IT, and most would like to replace their

paper-based records with a well functioning EHR system. But I also know that small practices

and hospitals face unique barriers to successfully adopting EHR systems. These providers

usually have less access to capital to spend on infrastructure improvements like health IT, and

often lack staff with IT training and don’t have the background or the time to do it themselves.

Further, they feel like it is tough to choose from among the EHR systems available in the

marketplace and they simply cannot afford to make a mistake in choosing an EHR system. And

every provider I know, including the ones in small practices, worry about losing patient trust if

the information they maintain in the EHR system does not remain private and secure.

Fortunately these barriers are not insurmountable, and ONC is committed to helping

small medical practices and hospitals overcome the challenges they face in adopting and utilizing

health IT.

The Benefits of Using Health IT

ONC’s core mission is to improve patient care, improve health outcomes, and make the

health care system more efficient through effective use of health IT.

The benefits of widespread adoption and meaningful use of health information

technology are well demonstrated. Studies have shown that health IT can have measurable

effects on patient safety, enabling better coordination of care, promoting better population health

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management, improving efficiency, reducing medication errors, and raising overall health

outcomes.

A recent article in Health Affairs looked at 154 studies examining the impact of health IT

on the practice of medicine. The article found over 92 percent of the studies reached positive

overall conclusions on the effects of health IT on key aspects of care, including efficiency of

care, effectiveness of care, and patient safety. The authors also found that providers outside of

large integrated care networks (such as Kaiser Permanente), the original innovators in health IT,

are beginning to implement, evaluate, and experience benefits from health IT previously reserved

for these early adopters. i

Health IT can also make it easier for patients to access their own health information, thus

empowering them and putting them at the center of their own care. For example, patients can

use health IT to retrieve their immunization records and other medical history, and automatically

receive lab and test results which they can use to track progress toward a specific health goal.

Health IT can also help assure that health information remains private and secure by

implementing access control, auditing and encryption capabilities that limit who can access

patient information to only those who are authorized to do so, keeping a record of who has

accessed patient information and encrypting data when not actively in use. These critical

features of HIT are difficult or near impossible to achieve in a paper-based environment.

To fully realize the potential benefits of health IT, ONC is aligning our activities with

larger initiatives within the Department of Health and Human Services (HHS) and across the

federal government. For instance, we are working to support the National Quality Strategy,

which was announced in March and represents the first effort to create national goals and

priorities to guide local, state and national efforts to improve the quality of care in the United

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States. The National Quality Strategy sets out top line priorities, which include improving care

for all Americans at the individual and community level and reduce the overall cost of health

care services. Aligning our efforts on health IT with this initiative from the beginning will make

it easier to achieve the program’s aims and makes every dollar the Department invests go farther.

In addition, ONC is working on the Partnership for Patients initiative, a new public-

private partnership involving HHS and hundreds of providers from around the country that

focuses on improving patient safety in hospitals. The core goal of the Partnership is to improve

patient safety by reducing adverse events in hospitals, and improve care transitions when patients

leave the hospital. Strategic use of health IT can help providers achieve these two goals, and

would have a tremendously beneficial effect on patients and their families.

Overcoming barriers to the adoption and use of health IT will also translate to job

creation. The Bureau of Labor Statistics projects that number of jobs for medical records and

health information technicians will grow by more than 35,000, or roughly 20 percent, from 2008

to 2018. [i] Other sources suggest that many jobs are being created among private sector firms

that install and maintain EHR systems for providers. The software and tech industries are also

adding jobs as more EHR products are developed and hardware is manufactured. Our

experience suggests that many jobs are being created among private sector firms that install and

maintain EHR systems for providers. The software and tech industries are also adding jobs as

more EHR products are developed and hardware is manufactured. Much of this job creation

seems to have happened in small businesses since 60 percent EHR products certified to date by

certification bodies authorized by ONC have been developed by companies with 50 or fewer

employees. As mentioned earlier, ONC has initiated a multi-faceted training program that is

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helping to prepare skilled health IT professionals, including curriculum development,

competency exams, and training.

ONC’s Role in Supporting the Adoption and Meaningful Use of Health IT

The important role health IT can play in improving health care quality and reducing costs

was recognized by the previous administration, when the ONC was established by Executive

Order 13335 in 2004. The order directed ONC, “to provide leadership for the development and

nationwide implementation of an interoperable health information technology infrastructure to

improve the quality and efficiency of health care…”

The Health Information Technology for Economic and Clinical Health Act (HITECH

Act), which was part of ARRA, included specific authorities for ONC. The Recovery Act

provided a direct appropriation of $2 billion to support ONC’s mission and created the Medicare

and Medicaid EHR Incentive Programs that provides direct payments to eligible doctors,

hospitals and certain other eligible professionals who adopt, implement, upgrade and

meaningfully use certified EHR technology.

ONC works with several other components of HHS in implementing provisions of the

HITECH Act. ONC has the lead role in administering various programs funded by the $2 billion

appropriation and the Center for Medicare & Medicaid Services (CMS) has the lead role in

administering the Medicare and Medicaid EHR Incentive Programs. The two agencies work in

tandem and the efforts of each directly support and complement the other. An illustrative

example of the ONC and CMS collaboration is the development of both the policy and technical

standards for meaningful use Stage 1, and the process of considering the policies and technical

standards for meaningful use Stage 2, which we are currently engaged in drafting.

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 In pursuing its work, ONC strives to remain as transparent as possible and listens to input

through a wide variety of channels. Our work is highly informed by two standing Federal

Advisory Committee Act (FACA) committees established by the HITECH Act: the HIT Policy

Committee and HIT Standards Committee. These two committees are comprised of dozens of

health IT experts from a variety of fields and backgrounds, from both government and the private

sector.

Since their inception in 2009 through May 16, 2011, these committees, their

subcommittees or working groups, have met publicly 340 times, an average of almost one

meeting every other day. What is perhaps most incredible about this statistic is that the people

who serve on these committees are not paid for their work, but nonetheless dedicate an enormous

amount of time and energy toward providing advice about how to maximize health IT’s impact

on improving care and efficiency.

I would be happy to talk in more depth about all of ONC’s activities, but in the interest of

time I will summarize our major initiatives.

The Health IT Regional Extension Program

ONC is spending $774 million to help fund a nation-wide network of 62 Regional

Extension Centers (RECs) and the Health IT Research Center (HITRC). Our regional extension

center program offers providers training, information, and technical assistance to accelerate the

adoption and meaningful use of certified EHR technology. Each REC is independent and is

usually operated by a local non-profit or consortium to meet the needs of the community and

region they serve. The particular focus of RECs is helping primary care providers, small

practices, critical access hospitals, and other undeserved or under-resourced providers achieve

meaningful use.

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 The Health IT Research Center provides technical assistance and develops best practices

for the regional centers for the implementation, adoption, and effective use of health IT.

As of May 24, the REC program has enrolled 70,481 providers, 94 percent of whom are primary

care providers and 38 percent of whom are small physician practices with fewer than 10 doctors.

While every REC is focused on helping small practices overcome barriers to adoption and

meaningful use of EHR technology, here are several noteworthy examples of what is being done

in the field:

• The Georgia and Massachusetts RECs are working with commercial banks to help

providers secure loans for hardware/software;

• The REC in Los Angeles is assisting all of the small provider practices it has enrolled

to conduct project management of the EHR implementation process and is working

directly with vendors to mitigate problems that are identified;

• The Ohio REC has developed an extensive needs assessment that proactively

identifies any potential barriers to implementing EHR systems at the start of the

process. The uses the needs assessment with the provider to address any issues

before going live;

• The Arizona REC is working closely with the Community College workforce

programs in the state to give internships to students and place them in small practices.

The Academic Program Development at community colleges focus on positions that

require three to six months of intensive training. Individuals are trained in the mobile

workforce and permanent staff positions: implementation support specialists, practice

workflow and information management redesign specialists, clinician consultants,

implementation managers, technical/software support staff, and trainers. These

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 positions that were identified as the areas where the largest numerical need exists –

approximately 41,000;

• The REC in Minnesota/North Dakota is holding a series of Meaningful Use “Boot

Camps” to educate providers, especially those in small practices, about what they

need to do to achieve meaningful use; and

• A group of REC experts in privacy and security helped to develop a privacy/security

check list that RECs are now using to assist small practice providers to protect their

EHR Systems.

The State Health Information Exchange Cooperative Agreement Program

ONC has awarded $564 million through 56 grants to all fifty states, the District of

Columbia and five U.S. territories to rapidly build the infrastructure for exchanging health

information across the health care system both within and across states. These grants are

designed to mobilize health information exchange capabilities to support providers in achieving

meaningful use, including through technology infrastructure, shared services, and standards

adoption. Many states are using the Nationwide Health Information Network (NwHIN), to

conduct simple, secure messaging of health information between providers utilizing an email-

based protocol identified under an ONC initiative. This will give all providers --- whether they

practice in rural clinics, small practices or urban hospitals --- easy-to-use health information

exchange options to enable rapid progress in meeting meaningful use requirements and

improving patient care this year. We are also working to close the gaps in health information

exchange capabilities by developing strategies to make sure every eligible provider has at least

one option for exchanging health information that meets the requirements of the Medicare and

Medicaid EHR incentive programs.

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The Health IT Workforce Development Program

ONC is providing $118 million to four different programs to train the health IT

workforce of the future. Due to the rapidly increasing demand for health IT products and

services, it is projected there will be a shortfall of 51,000 health IT workers over the next four

years, which creates job opportunities for well trained workers. Small physician practices,

clinics and hospitals are among the groups most adversely affected by this shortfall, since they

usually have few if any IT workers on staff and can find it difficult to hire knowledgeable

workers to install and support their health IT systems. ONC has worked to address this situation

by funding education programs at 82 community colleges across the country where training can

be completed in six months or less, accompanied with help with job placement, as well as

providing support for nine university-based programs that provide training at the post-

baccalaureate and master’s level. ONC is also providing funding to, Oregon Health & Science

University, University of Alabama at Birmingham, Johns Hopkins University, Columbia

University and Duke University, to develop high quality instructional materials to support

training of the health IT workforce. Developed initially for use by our funded community

colleges, these materials will soon be made available to all institutions of higher education that

wish to establish health IT programs.

So far, over 2,400 students are expected to have graduated from the community college

training programs by the end of May, and another 4,700 are currently enrolled and receiving

training. The graduates produced by these programs represent a down payment on ONC’s

commitment to close the workforce gap and help ensure that providers and others have access to

a well-trained workforce.

The Beacon Community Cooperative Agreement Program

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 ONC has awarded $265 million in grant funding to 17 Beacon Communities throughout

the United Sates, ranging from Maine to Hawaii. The program goals include building and

strengthening a health information technology infrastructure; improving health outcomes, care

quality, and cost efficiencies; and spearheading innovations to achieve better health and health

care. In the first year of the program, the Beacon Communities established foundational

structures and partnerships in governance, clinical transformation, health IT, and measurement

tools. Now, they are implementing IT-enabled clinical interventions and public engagement

tools to improve health and health care. Beacon Communities are increasingly disseminating

key implementation insights with others in the country developing regional approaches to

transform the health care system, one community at a time.

Amongst several other interventions, the Southern Piedmont Beacon Community in

North Carolina is using IT systems that support care managers working with individuals with

chronic conditions, thus reducing unnecessary emergency department visits and avoidable

expenses. The Crescent City Beacon Community in the New Orleans area is optimizing clinical

decision support tools and improving processes in the community clinic and hospital settings,

especially around diabetes care.

Certifying EHR Systems, Coordinating Federal Health IT Activities, and

Protecting Privacy & Security

In addition to funding these important grant programs, ONC also supports other

initiatives to facilitate the nationwide adoption and use of health IT.

ONC is at the center of federal efforts to establish standards for EHR systems and let

providers and the public know which EHR systems are meeting these standards. In close

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conjunction with our two Federal Advisory Committees, ONC identified standards to enable

secure health information exchange, or when those standards did not exist for health care,

convened industry organizations, consumer groups, federal agencies, and other stakeholders to

develop new standards.

These standards form the basis of the program and processes for testing and certifying

EHR systems. We currently have six authorized private-sector certification bodies which have

certified more than 735 separate EHR products. Of these certified EHR products, 60 percent

have been developed by small businesses with 50 or fewer employees, and 87 percent of these

businesses have less than 200 employees. This incredible statistic validates ONC’s approach to

encouraging the adoption of health IT: set out some basic rules for everyone to follow, level the

playing field, provide incentives where more progress is needed, and step out of the way to let

the market do the rest. This approach is leading to the development of innovative EHR products

that are easier for small practices to implement and less expensive than ever before.

As part of the effort to promote electronic information exchange and interoperability and

to add functionality to the NwHIN, ONC used its platform to initiate the Direct Project.

Launched in March 2010, the Direct Project was charged with arriving at standards to support

the secure exchange of clinical health information between providers using a simple, email-based

approach. The Direct Project used a unique approach that invited the greater health IT

community to identify, develop and select a standard that met their needs. Within 10 months, the

groups working on the project had demonstrated the success of this email-based approach to

information exchange, and 12 months later more than 60 HIT vendors committed to

incorporating the Direct Project’s standards for health information exchange. Providers may use

the Direct Project’s transport standards to meet the Stage 1 meaningful use incentive payment

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program requirement for exchange of clinical information. For instance, a primary care

physician can use these standards to transmit a clinical summary of a patient to a specialist and

receive a summary of the consultation.

The innovative approach to arriving at the standards used by the Direct Project will

continue to evolve as we bring the health IT community together to expand the functionality of

the NwHIN and modernize the way health information is exchanged. For instance, this way of

leveraging skills across the health IT landscape is now being used to identify standards to

support better ways of providing laboratory information to providers, and arrive at a standardized

way of exchanging key clinical information when patients transition out of a hospital stay.

ONC is also charged with coordinating health information technology activities

throughout the Department of Health and Human Services, as well the rest of the federal

government. In carrying out this mission, ONC chairs or serves on numerous committees,

coordinating councils, working groups, and task forces.

One of these groups is the Federal Health Information Technology Task Force, which

ONC co-chairs with the Office of Management and Budget, and involves numerous other federal

agencies, including CMS, Department of Veterans Affairs, Social Security Administration,

Department of Defense, Department of Commerce, Department of Agriculture, and the Office of

Personnel Management. The overall goal of the Task Force is to promote communication and

information sharing between different federal agencies who are each involved with health IT

while adhering to high standard of privacy and security. Through this forum, agencies that might

not otherwise be communicating or interacting with one another have the opportunity to learn

from what others are doing, align toward common policy goals, and reduce potential overlap and

redundancy.

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 Another important activity we are engaged in is ensuring that health information remains

safe and secure when it is in digital form. Leading this effort at ONC is the Chief Privacy

Officer, a position that was created by the HITECH Act. ONC’s Chief Privacy Officer works in

partnership with other divisions in HHS, as well as other agencies throughout the federal

government to coordinate efforts to protect privacy and security of electronic health care

information. We work especially closely with the Office for Civil Rights, which is the entity

within HHS that is responsible for enforcing the protected health information privacy,

transactional, and security rules established under the Health Insurance Portability and

Accountability Act (HIPAA).

ONC has taken a number of important steps toward making electronic health records

private and secure. Last July, ONC issued its standards and certification final rule, which

specifies that in order for an EHR to be certified, it must be capable of encrypting electronic

health information. We are analyzing breach notifications reported to the Secretary pursuant to

the HITECH Act, have identified security vulnerabilities and are taking affirmative steps to

address them. For example, ONC is working with the National Institute of Standards and

Technology to explore the technical means of building more security into EHRs to make

protecting information as seamless and easy as possible for providers. And lead by the

University of Illinois at Urbana-Champagne, ONC’s Strategic Health IT Advanced Research

Program is developing innovative technologies and policies to reduce privacy and security risks

to electronic health information.

In addition, a core part of Stage 1 of the meaningful use incentive program is a

requirement that providers conduct a security risk analysis of their EHR system, implement

security updates and correct identified security deficiencies as part of its risk management

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process. As ONC and CMS look ahead to requirements for Stage 2 and Stage 3 of meaningful

use, we are working closely with the HIT Policy Committee, States, a number of healthcare

associations, healthcare providers, consumer advocates, and other representatives of the health IT

industry to explore additional requirements that will ensure adequate privacy and security

protections for protected health information, or PHI.

We are also in the process of revising ONC’s 2008 National Privacy and Security

Framework. Our aim is to create a framework where patients and providers are assured every

appropriate step is taken to protect patient information, while permitting data to flow easily

enough to effectively coordinate care and support quality improvement efforts. To this end, we

have established a process for obtaining and reviewing recommendations on priority privacy and

security issues from our HIT Policy Committee with the goal of resolving these key issues by the

end of the year.

ONC has also built privacy and security into all of its programmatic efforts, from

providing technical assistance to Regional Extension Centers and State Health Information

Exchange fund recipients, to reviewing curriculum for new HIT training to ensure that the future

generation of technical workers is well grounded in privacy and security.

Health IT Implementation

A necessary first step in realizing the full potential of health IT is to help providers to

adopt and meaningfully use certified EHR technology. The concept of meaningful use is central

to the health IT provisions that were included in the HITECH Act. ONC and CMS have worked

closely over the last two years to develop and implement the Medicare and Medicaid EHR

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incentives program. My colleague from CMS will talk about the meaningful use program in

more detail.

The HITECH Act recognizes that if all we do is put an EHR in every provider’s office or

hospital, we will have failed to realize health IT’s full potential. Instead, doctors, hospitals, and

other providers need to use robust EHR technology in a meaningful and interoperable way to

improve care.

The Medicare and Medicaid EHR Incentive Programs are premised on the fact that even

though electronic health record systems have been shown to enable better patient care, better

overall outcomes, and can make care much more efficient, adoption of robust EHR systems have

been persistently low. As recently as 2008, 12 percent of hospitals and just 17 percent of office-

based primary care physicians reported using a basic EHR system. ii Since the passage of

HITECH, we have started to see those figures rise dramatically. Last year, 19 percent of

hospitals and 30 percent of primary care doctors – more than a 50 percent increase in two years –

reported using a “basic” EHR. iii By these measures, we are approaching a tipping point where

EHR systems become commonplace and the entire health IT marketplace becomes truly self-

sustaining.

The Medicare and Medicaid EHR Incentive Programs are designed to stimulate adoption

and use of EHR, but I must emphasize this program is not about technology for its own sake. It

is about getting providers and hospitals to use electronic health systems as a tool to help bring

about transformational improvement of the health care system. This is where health IT becomes

part of a “virtuous cycle” to improve care, which in turn leads to more innovation and

development.

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 There are plenty of ideas about how to improve the way care is delivered, including

disease registries, accountable care organizations, patient-centered medical homes, bundled

payments, and decision support tools. But I would maintain that an absolutely essential

component to making any of these strategies work effectively is they must be supported by the

robust use of health IT.

ONC’s Strategic Plan for the Future

Through the implementation of the Affordable Care Act, the next several years will be

pivotal for the future of our health care system and ONC is committed to doing everything we

can to ensure that health IT supports the fundamental goals of better care, improved health, and

reducing the cost of care.

ONC recently laid out a vision for the future in our draft Federal Health IT Strategic Plan

for 2011-2015 and is in the process of analyzing and addressing public comment on it. As

outlined by the Federal Health IT Strategic Plan, ONC has identified six underlying principles

that will guild our ongoing work to unlock the vast promise and potential of electronic health

information to transform, modernize and improve the way care is delivered. We are committed

to putting patients at the center of everything we do by enabling patients to get access to their

own health information, participate effectively in their own care, and by making sure sensitive

information health remains private and secure.

• We will remain open and transparent, listening to input and advice from a wide variety of

voices.

• We will rededicate ourselves to excellence in implementation, selecting ambitious but

achievable goals, learning from experience, and adjusting as we go.

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 • We will continue to address the unique challenges faced by those with fewer resources,

such as small practices and community access hospitals.

• We will continue to work hard to foster innovation by finding the right balance between

standards that make health IT’s benefits possible, while preserving potential for new,

sustainable approaches.

• And we will keep our eyes on the goal of promoting use of health IT as a tool to help

deliver better, safer, more efficient care, not as an end in itself, but to improve patient

health.

Conclusion

Health information technology is a critical part of the foundation that supports efforts to

modernize and transform our health care system. Now is the time to get down to the hard work

of implementing and using health IT in a way that leads to better, less expensive care, and I am

proud of the role ONC plays in achieving that goal. Thank you for giving me the opportunity to

appear before you today. I look forward to continuing to work together and answering any

questions you may have.

i
Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the
recent literature shows predominantly positive results. Health Affairs (Millwood). 2011 Mar;30(3):464-71.

Bureau of Labor Statistics. Occupational Outlook Handbook, 2010-2011 Edition. Medical Records and Health
[i]

Information Technicians. Available online at: http://www.bls.gov/oco/ocos103.htm (accessed 26 may 2011).

ii
The US Department of Health and Human Services, Office of the National Coordinator for Health Information
Technology. Fiscal Year 2012 President’s Budget Request to Congressional Appropriations Committees, Online
Performance Appendix, FY 2010 Performance Report, FY 2012 Performance Plan. Available online at:
http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11673_953471_0_0_18/Online-Performance-
Appendix-021411.pdf (accessed 23 May 2011).
iii
Ibid.

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