There are several circumstances where people do not get the desired healthcare facilities; for example, there is a consensus that citizens in the US get more than the required medical facilities whereas at the same time, people with general hypertension are devoid of basic healthcare necessities (Cutler, 2005). Availing healthcare opportunities is whether a U.S. citizen’s right or a privilege that is granted to him by the government is still a debatable topic. According to a consensus, there are about 20M to 22M U.S. citizens who have the opportunity to avail health-based services in the form of medical insurance, exchanges in healthcare and healthcare policies that extend from parents to their children under the age of 26. But at the same, there are about 25M people who are devoid of access to basic healthcare (Bauchner, 2017). Not only does the cost and accessibility are the main issue concerned with the U.S. healthcare system, but the inclusivity of minority groups has also been a hot debate for many years.
The Healthcare system in the US has been on a constant journey of evolution ever since in context to the latest technologies, treatments and other reforms. Most recently, it has been established that the cost of medical facilities in the United States of America has increased with the passage of time. In the year the 1950s, the medical expenditure of a single person was $500, whereas it rose to $5000 dollars in the year 2005 (Cutler, 2005). An increase in medical expenditure is not the issue but getting the value of each dollar spent is what matters.
The world is evolving exponentially, and where every single thing is coming under the wave of this inevitable revolution, the healthcare system of the U.S. is not far behind. The digitalization of the healthcare system in the form of ‘telehealth’ and ‘telemedicine’ has been a newly and recently introduced concept. In the early years, the idea of remote medicine was only confined to the use for stroke assessment and management (Julien et al., 2020) but today, this concept is not only well accepted by the citizens of the whole country but also greatly appreciated by the healthcare workers as well. Morbid conditions such as cancer (Shalowitz & Moore, 2020), myocardial infarction (Miller et al., 2020), diabetes (Andersen et al., 2020), cerebral vascular diseases such as stroke (Zachrison et al., 2020), and complex surgeries (Forbes et al., 2020) are now being performed and treated in the U.S. with the help of remote medicine.
The overall condition of the healthcare system’s availability and resourcefulness in the U.S. indicates that the years ahead are uncertain regarding the quality of healthcare availability, moderate health insurance for all citizens despite race and ethnicity and the containment of the annual healthcare budget. All healthcare workers, especially working in Congress and other government institutions should realize that healthcare necessities are basic rights for all citizens not just a privilege for the majority of people who have enough money and access since affordability is the major reason for being uninsured (Foutz et al., 2017). This state of mind is exceedingly important as it is an emblem of a fair and just society (Bauchner, 2017). The U.S. Healthcare system is in need of a more systemic redemption as there is a majority of people who are deficient in healthcare coverage despite the erstwhile expansion of healthcare coverage achieved by the Affordable Care Act (Crowley et al., 2020). Improving primary care delivery would eventually help in escalating the quality and receding the cost of healthcare delivery across the U.S. (Peikes et al., 2020).
In quondam times, the only treatment that could be offered by the doctors was care and commiseration. But with the medicinal advancement, the sole goal of a doctor became to treat the ailment of their patients no matter what; hence the relationship between patients and doctors has eroded in the process. Patients are excluded from the important decision-making process of their treatment, and the only thing that stands important is the treatment of the disease. A physician is only able to construct an effective patient-centred treatment plan only when he is able to constructively understand the state of well-being of his patient. When a patient is not informed about his medical condition and the treatment he is going through, the overall level of satisfaction and optimism decline abundantly. Studies have shown that there are about eight’ characteristics that ensure a copacetic response from a patient’s point of view. One of the main characteristics is ‘high-quality information about the disease and treatment plan (Barry & Edgman-Levitan, 2012). While a patient-centred approach has its pros, at the same time, it is obligatory for the clinician to facilitate the patient by providing decision aids and increasing the patient’s awareness regarding the disease and the treatment process and its eventual positive and negative outcomes because a well-informed and abreast person is then only capable enough to make a rightful decision about his life.
The Institute of Medicine (IOM) has coined a definition of patient-centred care that goes by “care that is respectful of and responsive to individual patient preferences, needs, and values” and that it makes sure “that patient values guide all clinical decisions.” (Barry & Edgman-Levitan, 2012). This definition clearly emphasizes on how important it is for clinicians and patients to work together for a better health outcome. It is imperative for a patient to schedule in when important and life-changing decisions are being made related to his ailment and treatment. And it is obligatory for a clinician to give equal importance to the opinions and sentiments of the patients while being at the junction of circumstances when there can be implications in either direction, such as opting for major surgery, signing up for lifetime medications and/or undergoing diagnostic tests that can have serious aftereffects (Ammenwerth et al., 2012). On the other hand, there are conditions when there is little or no value in a patient’s opinion and a clear and dominating path is visible ahead, such as in the case of pneumothorax, a pleural tap is a necessary emergency procedure that has to be done no matter what the patient or the family suggests.
There is galore empirical evidence available that stresses the importance of an empathic relationship between a doctor and his patients (Kim et al., 2004). The contentedness with the healthcare provider and the medicinal regimen is directly associated with the interpersonal and empathetic communicative relationship between the patient and the healthcare provider (Hojat et al., 2010). Although good and empathic communication skills are now being taught by medical institutions from the very start but there is still a lack of measuring tools to evaluate and enhance a physician’s interpersonal skills hence making it ineffectual to incorporate a healthy doctor-patient relationship. An effectual “shared decision-making” can only be achieved by the active participation of at least the physician and the patient. Moreover, other healthcare team members and friends and family also play a vital role in this process (Barry & Edgman-Levitan, 2012). Better communication with patients leads a clinician to understand their needs from their perspective and hence tackle them in a better way (Foronda et al., 2016). An empathetic clinician will be able to formulate a fruitful treatment plan for their patients, eventually improving the outcomes and leading them to be a better clinician overall (Hojat et al., 2010).
Family-centered care (FCC) is a relatively new concept and is defined by the Institute of Family-Centered Care as “an approach to the planning, delivery and evaluation of health care that is governed by mutually beneficial partnerships between health care providers, patients and families. FCC applies to patients of all ages, and it may be practised in any health care setting” (Shields, 2010). In this type of treatment approach, a healthcare worker considers the patient as well as the whole family as the recipient of the care; hence the treatment plan is designed by keeping in mind the status of the whole family, including the patient itself. There are many articles and various policies that have mentioned or prefer using a healthcare delivery system with a family-centered approach, yet there is no such evidence that proves its benefits or otherwise. When a child enters a hospital with a certain disease, it affects his whole family, so the treatment plan should be designed by keeping the child in the centre in such a way that it affects the whole family. The same theory is applicable to an adult patient; for example, if an aged person suffers from a stroke and is paralyzed for the rest of his life, then the responsibility of taking care of the patient falls upon his family or other healthcare providers. Hence when designing the treatment protocol for a paralyzed patient, it is imperative to keep in mind the whole family and their well-being as well (Shields, 2010).
If we look back at history, there have been a plethora of circumstances and debates where clinicians, doctors and even laymen have argued about the implications of a family-centred approach in the healthcare delivery system. A part of the consensus said that a family-centred approach is desirable in the case of a child admitted in the hospital, whereas, on the other hand, it was argued that including family in the clinical scenarios would eventually complicate the process. Back in the time in the U.S., Spitz was of the view that if a child is left alone in a hospital without his mother, he develops a condition which he called “hospitalism” which is characterized by the child not adjusting normally to his family once he is discharged from the hospital (Johnson et al., 2008).
Family-centred care is mostly practised in pediatric cases in which underaged children are unable to give informed consent or make life-changing decisions for themselves. With this approach, a patient is never treated as an individual since the whole family is central to the patient’s well-being. Since the model is not implicated as a whole but rather in pieces, it creates confusion not only for the patients but also for the family and the healthcare workers as well. This is the reason why no randomized controlled trials could be performed on this kind of model, and hence no empirical data is available to stand by it (Shields, 2010). There is so much literature on family centred approach, yet not even a single author claims its benefits or positive impact practically. Moreover, hospitals and organizations claim that they use this approach or at least mention it in their clinical guidelines but truth be told, not even a single healthcare worker would use this terminology in his day-to-day rounds (Shields, 2010).
In order to interweave a family-centred approach in our clinical setups, we need to consider a few strategies. Change in the infrastructure of the hospitals to provide beds, waiting areas, eating places etc., for the patient’s family members and educational uplift for all the healthcare workers to increase awareness of the family-centred approach. Organizations should cohere the involvement of families and provide avenues for family-to-family abetment via face-to-face meetings or social platforms. Institutions such as Institute for Patient and Family-centered Care in America is the example of such practicality (Shields, 2010). It is necessary to involve family members and friends as they are central to the implication of a family-centred approach in healthcare.
The introduction of consumer health informatics has changed the paradigm from a physician-centred clinical approach to a more patient-centred approach (Lewis et al., 2005). And a few years later, the emphasis on a holistic approach has led to the inclusiveness of the family-centred approach as well. While patient involvement in clinical decision-making has spiked in the last few years, the plenitude of health-related information has been a source of consolation and as well as botheration for the health consumer. In older times, only the physician had the authority and access to the patient’s medical records; neither the patient himself nor his family had any relation to whatsoever medical treatment he was going through. The only source of information for the patient was his physician. This approach, although had its advantage, as it remained the only authentic source of medical information for the patient, it had its drawbacks as well. Both the patient and his family were left out of the life-changing medical decisions. This raised a serious matter that a person should have a right to decide what is better for his life, and his family and caregivers should have a say in it as well.
From a clinical point of view, both the patient centred and the family-centred approach deliver a dignified role in maintaining and providing a better Healthcare delivery system. In the recent few years, there has been a cognizance about incorporating patients as well as their family members in the clinical decision-making process, especially when the clinicians are at a crossroad scenario that leads to multiple consequences (Johnson et al., 2008). The family-centred approach is as important as a patient-centred approach. There are circumstances when the decision about the health of a person depends upon the unanimous collaboration of the patient himself, his family and his physician. For example, if a person is diagnosed with Triple Vessel Coronary Artery Disease (TVCAD), it is mandatory for the patient’s physician to lay down all the possible treatment options in front of him, whether he opts for CABG, angioplasty or lifetime medications should be a conjoined decision of the patient, his physician and patient’s family. In the case of the pediatric population, it is essential to understand that when dealing with a child, it is not just the biological processes or organ disorders that need correction but also its impact on a child’s and his family’s mental, environmental and social health (Lehmann et al., 2009).
In circumstances that deal with mental health recovery, both a patient-centred and family-centred approach is desirable. High-risk youth has been found to respond well and in a positive way when treated in a family centred and with ecologically based interventions (Stormshak, 2009). While on the other hand, people suffering from chronic illnesses such as end-stage cancer prefer to sign Do Not Resuscitate (DNR), is an example of a pure patient-centred approach. If families and friends are involved in this matter, then this will turn into a more complicated scenario not only for the healthcare givers and also for the patient as well. But in the case of young children and adolescents who are unable to give informed consent regarding their medical condition, the family-centred approach comes in handy because parents and other caregivers of such children are responsible for their health (Johnson et al., 2008). Moreover, the geriatric population who is dependent on their family members need to include them while their medically important life decisions are being made.
But at the end, the concept of patient-centred care is supported by the literature in many places (Barry & Edgman-Levitan, 2012) (Johnson et al., 2008), while family-centred care, although gained its fair share of popularity a few years ago, now clinicians and researchers have started to question its efficacy and workability in practical life (Shields, 2010). More research, particularly randomized control trials, is needed to be performed in order to authenticate the applicability, practicality and feasibility of family-centred approach in healthcare systems.
As soon as the twentieth century began, we stepped into an ever-so-evolving Digital Age or New Media Age. Information and communication technology (ICT) has advanced itself more than ever in the past century (Julien et al., 2020), and the aftermath of this advancement has led to the evolution of the medical industry as well. Advancing medicine has introduced a plethora of upgraded diagnostic and interventional tools and applications that have made the life of every healthcare giver and patient very easy. These technologies have changed not only our healthcare system but also our beliefs in relation to the cultural and economic dimensions as well. It is evident that the introduction of new technologies in the medical field requires end consumer satisfaction and acceptability at the same time. Hence, different authors perform different studies in order to determine the feasibility of the newly introduced technology and prove its favorability or otherwise in terms of security, ethnicity and monetary issues. Health information technology (HIT) has evolved with a number of applications that have facilitated medical delivery by healthcare professionals.
Electronic medical record system or EMR is an arising tool that has expedited the documentation of patient’s official medical records by the physicians and nurses, a faster coalescence of patient’s medical investigations completed in remote locations, enhancing literature research and designing a better Healthcare plan (Kumar et al., 2020). Physicians are easily able to get their hands on the past medical history of their patients even after several different referrals since all the caregiving institutions are technically connected through the EMR system.
These recently introduced coalesce of telecom and the medical industry has opened new ways to deliver remote medicine in a highly effective manner. Tele-dermatology, teleradiology, teletrauma, telestroke, telepathology, telerobotic surgeries, telepsychiatry, telepathology and telecardiology are some of its most appreciated and practised sub-branches in America. Although there are quite a few ethical challenges and concerns regarding this way of healthcare delivery but at the same time, it has diminished the obstacle of distance not only for the patients who acquire high-end medical coverage but also eased ways for healthcare professionals to communicate with one another in times of difficulty (Forbes et al., 2020).
CPOE is “ an electronic application used by physicians to order drugs, laboratory tests and request for consultations, ensuring that all orders are legible and complete” (Wolfstadt et al., 2008). An exceptional amount of patient death has been recorded in the past few years only because of errors in maintaining patient records (Poon et al., 2004). This method has proven to eradicate any healthcare-related adverse events, but there are as low as 5% of healthcare systems in the U.S. that have properly implemented this system (Cutler et al., 2005).
CDS is defined as “providing clinicians, staff, patients, or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care” (Musen et al., 2014). This system allows clinicians to reacquire the medical history of the patient as well as transmit the available information in order to formulate highly specific treatment protocols under the particular clinical context.
These electronic health record systems have led to the transformation of laymen from condescending patients to informed and highly responsible consort in their own care. With the help of such portals, patients are able to access their clinician’s documentation, therefore, leading to a staunch patient-centred healthcare approach (Ammenwerth et al., 2012).
Empowering parents to utilize health informatics in the management of care for their special needs child
Health informatics has been a revolutionary source of Healthcare delivery for the past few years. Ten healthcare overall has undergone a revolutionary change in the last few decades, whereas healthcare informatics has seen an evolutionary reform. This is a matter of pondering because if we intend to include and normalize the patient-centric approach in the healthcare set-up, then it is mandatory to revolutionize the healthcare informatics in order to bring the care providers, patients and their families on the same platform (Safran, 2003). This is especially important for the underprivileged and ‘digitally deprived’ population of people as they are the ones who lack the basic resources of medical facilities due to high cost or unavailability of clinicians. The empowering of parents is specifically important regarding the use of healthcare-related technologies as they are the ones who have to take care of medically challenged children who are yet to become adults in the near future. It basically means to keep themselves posted regarding the disease process and the treatment process throughout (Stormshak, 2009).
The advancement in health information technology has not been poignant in the former years, but the progressiveness in information technology has been quite noticeable. The introduction of smartphones, laptops, high-speed internet and the World Wide Web has transformed this era into a more “Digital Age” (Zachrison et al., 2020). But this revolution has yet to occur in the healthcare system. There are many ways to ramble information technology into the healthcare system, but the most approachable is by spreading awareness and empowering the general public to utilize this technological paradigm to conveniently acquire medical facilities. Telehealth and telemedicine, electronic medical record (EMR) systems, electronic patient portals, social platforms, clinical decision support systems, billing transactions, ordering systems etc. are examples of healthcare informatics that can help parents to manage their medically challenged children.
Healthcare informatics has been revolutionary in the case of Neonatal Intensive Care Units (NICU). Preterm babies now have upgraded and state-of-the-art ventilators to support them throughout their fight for life. Today’s ventilators can support the growth of a pre-term baby weighing as low as 1 pound, eventually growing into a healthy adult in future (Tang et al., 2012). These upgraded and state-of-the-art ventilators not only support life of a newborn but also give confidence and hope to the parents as they watch their baby grow with each passing day. Many parents face a lot of fear and anxiety when they encounter such high-level medicinal machines and drugs in the neonatal ICU. They often describe their experience as emotionally overwhelming as they are unaware of the sensitive environment of the NICU. Moreover, parents with more than one child back at home are constantly swinging back and forth to keep a check on their child in the NICU. As parents become, overwhelm they try to gather information from all sorts of sources. All these situations are intelligently catered by the health informatics starting from the child’s journey at the NICU to his discharge.
Parents of young children suffering from chronic disorders should be empowered to take help of communication technology as it has shown a higher level of family satisfaction (Safran, 2003). Healthcare informatics provide electronic access to the parents, doctor and nurses of the child hence aiding in formulating an effectual treatment plan with better outcomes. It is a well-known narrative that health care is costly (Tang et al., 2012). A near majority of the reasons for it being costly is the repetition of diagnostic tests, prescribed medicines and other medical expenses. Healthcare informatics has provided a tool called Electronic Medical Record systems (EMR) through which the patient’s medical history and the information about his current treatment are easily accessible to the patient, his doctors and his caregivers. Parents of ill children can have access to the record hence helping them to keep themselves up-to-date regarding their child’s treatment progress. As EMRs are interconnected through various hospitals, doctors can easily reach the past medical history of their patient no matter how many referrals he has been through.
Healthcare informatics also includes journals that are published by clinicians, researchers and medical students giving an opportunity to the parents of chronically ill children to educate themselves with high-end and authentic medical information regarding their child’s condition. Consumer health information also provides all the necessary data and knowledge related to billing, insurance, hospital admissions and discharges. This helps the parents to understand the science of health resources and aids them in deciding what is preferable to them (D’alessandro & Dosa, 2001) and what is not. In earlier times as the primary care doctor was the only authentic source of medical and all health-related information, today thanks to health informatics, there are a number of search portals that provide access to evidence-based medical information uploaded by physicians, doctors, nurses, researchers, medical students and other reputed healthcare professionals. Emotionally and mentally overwhelmed parents of young children should be guided to take advantage of these reliable sources and enlighten themselves with useful information that would help them in practising a family-centred approach to their child’s wellbeing. Physicians and other healthcare workers should encourage parents of ill children to get access to these informative portals; in this way, they shall also practice the family-centric approach in their medical practice.
As long as the child is in the hospital, the doctors and nurses and other healthcare providers help the parents with any query related to their child’s condition (Stormshak, 2009). But once the Child has been discharged from the hospital, there should be a dependent source available for the parents to manage any adverse events or even regulate the daily medicinal routine of their Child. Hence, parents should be encouraged to make use of the decision support system that provides them with information regarding any sort of drug interactions or alarms them about any forthcoming adverse event. Reminder systems help them in organizing and managing the routine of their medically challenged child, which might include his medicines, eating schedule and other important tasks such as position change, peg tube alteration etc. the diagnostic expert system is also one of the best gifts of healthcare informatics. As clinicians are not readily and easily available all the time, parents can take the help of this system to tally the unusual symptoms of their Child and formulate a temporary diagnosis and treat it for the time being until a professional checkup is not available.
Communication is key to better health outcomes (Foronda et al., 2016). This has been established by a number of researchers and healthcare providers. It not only reduces the mental and emotional stress of parents who are already snowed under financial stress but also gives them hope and positivity to look up to a better future. There can be many ways in healthcare informatics through which a distressed parent can get in touch with their child’s primary care physician and other healthcare givers. Telemedicine and telehealth have been proven sources of providing remote medical facilities (Forbes et al., 2020). Families living in remote areas who do not have access to high-end medical resources can get in touch with speciality doctors through phone, emails, videoconferencing or even through a simple text message chat. This way of acquiring medical help saves time, reduces travel expenses and time, reduces healthcare costs and improves better health outcomes in children, especially for working parents (von Thiele Schwarz, 2016).
Leveraging health informatics to promote family-centric care for caregivers of medically complex children
Consumer health informatics is an evolving branch of technology that enables the general public to get access to all the healthcare-related information hence enabling them to take well-informed decisions about their health. These applications can help deliver a swift, reliable and low-cost healthcare delivery. We are headed towards a time where “co-care” is preferred rather than individual care. Especially in the case of medically challenged children with chronic conditions, the concept of co-care is rather preferable to any other case. The collaboration of clinicians, the child, the family members and as well as the latest health informatics can result in much more positive outcomes. Information and communication technology (ICT) plays a vital role in context with the “distributed cognition” where relevant data is shared and available for the patient and his family members, the community and throughout the time and space at the right time and right place (von Thiele Schwarz, 2016).
A survey of a national level has documented that there are about over a third of autistic children, over a fifth of mentally challenged children and over a fifth of children who require special care needs are unable to seek necessary medical treatment either due to lack of resources, speciality doctors, medical insurance or travel hindrances (Krauss et al., 2003). The majority of the children with complex disorders suffer from physical, mental or behavioural challenges, and their parents are either too busy to take an off from work or cannot simply afford to acquire competent physicians and healthcare workers. Health informatics has played a vital role in this matter by simplifying the reach for medical care, particularly in the case of children with complex medical disorders, and ensuring well-timed, apt and attuned specialized medical care without the hassle of any confusion or delay. Health informatics has implicitly influenced clinical data for clinicians and children’s family members to improve health outcomes (Lehmann et al., 2009).
Pediatric informatics is defined as “clinical informatics that advances child health” (Lehmann et al., 2009) and gathers data from IT technology to formulate better diagnostic and interventional tools for children and young adults. This healthcare informatics’ sub-branch is solely related to the pediatric population. With the help of information technology, the societal burden of chronic diseases in children can be decreased to a great extent. For example, children suffering from asthma have depicted an improvement in quality of life, decreased emergency rounds to the hospitals and decreased exacerbations after remote telemonitoring (Lehmann et al., 2009).
The Child Health Improvement through Computer Automation (CHICA) system is a framework for a knowledge-based guidelines and a storehouse for patient data. This system helps clinicians to organize out-patient-specific information either from the child or from their parents, ease the screening procedure, and highlight the necessary and appropriate preventive measures (Anand et al., 2004). This system not only helps the clinicians to remain up-to-date for every out-patient visit but also allows the families of the children to be well acquainted related to their child’s health and treatment. This will eventually promote a more family-centric approach to healthcare delivery in the outpatient department as well.
In order to give their child the best treatment possible, the parents of chronically ill children gather information from different references such as online blogs, medical papers, online portals of different practitioners and especially on the internet. Parents prefer orthodox internet access as a reliable source of information regarding the health of their children (Khoo et al., 2008). Parents have been using the internet and online blogs for gathering medical information for the past many years. They acquire the internet for multiple reasons, such as faster access to medical opinions, alternative physician recommendations, upgrading their knowledge to the latest medical information, worrying about their children’s health, self-diagnosing them and educating themselves prior to visiting any doctor or physician to seek professional medical advice (Walsh et al., 2012). However, contrary to traditional beliefs, it has been established through different studies that the information available on the internet is not very reliable and trustworthy, especially in the case of young children.
Children with cognitive disabilities such as Attention deficit hyperactivity disorder (ADHD), dyslexia and learning disability have shown a positive improvement in their disease course through the use of computer-based software that has eased them in practising cognitive skills (Walsh et al., 2012). Children suffering from autism have also shown an optimistic response to healthcare informatics. They have shown an improvement in talking skills when exposed to computer-based practising software instead of the traditional interactive sessions (Moeinedin et al., 2009). In addition, pediatric oncology, juvenile diabetes and some respiratory disorders have also shown a promising response to computer-based programs in children. These improved outcomes with the help of health informatics have encouraged healthcare providers to spread awareness among the parents to make use of these technologies to achieve an improved outcome in the disease course of their children.
Children with special care needs (CSHCN) are one of the greatest consumers of telemedicine, especially those who live in rural areas. This technology has helped to overcome the barriers of long route travelling, speciality physician and tertiary healthcare providers’ hunt, parents coping their office timings with the appointment timings of their children and the temporary dependence on emergency department services and over-the-counter medications (Marcin et al., 2004). With the help of telemedicine and telehealth services, parents and other caregivers are able to attend the physician sessions of their children without missing their office. In this way, medically complex children are emotionally supported by their parents while attending their doctor’s appointments from the comfort of their homes.
In the past few years, the only source of medical information for a patient was his primary care physician. This limited source of information led to the patient’s constrained amount of medical knowledge and thus limiting his role in clinical decision-making. The introduction of health informatics has not only opened gateways to enormous medical information for patients and their family members, but at the same time, it has led to a great degree of misinformation among the lot. People believe in any information that is posted online or shared on social media platforms without any authentication or verification. Although studying online blogs and surfing the internet to medically educate oneself is fruitful in a patient-centred approach, but believing unverified pieces of information can be detrimental to one’s own health.