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TYPE Mini Review

PUBLISHED 28 September 2023
DOI 10.3389/fdgth.2023.1203945

Current challenges and potential

solutions to the use of digital
EDITED BY
Lisette van Gemert-Pijnen,
University of Twente, Netherlands
health technologies in evidence
REVIEWED BY
Khizra Sultana,
generation: a narrative review
King Abdullah International Medical Research
Center (KAIMRC), Saudi Arabia Hassan Mumtaz1 , Muhammad Hamza Riaz2, Hanan Wajid3,
*CORRESPONDENCE Muhammad Saqib4*, Muhammad Hamayl Zeeshan5,
Muhammad Saqib
[email protected]
Shaheer Ellahi Khan1, Yesha Rajendrabhai Chauhan6,
RECEIVED 11 April 2023 Hassan Sohail5 and Laiba Iman Vohra7
ACCEPTED 12 September 2023 1
Department of Public Health, Health Services Academy, Islamabad, Pakistan, 2Department of Internal
PUBLISHED 28 September 2023 Medicine, Allama Iqbal Medical College, Lahore, Pakistan, 3Department of Internal Medicine, Shalamar
CITATION
Medical & Dental College, Lahore, Pakistan, 4Department of Internal Medicine, Khyber Medical College,
Peshawar, Pakistan, 5Department of Internal Medicine, Dow University of Health Sciences, Karachi,
Mumtaz H, Riaz MH, Wajid H, Saqib M,
Pakistan, 6Department of Internal Medicine, Baroda Medical College, Gujrat, India, 7Department of
Zeeshan MH, Khan SE, Chauhan YR, Sohail H
Medicine, Ziauddin University, Karachi, Pakistan
and Vohra LI (2023) Current challenges and
potential solutions to the use of digital health
technologies in evidence generation: a Digital health is a field that aims to improve patient care through the use of
narrative review. technology, such as telemedicine, mobile health, electronic health records, and
Front. Digit. Health 5:1203945.
artificial intelligence. The aim of this review is to examine the challenges and
doi: 10.3389/fdgth.2023.1203945
potential solutions for the implementation and evaluation of digital health
COPYRIGHT
© 2023 Mumtaz, Riaz, Wajid, Saqib, Zeeshan,
technologies. Digital tools are used across the world in different settings. In
Khan, Chauhan, Sohail and Vohra. This is an Australia, the Digital Health Translation and Implementation Program (DHTI)
open-access article distributed under the terms emphasizes the importance of involving stakeholders and addressing infrastructure
of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction in
and training issues for healthcare workers. The WHO’s Global Task Force on Digital
other forums is permitted, provided the original Health for TB aims to address tuberculosis through digital health innovations. Digital
author(s) and the copyright owner(s) are tools are also used in mental health care, but their effectiveness must be evaluated
credited and that the original publication in this
journal is cited, in accordance with accepted
during development. Oncology supportive care uses digital tools for cancer patient
academic practice. No use, distribution or intervention and surveillance, but evaluating their effectiveness can be challenging.
reproduction is permitted which does not In the COVID and post-COVID era, digital health solutions must be evaluated
comply with these terms.
based on their technological maturity and size of deployment, as well as the quality
of data they provide. To safely and effectively use digital healthcare technology, it is
essential to prioritize evaluation using complex systems and evidence-based
medical frameworks. To address the challenges of digital health implementation, it
is important to prioritize ethical research addressing issues of user consent and
addressing socioeconomic disparities in access and effectiveness. It is also
important to consider the impact of digital health on health outcomes and the
cost-effectiveness of service delivery.

KEYWORDS

socioeconomic disparities in health, telemedicine, artificial intelligence, privacy,

pandemics, humans

1. Introduction
Digital healthcare refers to instruments and services that employ information and
communication technologies (ICTs) to enhance and optimize health and lifestyle
management, as well as play a role in prevention, diagnosis and treatment of diseases.
Since technological competencies have developed and the usage of user-generated digital
health data has become more significant in recent years, it may now be used in addition

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to traditional electronic health data. Additionally, the current shift The management of healthcare records and remote monitoring
toward patient-centered, value-based care offers a chance for user- has undergone a steady evolution in recent decades. Despite the
generated digital health data to play a crucial role in medical challenges, it is still important to incorporate key concepts such as
practices and in the creation of Real-World Evidence (RWE) (1). computerizing error logs and crash reports in the case of electronic
The US Food and Drug Administration (FDA) views the field of monitoring systems. The Global Task Force on Digital Health for
digital health as having a vast reach that encompasses areas TB was established by the World Health Organization (WHO)
including wearable tech, telehealth and telemedicine, mobile with the goal of ending tuberculosis through the development of
health, health information technology, and customized medicine digital health innovations. Falzon et al. (8) provided insights into
(2). Based on the possible levels of concern to patients, the digital health products, services, and interventions that are being
following categories of digital solutions can be made: approaches used globally to improve the management of TB in their paper (8).
that increase system effectiveness but have no discernible impact Digital health has the potential to revolutionize the way
on patient outcomes, clinical decision support (CDS) and healthcare is delivered, particularly in resource-limited settings. The
prediction models that direct therapy, provide active monitoring, WHO has outlined the potential benefits of digital health, including
compute and/or diagnose problems and mobile digital health increased access to healthcare, improved quality and safety of
that informs or delivers basic monitoring, encourages behavior healthcare, and increased efficiency in healthcare delivery. However,
modification and self-management (3). Digital health evidence it is important to address the challenges and ethical considerations
may be created from digital health data by using computer associated with the implementation of digital health solutions.
sciences and other suitable analytical techniques (1). One of the These challenges include issues related to data security and privacy,
main goals of digital health is the facilitation of data transfer the digital divide, and the need for adequate regulation (9).
between patients, devices, and physicians. The ideas of M. Apro and his team (10) have explored the potential use of e-
customized, preventive, and predictive digital health are strongly health tools to assist in the care of cancer patients by tracking their
connected. With improvements in this connection, information symptoms and managing their treatment. One study found that the
exchange between practitioners and patients can happen in a use of a web-based therapy significantly reduced tumor symptom
more timely and intelligent manner (4). distress. A randomized controlled trial (RCT) discovered that a
The Digital Health Translation and Implementation Program web-based exercise intervention led to significant improvements
(DHTI) was established by the Murdoch Children’s Research in overall health status and reductions in pain intensity compared
Institute in Australia to incorporate digital technology into to control groups (10). Magrabi et al. (11) have highlighted the
healthcare management. The DHTI team, composed of specialists importance of evaluating digital health solutions in the context of
in digital health, researchers, and clinicians, develops hospital- the COVID-19 pandemic. They suggest that technologies should
ready solutions to solve challenges in the healthcare system and be evaluated based on their technological maturity and the size of
improve patient care. To assess the usability of the virtual tool their deployment and should use the complex systems model to
model, the DHTI team conducted a series of tests, including assess the value of data provided by the technology (11).
semi-structured interviews with healthcare professionals, a survey
of individuals in the community, and a survey of parents of
children suspected of having concussions. The data collected was 2. Avenues of digital health revolution
used to refine the design of the electronic tool and emphasized and challenges
the importance of evaluating usability in various contexts (5).
Ayomide Owoyemi and his team (6) conducted a literature Digital health technologies have the potential to revolutionize
review that analyzed the various digital health tools used in the way healthcare is delivered, with the ability to facilitate
various healthcare settings and conditions in Africa. The review remote monitoring, improve disease management, and provide
paper examined a range of articles and papers on the use of more personalized treatment. These technologies include
digital tools, the health conditions being addressed, the type of telemedicine, mobile health apps, wearable devices, electronic
study being conducted, the population involved, the challenges health records, and artificial intelligence. By gathering data from
encountered, and the strategies implemented to overcome these patients’ vital signs, lifestyles, and medical histories, digital health
challenges in African countries. Many African countries have can support the development of a personalized medicine model.
adopted digital health tools to expand the range of health services However, it is important to carefully evaluate the effectiveness
offered in hospitals and primary care center. These tools have and safety of these technologies before widespread
been highly effective in improving the health of the population by implementation, utilizing both traditional evidence-based
enabling the monitoring of disease outbreaks and surveillance, approaches and complex systems models (12, 13).
contact tracing in the event of an infectious disease, the use of
electronic medical records, and the provision of services through
telemedicine (6). However, certain challenges have emerged in 3. Utilization of digital health
Africa, such as workforce and infrastructure gaps, disparities in mechanisms
digital adoption among the public, low socioeconomic levels, and
a lack of electronic infrastructure (7). To address these challenges, It is important to note that digital health solutions can greatly
it is crucial to evaluate the electronic tools being designed. aid in the fight against COVID-19 and other pandemics. These

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solutions include telemedicine, mobile health, wearable tech and 4. Challenges faced of using digital
biosensors, electronic health records, artificial intelligence, and health during and post COVID-19
machine learning. These tools can be used for primary care and
prevention, screening, monitoring, and surveillance. In addition, Several challenges impede the forward progress of digital
social media platforms and Google Trends analyses can be health. These include lack of evidence-based standards, privacy
helpful in tracking the spread of the virus and understanding concerns, issues with data governance, and ethical issues among
public response. However, it is crucial that healthcare many others (12, 14). One major issue is the sensitivity of health
professionals are trained in the use of these digital tools and are data, which can raise privacy concerns when digitized (14).
involved in the implementation process in order to fully utilize Governments also face challenges in managing and protecting
their potential. By prioritizing people and processes over data (15). Another ethical issue is the issue of consent, as many
technology, digital health solutions can be effectively used to users may not fully understand the conditions of use when they
improve the overall health and wellness of individuals and agree to them (12). Additionally, there is a lack of evidence on
communities (13, 14). Some ways in which care teams could the effects of digital health strategies on health outcomes, cost-
focus on for future readiness are summarized in Figure 1. effectiveness, and system efficiency (16). The effectiveness of
Digital health technology has become a key tool in the fight telehealth platforms may also be affected by the income and
against COVID-19, with various models being implemented to socioeconomic status of users (14). Certain groups, such as
help with primary care and prevention, screening, monitoring, minorities, the elderly, and those in low-income or rural areas,
and surveillance. Telehealth, smartphone apps, and websites are may have difficulty understanding and using digital health
all being used to provide virtual visits, virtual treatment, remote solutions due to lower health literacy levels (16).
patient monitoring, risk assessment, and triage. In Singapore, the
TraceTogether app has been used to monitor COVID-19 infected
individuals and notify those who have come into contact with
5. Opportunities for future use
them. In the triage process, individuals are first classified as
of digihealth
potentially infected or uninfected before arriving at the hospital,
and then undergo rapid clinical evaluation and testing at the It is important to ensure that telehealth becomes a permanent
hospital to quickly determine their risk level for COVID-19. It is part of national healthcare systems, rather than just being used in
important for healthcare professionals to be trained in the use of emergency situations (13, 16). This would allow for more
these digital tools and be involved in the implementation process widespread use of telehealth during epidemics. Investment in 5G
in order to fully utilize their benefits and improve the overall technology and the development of modern communication
health of individuals and communities through proactive and infrastructure in developing countries can also facilitate the
preventive care models (13, 14). implementation of telehealth in these regions (14). Digital health

FIGURE 1
The changing needs of care teams of the future; adopted and published with permission from Dr. Rizvi T.H. (see Rizvi TH, University of Oxford, The
changing needs of care teams of the future [Infographic-Internet], 2022, Available from [https://www.linkedin.com/posts/drtazeenrizvi_healthcare-
health-wellbeing-activity-7014261135415648256-ouWU?utm_source=share&utm_medium=member_desktop]).

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FIGURE 2
(A) accelerating digital health with consumer focus; (B) augmenting healthcare delivery models with digital technology; adopted and published
with permission from Dr. Rizvi T.H. (see Rizvi TH, University of Oxford, Accelerating digital health with consumer focus [Infographic-Internet],
2022, Available from [https://www.linkedin.com/posts/drtazeenrizvi_digitalising-healthrecords-digitalhealth-activity-7009510993365999617-lxEC?
utm_source=share&utm_medium=member_desktop]; Augmenting healthcare delivery models with digital technology [Infographic-Internet],
2022, Available from [https://www.linkedin.com/posts/drtazeenrizvi_accessibility-healthservices-digitalhealth-activity-7004120405506465792-7JdT?
utm_source=share&utm_medium=member_desktop]).

has evolved from simply digitizing medical records to been used, including for the analysis of optical microscopic
implementing comprehensive information and communication malaria detection using ML techniques (18). ML has also been
solutions for delivering high-quality healthcare across the care used to predict the occurrence of dementia and Alzheimer’s
continuum. Companies are using connected sensors, disease by analyzing a range of genetic and environmental
smartphones, diagnostic algorithms, and wearables to capture factors (19).
health data, provide feedback, and facilitate proactive care
models. Patient-centric systems that promote patient engagement 6.1.2. Digital apps used for decision support
are becoming more important as consumers become more and management
empowered. Health companies and leaders should embrace One of the first digital health applications to be approved by
new approaches presented by the emerging health ecosystem. the FDA for managing diabetes mellitus was called BlueStar (20).
An infographic outlining how digital health technology can Decision support apps like this allow patients to manage their
be used for different purposes along with an infographic health beyond clinic visits. The unprecedented proliferation of
depicting augmentation of healthcare delivery models is shown such tools has led to increased recommendations from national
in Figure 2. regulatory bodies, such as the draft guidance from the FDA
addressing concerns about the use of clinician and patient
decision-support systems (21). Software that meets the
6. Using digital health technology to requirements for a device under the Federal Food, Drug, and
better generate evidence and deliver Cosmetics Act is subject to FDA regulation. Digital health
evidence-based care technologies have the potential to improve health outcomes by
increasing patient involvement in self-care and caregiver care,
6.1. Current landscape of digital health improving communication, and tailoring services to individual
needs. In 2018, over $9 billion was invested in digital health
6.1.1. Machine learning startups by venture capital and private equity, an increase of $2
Machine learning (ML) is a method that allows computers to billion from the previous year (22).
process and analyze data more efficiently. It has become more
popular as the availability of large datasets has increased. ML has 6.1.3. To improve research recruitment
several advantages over traditional statistical techniques, Recruiting patients for clinical research can be a significant
including its flexibility and ability to handle large amounts of challenge, especially for randomized controlled trials (RCTs).
data, making it useful for a variety of applications, such as Poor recruitment can lead to increased costs, longer completion
predicting risks, making diagnoses, and forecasting survival rates times, or even the termination of a study (23). In a study on
(17). In the field of medicine, many different algorithms have boys with Klinefelter syndrome, recruiting children presented

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unique difficulties. To investigate the effectiveness of traditional However, there are also challenges to implementing digital health
and IT-based recruitment methods for reaching hard-to-reach solutions, including poor coordination, inadequate stakeholder
populations such as these, the authors conducted a literature involvement, weak health systems, and lack of interoperability.
review and compared IT-based outreach to traditional methods To overcome these barriers, it is important to adopt a problem-
such as brochures, flyers, and physician referrals. They found centered approach, involve all relevant stakeholders, budget
that distributing flyers and brochures and sending letters to accurately, standardize processes and resources, establish an
doctors and patients at a large hospital and affiliated clinics evaluation framework, and provide training and support to users
resulted in only 4 (9%) participants over a three-month period, throughout the transformation process.
while web-based tools were more effective at recruiting these
individuals. This demonstrates the potential of IT-based tools to 6.2.1. Health data disparity
improve patient recruitment in clinical research (24). Health data disparities refer to differences in the quantity,
quality, or both of health data among different people, groups, or
6.1.4. To obtain informed consent populations. These discrepancies can occur within communities
Informed consent is a process that ensures that research as well as across various demographics, fields of study, and
subjects are fully informed about the details of a study and freely medical conditions. For example, in genome-wide association
choose to participate. This process is governed by ethical studies, as of 2018, 78% of participants were European, 10% were
standards and laws to protect the rights of human subjects. The Asian, 2% were African, 1% were Hispanic, and less than 1%
goal of informed consent is to provide potential participants with were from any other ethnic group, resulting in a bias towards
sufficient information in a clear and understandable form so they European genetics in human analysis (28).
can make an informed decision about whether or not to
participate in the research. Informed consent is a crucial aspect 6.2.2. Quality of data
of patient engagement, but as the process has become more Maintaining the quality and reliability of data is a continuous
formalized, it has also created some challenges. To address these challenge. “Big data” refers to the use of humongous amounts of
challenges, innovative methods such as video consent, patient-related data, such as electronic health records (EHRs) or
smartphone consent, and digital informed consent are being used other sources, to understand population risk, treatment
(25). For example, the Patient and Provider Assessment of outcomes, and trends in healthcare utilization (29).
Cholesterol Management (PALM) study used a tablet-based
platform to gather patient-reported data on behaviors and 6.2.3. Productivity paradox
attitudes related to lowering cardiovascular risk and managing The productivity paradox, also known as the lack of
lipid levels. The study also surveyed healthcare providers about productivity improvements resulting from advances in
their attitudes towards existing lipid-lowering targets and barriers technology and increased computing capabilities, has been
to optimal cardiovascular risk reduction (26). observed in industries other than healthcare. Inefficient
management of information technology, a lack of infrastructure
6.1.5. Digital formularies to support modern software, and poor technology usability are
A formulary is a list of drugs that is used by a purchaser, the main contributors to this issue (30).
pharmacy, or provider organization to identify which
medications are preferred or not based on factors such as price 6.2.4. Privacy
and therapeutic value (27). In some cases, formularies specify Data breaches at major companies such as Amazon, Sony, and
which drugs can be prescribed, while in other situations, Equifax have raised concerns about the security of sensitive data
formularies are used to negotiate reduced pricing, such as for a stored in large systems. Digital health also needs significant
specific proton-pump inhibitor. With the large number of health improvements in data security, as demonstrated by recent
apps available, a “digital formulary” for apps that covers a range instances of health-related data hacking, which have included
of applications, including monitoring, diagnosis, and ransom attacks on clinic computer networks and unauthorized
therapeutics, could be a useful tool for incorporating apps into remote modification of defibrillators (31).
clinical treatment. Recently, Express Scripts, a major US
pharmacy benefits management company, unveiled a digital
health formulary which could prove to be a significantly useful 6.3. Future implications of digital health
tool in clinical care in the future (22).
6.3.1. Randomized clinical trials
Digital health technology has the potential to facilitate and
6.2. Potential problems with digital improve traditional RCTs, which are becoming increasingly
health care expensive and complex, and take a long time to complete and
implement (23). Although digital technologies have not been
Digital health innovations have the potential to address various utilized to the maximum efficiency and data regarding
challenges faced by healthcare systems, such as barriers to integration of these technologies to clinical trials haven’t been
engagement, resource constraints, and unmet patient needs. examined in detail, it is still important to assess these

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technologies in order to conduct more efficient and practical regulators, and technology developers can help achieve the
studies. Once issues such as accuracy, reliability, access, ultimate goal of providing better healthcare and support for
confidentiality, and the need for regulations have been patients.
addressed, the potential benefits of digital health technology for
clinical utility in patient-care and research purposes can be 6.4.1. Limitations
better understood. However, it is also important to consider Digital health technologies utilized for evidence-based
potential negative effects such as a paradoxical loss of medicine, such as telerehabilitation, face several limitations.
productivity, decreased quality of care, and other undesirable One key barrier is the reliance on hands-on approaches in
outcomes of incorporating digital technologies into clinical healthcare, such as manual therapy and acupuncture, which are
pathways (32). difficult to replicate remotely. To overcome this, a hybrid model
combining online sessions with in-person visits for hands-on
6.3.2. Ambivalence in digital health techniques can be implemented. Additionally, the quality of
The concept of “ambivalence” has recently been proposed as a health information available online is often non-scientific,
way to understand the complexities and nuances at play when biased, and not aligned with evidence-based practices. This can
digital technologies are integrated into care practices, in response mislead patients and create unrealistic expectations. Limited
to polarized views on the pros and cons of digital health. In a digital health literacy among certain social groups, resistance to
study of 97 HIV patients’ interviews and co-design workshops, change among healthcare professionals, technological issues,
Marent et al. (33) argue that a relational and multifaceted and resource constraints also pose challenges. Communication
understanding of ambivalence can provide a nuanced and trust-building in the digital environment, as well as
understanding of the multiple impacts and social enactments of infrastructure and public policy considerations, further impact
digital health. This suggests that implications and reactions vary the adoption and effectiveness of digital health technologies.
across dimensions and within specific practices, rather than being Overcoming these limitations is crucial to ensure equitable
uniformly positive or negative. For example, cross-dimensional access, quality care, and patient engagement in digital health
ambivalence means that an HIV patient may appreciate certain interventions (34). The lack of standardized data-sharing
features of a digital device (such as timely reminders to take agreements and transactional standards between institutions
medication) while disliking others (such as access to blood test hinders the infrastructure needed for effective data sharing and
results, which can bring uncertainty) (33). integration in public health. The COVID-19 pandemic has
highlighted the importance of data sharing and ethical
considerations in the field of digital health. Challenges include
6.4. Improving digital health care: Way maintaining control over generated data while promoting their
forward use for scientific discoveries and obtaining informed consent for
data collection and access. Limited resource capacity, including
One of the key considerations in providing digital health is infrastructure and internet access, poses challenges for
understanding the needs and perspective of patients. There can implementing and evaluating digital health technologies,
be many challenges and difficulties in integrating digital health particularly in resource-limited settings. Digital health literacy
into daily life, such as concerns about data security and privacy, among the general population plays a crucial role in the
and a lack of alignment with patients’ needs and values. To acceptability and adaptability of digital health solutions. The
address these issues, it is important to develop robust systems shortage of qualified professionals in digital health further
with strong data security and privacy, and to engage with impedes the widespread adoption of digital health applications.
technology developers and patients early on to ensure that Insufficient policies, governance structures, standard operating
digital innovations address patients’ concerns. It is also essential procedures, and financial resources hinder the successful
to involve healthcare professionals and adapt healthcare systems deployment of digital health interventions. Culturally adapted
to the use of digital health. In healthcare systems, the current technologies and careful consideration of the local context are
infrastructure may not be able to accommodate the integration necessary for effective implementation. The transition from
of new digital health technologies, and there may be concerns face-to-face care to digital health-enabled remote care varies
about reimbursement for these services. To address these in its advantages and disadvantages depending on the
challenges, it is necessary to conduct rapid pilot experiments country, program, and specific digital health technology
with existing healthcare infrastructure to develop systems that employed (35).
can adapt to digital health technologies, and to engage with While this review article offers valuable insights into the
clinical researchers to ensure that digital technologies being utilization of digital health technology, it is important to
tested are cost-effective and can be effectively integrated into acknowledge a few limitations. Firstly, the scope of the article is
the digital healthcare infrastructure and systems. Many digital focused on specific aspects of digital health, such as machine
health solutions are still in their early stages and will need time learning, decision support apps, research recruitment, informed
to evolve and be validated for clinical accuracy. Improving the consent, and digital formularies. While these topics provide a
relationship between researchers, scientists, clinicians, solid foundation for understanding the current landscape, it is

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possible that other important aspects of digital health may not Acknowledgments
have been extensively covered. Secondly, as the field of digital
health is evolving rapidly, there is a chance that some of the We are extremely thankful to Tazeen H. Rizvi for providing us
information presented in this article may become outdated over full permission to use the amazing infographics in our review paper.
time. It is crucial to stay abreast of the latest developments in
the field and consider incorporating newer innovations or
trends into future revisions. Despite these limitations, this Conflict of interest
review article offers valuable insights into the potential of
digital health technology and serves as a foundation for The authors declare that the research was conducted in the
further exploration and research in this exciting and rapidly absence of any commercial or financial relationships that could
evolving field. be construed as a potential conflict of interest.

Publisher’s note
Author contributions
All claims expressed in this article are solely those of the
HM: Conceptualization, Methodology, Software, supervision. authors and do not necessarily represent those of their affiliated
MS and HS: Data curation, Writing- Original draft preparation. organizations, or those of the publisher, the editors and the
YC, and MZ: Visualization, Investigation. MR and HW: Writing- reviewers. Any product that may be evaluated in this article, or
Reviewing and Editing. All authors contributed to the article and claim that may be made by its manufacturer, is not guaranteed
approved the submitted version. or endorsed by the publisher.

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