Showing papers in "Health policy and technology in 2013"
TL;DR: In this article, the authors analyze the merits of several relevant models and explore their potential significance for the success or otherwise of health related Information Technology projects, highlighting their weaknesses in relation to the lack of differentiation between technological and human factors which limit their applicability in practice.
Abstract: There have been many attempts to apply previously developed models of technology acceptance and the diffusion of innovations; however the models have weaknesses in predicting the behaviour of individuals and organisations, particularly within the complex health domain. The insights recent work on these models offer is relevant to health informatics development and innovation and need to be considered in the development of organisational strategies. This paper analyses the merits of several relevant models and explores their potential significance for the success or otherwise of health related Information Technology projects, highlighting their weaknesses in relation to the lack of differentiation between technological and human factors which limit their applicability in practice.
100 citations
TL;DR: In this article, a review of U.S. and EU regulation and compliance of national and trans-border data flows, focusing on cloud computing in the health sector, is presented.
Abstract: The emerging market of cloud computing poses many challenges for policy-makers, healthcare organizations and the IT industry, as health data and information is increasingly transferred across national or state borders where little consensus exists about which authorities have jurisdiction over the data. This review of U.S. and EU regulation and compliance of national and trans-border data flows, focuses on cloud computing in the health sector. As transatlantic regulatory frameworks are developed to keep pace with the fast-moving market of cloud computing, evidence suggests that cloud clients and providers need to work together to meet stringent compliance rules to avoid penalties and potential reputational damage. Traditional sourcing relationships where cloud providers act as ‘conduits’ for health data are being superseded by more stringent demands to become ‘business associates’ of their clients, with shared responsibilities and accountabilities for the protection and security of health data.
57 citations
TL;DR: A novel steganography technique that conceals patient information inside a medical image using a dynamic key generated by graph 3 coloring problem is proposed, which ensures reversibility as the original medical image is restored after extracting the embedded data from the stego medical image.
Abstract: Securing data in telemedicine applications is extremely essential and therefore it is mandatory to develop algorithms which preserve the data transmitted. Steganography (information hiding technique) plays a crucial role in telemedicine applications by providing confidentiality, integrity, availability and authenticity. This paper proposes a novel steganography technique that conceals patient information inside a medical image using a dynamic key generated by graph 3 coloring problem. The proposed method ensures reversibility as the original medical image is restored after extracting the embedded data from the stego medical image. Despite the embedding of patient information in the medical image, the visual quality of the image is preserved. Experimental results show that the proposed method is resistant against uniform affine transformations such as cropping, rotation and scaling. The proposed method is designed by considering issues related to transmission errors which could contaminate the medical images transmitted. The performance of the proposed method is compared to other information hiding methods against various parameters such as robustness of stego-image against affine transformations, toughness of the dynamic key generated, detection of transmission error, embedding rate and reversibility.
25 citations
TL;DR: Investigation of the use of innovation payments in the English NHS found that only about one-third of respondents believed innovation payments were effective in meeting their aims in practice.
Abstract: Objectives This study aimed to investigate the use of innovation payments in the English NHS. Methods A structured on-line survey was developed to explore the use of innovation payments. The survey was disseminated to NHS hospital finance managers. A total of 20 surveys ( n =20) were returned. Results The majority (70%) of responding hospitals have applied for innovation payments. In one-third of cases, the payment was for medical devices, followed by drugs (31%), diagnostics (19%), and other technologies (15%). Innovation payments were generally requested because the existing HRG tariff did not reflect the cost of the technology. Processes for determining the payment varied across hospitals, with rates based on supporting evidence of the technology's benefits most common. While a good concept in principle, only about one-third of respondents believed innovation payments were effective in meeting their aims in practice. Conclusions Improvements to the current approach to innovation payments are needed.
15 citations
TL;DR: In this paper, the role of three behavioural triggers related to control, trust, and privacy in social networks for health care was investigated. But the authors did not find that trust in the health care providers was not a significant driver of social network use.
Abstract: Objective To profile social networkers and those who use social networks for medical purposes and investigate the role of three behavioural triggers related to control, trust and privacy. Data sources We use data from Europe (Eurobarometer 74.3, 2010) containing information about reported behaviour and perceptions on social issues such as media, privacy and social networking. Study design Probit models showing associations between individual socio-economic variables and reported social networking, and social networking for health. Extra variables proxying for control, trust in health care providers and privacy of personal information are then added. Following this, two part models accounting for zero observations are utilised. Findings The age profile of social networkers using it for medical care differs from that of social networkers per se. Privacy perceptions appear to be a deterrent of social networking whilst trust in the health care providers is not a significant driver of social network use. Conclusions There is some evidence of a digital divide owing to age, while income is not significantly associated with social networking for health. Social networking does not perfectly substitute for conventional health care.
15 citations
TL;DR: The research presents a norm based framework that involves the user in the design process that is structurally stable and implementable and can be applied in introducing technology in other socially dominated environments.
Abstract: Benefits of telecare have been lower than expected partly because of the social aspects in homes. This paper examines how social aspects are dealt with in telecare design. The objective is to provide guidelines on how social aspects can be captured and applied when designing telecare. A pilot study was conducted in a telecare provider domain to determine how social aspects encountered were dealt with. Social constructivism is applied to capture the user preferences and organisational semiotics to provide structure to the social aspects. The research presents a norm based framework that involves the user in the design process. Validation results confirm that the framework is structurally stable and is implementable. Applying technology in homes offers challenges because of user preferences. Capturing these preferences and applying them at source raises the quality of care. The results of this study can be applied in introducing technology in other socially dominated environments.
13 citations
TL;DR: This paper addresses the gap in extant literature through the development and testing of a conceptual model, exploring determinants of individual infusion of m-health technologies and their subsequent outcomes.
Abstract: Despite substantial research on IT implementation in the IS field, the healthcare industry has historically been considered a technological laggard and lacks direction on how to successfully infuse new technological innovations within individuals work practices. Theoretically, m-health technologies, if infused in work practices can potentially enhance the quality of healthcare delivery. The question remains as to whether practitioners' performance significantly improves and individual knowledge is enhanced through the infusion of these technologies. While a significant amount of extant literature focuses on initial technology adoption and acceptance, there remains a dearth of literature which focuses on the long term utilisation and associated benefits. This paper addresses this gap in extant literature through the development and testing of a conceptual model, exploring determinants of individual infusion of m-health technologies and their subsequent outcomes. This study has several implications for both theory and practice.
13 citations
TL;DR: The factors, which have supported the implementation of a cross-border teleneuromonitoring collaboration between hospitals in the Netherlands, Germany and Switzerland are explored.
Abstract: Despite its potential benefits, telemedicine across borders in Europe is still in its early stages and little has been written about these collaborations. This paper aims to explore the factors, which have supported the implementation of a cross-border teleneuromonitoring collaboration between hospitals in the Netherlands, Germany and Switzerland. Semi-structured interviews with key actors were recorded and fully transcribed, and were analysed using framework analysis. Our results indicated that an array of factors facilitated collaboration in telemonitoring and assured its success and sustainability: (1) a real need to initiate the collaboration, (2) real benefits for all the parties involved, (3) agreed protocols and procedures from the start to overcome differences in healthcare systems, (4) two driving forces to sustain the collaboration; a quest for improved quality of care and for innovation, and (5) recognition that this is a bottom–up collaboration initiated by health care professionals who trusted each other.
11 citations
TL;DR: A solution-driven design process, e.g., focused on further developing a technological solution, is not conducive to a broad appraisal of healthcare system issues and restricts the scope of feedback that may be gathered regarding clinical and end users' needs.
Abstract: Objective Because the way clinicians contribute to the design of a new technology remains poorly understood, our study describes how two academic spin-offs developed a labor decision support software and a home monitoring system. Methods Our analyses triangulate different sources of data; interviews elicited how the team gathered the input of clinical and/or end users, the challenges it faced and how it addressed them; and documents either provided a chronological portrait of the design priorities set by each spin-off or factual information describing technological functionalities. Results By characterizing the design strategies the two teams put forward (solution- or problem-driven) and the user feedback they gathered, our analyses clarify why certain priorities were set among clinical, organizational and health system needs. While both teams relied significantly on the clinical expertise of their members, how and when they gathered user feedback differed greatly. Conclusion A solution-driven design process, e.g., focused on further developing a technological solution, is not conducive to a broad appraisal of healthcare system issues and restricts the scope of feedback that may be gathered regarding clinical and end users' needs. From a policy perspective, including clinical expertise in technology development is thus not enough; what matters is the scope of the issues that developers address.
10 citations
TL;DR: The gap between evidence, management practices and the adoption of innovations is explored, and the degree to which resulting managerial practice is consistent with aims and objectives of the recipient organisation serves to mediate innovation spread.
Abstract: Objectives: Our work explores the gap between evidence, management practices and the adoption of innovations. The article draws on the results of a longitudinal study examining the adoption of remote care (telecare) services. Method: Five UK organisations form purposively chosen case studies. In the process of adoption, we explore how managers interpret and construct evidence to inform practice. Results: Managerial interpretations of evidence are negotiated through a series of interlinked frames of practice. These frames align evidence with existing professional practices and needs, and mobilise collective decision-making and strategic action. Conclusions: The degree to which resulting managerial practice is consistent with aims and objectives of the recipient organisation serves to mediate innovation spread.
9 citations
TL;DR: Call rates increased with levels of deprivation at or above the national average, remaining consistent when accounting for employment, income and education deprivation.
Abstract: Objectives This research aimed to explore the impact of individual indices of deprivation on the uptake of NHS Direct. Method NHS Direct national call data for all 0845 4647 calls made during July, 2010, October, 2010, January, 2011 and April, 2011 ( N =1,342,245) were matched to lower super output area population estimates. Call rates were analysed for age, sex and deprivation (health, employment, income, education) usingnegative binominal regression. Results Significant main effects were found for all deprivation×gender×age and gender×age interactions for each of the deprivation indices ( p Conclusion Call rates increased with levels of deprivation at or above the national average, remaining consistent when accounting for employment, income and education deprivation. Further research should explore the underlying factors that contribute to low utilisation to shape future targeted promotional campaigns.
TL;DR: This paper proposes the relay of high definition video between the ambulance crew and the hospital using public Internet infrastructure through utilising a virtual path slice controller and proposes a set of criteria for evaluating the use of video in emergency scenarios taking into account technical, user, application and process requirements.
Abstract: In emergency situations, communication between the ambulance crew and an emergency department in the hospital can be crucial in determining the best decision for a patient's health. Currently, when an ambulance crew reports at an emergency, paramedics use voice communication from scene of emergency to the hospital. In critical life threatening situations, use of high quality visual images and live video streaming can allow paramedics on the scene of an emergency to take better informed decisions by liaising with expert consultants in the hospital emergency department. This paper proposes the relay of high definition video between the ambulance crew and the hospital using public Internet infrastructure through utilising a virtual path slice controller. The paper also proposes a set of criteria for evaluating the use of video in emergency scenarios taking into account technical, user, application and process requirements together with an overview of the benefits, risks and ethical issues.
TL;DR: This paper suggests use of a semantically enhanced building information model (BIM) to support the linking of clinician activity to the physical resource objects and space; and facilitates the capture of quantifiable data, over time, concerning resource use by key stakeholders.
Abstract: Health care provision is significantly impacted by the ability of the health providers to engineer a viable healthcare space to support care stakeholders needs. In this paper we discuss and propose use of organisational semiotics as a set of methods to link stakeholders to systems, which allows us to capture clinician activity, information transfer, and building use; which in turn allows us to define the value of specific systems in the care environment to specific stakeholders and the dependence between systems in a care space. We suggest use of a semantically enhanced building information model (BIM) to support the linking of clinician activity to the physical resource objects and space; and facilitate the capture of quantifiable data, over time, concerning resource use by key stakeholders. Finally we argue for the inclusion of appropriate stakeholder feedback and persuasive mechanism, to incentivise building user behaviour to support organisational level sustainability policy.
TL;DR: Funding channels have an impact on health intervention coverage and greater harmonization of funding from multiple sources into a single framework would help accelerate the attainment of universal health coverage in Zambia.
Abstract: Objective To determine the impact of different funding scenarios on the achievement of universal health coverage in Zambia. Methods We compiled a database of coverage trends for maternal and child health interventions for the period 2004–2009. Using the Arellano–Bond difference GMM model we estimated the effect of different funding channels on coverage for maternal and child health services over different time periods. Findings A 60% annual increase in funding channeled through the government system would lead to the achievement of overall intervention coverage of 85% for key maternal and child health interventions within a 6year period. A 60% annual increase in funding disbursed directly by donors would take over 9 years to achieve a similar effect. Conclusion Funding channels have an impact on health intervention coverage. Greater harmonization of funding from multiple sources into a single framework would help accelerate towards the attainment of universal health coverage.
TL;DR: An architecture of a mobile security capsule is presented, which enables the trust negotiation to provide a highly secure environment which can be used for the access of highly confidential medical data over the mobile network.
Abstract: This paper presents a detailed architecture and a token-based protocol for the trust delegation on medical data across a public mobile network. The trust is negotiated between a mobile emergency medical unit and a medical record database. The solution presented in this paper enables the development of a software tool that can be used by the emergency medical units in urgent need of sensitive personal medical records about unconscious patients. The trust delegated medical records are downloaded onto the handheld mobile devices of the mobile emergency medical personal. The downloaded medical records are used during emergency care and this data should be protected from future unauthorized distribution and misuse. This paper presents architecture of a mobile security capsule, which enables the trust negotiation to provide a highly secure environment which can be used for the access of highly confidential medical data over the mobile network.
TL;DR: The available evidence for the effects of iron supplementation on cognition and performance with emphasis of a beneficial effect on performance in heart failure patients is summarised.
Abstract: Iron is the most common metal in the earth's crust yet iron deficiency is the most common nutritional deficiency found in humans. The clinical causes and consequences of iron deficiency anaemia are well established. However, iron deficiency without anaemia is a less well described phenomenon. Here we review the available literature examining the deleterious effects of iron deficiency without anaemia on cognitive development and physical performance. We go on to summarise the available evidence for the effects of iron supplementation on cognition and performance with emphasis of a beneficial effect on performance in heart failure patients.
TL;DR: The potential cost savings to the hospital by using WBMRA in PAD are modeled based on collected data that accounts for all interventions in the radiological department of a set of 50 patients with Claudication in the period 2008–2012 at Ninewells Hospital (NHS Tayside).
Abstract: The Whole-Body Magnetic Resonance Angiography (WBMRA) consists of a contrast-enhanced Magnetic Resonance Angiogram (MRA) scan of the entire body in a single step. In the diagnosis of cardiovascular co-morbidities in Peripheral Arterial Disease (PAD), the utilization of WBMRA can streamline the diagnostic process by minimizing the usage of MRA, CT, and Angiograms. In this work, the potential cost savings to the hospital by using WBMRA in PAD are modeled based on collected data that accounts for all interventions in the radiological department of a set of 50 patients with Claudication in the period 2008–2012 at Ninewells Hospital (NHS Tayside). As the application of WBMRA is only marginally more expensive than lower-limb MRA, a large gain in efficiency is possible by eliminating unneeded MRA by 25% and Angiograms by 30% as well as several steps of consultations. We estimate that this can save up to £1.2M in NHS Tayside and Fife, £7.5M in Scotland and £90M in UK per annum. In addition, WBMRA can save £20M per year in the UK in the treatment of Diabetes.
TL;DR: A Real Time Web Based Information System to monitor changes in the antibiotic sensitivity of microorganisms, located at different areas and time periods based on data collected from accredited laboratories, can aid physicians to improve the choice of antibiotic to be administered using real time data.
Abstract: Drug resistance—arising from the misuse and overuse of antimicrobial agents—is becoming a major concern as new strains of resistant microorganisms are emerging and fewer new antimicrobial drugs are in development. This paper presents an idea of implementing a Real Time Web Based Information System to monitor changes in the antibiotic sensitivity of microorganisms, located at different areas and time periods based on data collected from accredited laboratories. This pattern can be mapped over geographical map of the area and can be interpreted by clinicians/policy makers. The authors demonstrate the use of such information system using cross sectional data obtained from a nasopharyngeal swab survey of 151 children affected with HIV. Such system can aid physicians to improve the choice of antibiotic to be administered using real time data.
TL;DR: Examination of rural health access to care, barriers to practice for Advanced Practice Nurses (APNs) in rural health, explore solutions, and arrive at a policy change that would improve rural citizens′ access to health care found the 2nd alternative was determined to be the most effective.
Abstract: Objectives The objective of this paper was to examine rural health access to care, barriers to practice for Advanced Practice Nurses (APNs) in rural health, explore solutions, and arrive at a policy change that would improve rural citizens′ access to health care. This policy change should improve access to care, be cost-efficient, and have ease of implementation. Methods Methods used for research included online health care journals, original research, and government statistics and websites. Sources were PubMed, Google Scholar, state Boards of Nursing publications including Scope of Practice statutes, and Rural Health Associations′ publications. Results Background information and evidence was gathered, and 3 alternatives were explored: (1) Increasing incentives to practitioners to practice in rural areas, (2) Removing regulatory barriers to practice for APNs in rural health, and (3) Funding original research to determine optimal provider mix in rural health care. Advantages and disadvantages to these alternatives were examined with respect to population benefit, cost-effectiveness, administrative feasibility, and resource allocation equity. The 2nd alternative was determined to be the most effective. Conclusion Access to health care for rural citizens is significantly worse than for urban dwellers, and the current methods of improving it are inadequate. The situation will be worsened by the projected shortage of primary care providers in the future, and therefore action to improve this is imperative. This situation can be greatly improved by removing barriers to practice for APNs to enable them to better provide care in rural areas, thus increasing rural citizens′ access to health care.
TL;DR: The Chinese experience implies that if there is no effective and powerful regulatory system, the UK Coalition Government's policy to abolish the arbitrary private patient income cap on the amount of income NHS Foundation Trusts may earn from privately funded patients could have some negative impacts, for instance, on tackling health inequalities and ensuring good provider behaviour.
Abstract: China's market-oriented health reforms since the early 1980s created a range of problems in its healthcare system. By mid-2000 healthcare costs had increased to a level which was too expensive even for average income families without any form of healthcare subsidy. On realising the severity of health related problems, China's central government launched its large-scale, expensive health reform in April 2009, intending to re-establish the universal healthcare system which would provide affordable basic health care to everyone in the country. Using unformatted, in-depth interviews with multiple stakeholders of health care in China, this study aimed to provide the latest research-based evidence about access to health care for ordinary citizens in China two years into the April 2009 health reform. It aimed to find out what implications could be drawn for the English NHS (National Health Service) Foundation Trusts reform pursued by the UK Coalition Government from China's experience of health reforms. The study provided evidence that, two years into the April 2009 health reform, there was a newly re-established, public health insurance based healthcare system in China. The new system was providing affordable basic health care to even the most remote and poorest of our participants who were among the most remote and poorest in China in July–August 2011. Given the geographical and population size of China, this is an enormous achievement. The Chinese experience implies that if there is no effective and powerful regulatory system, the UK Coalition Government's policy to abolish the arbitrary private patient income cap on the amount of income NHS Foundation Trusts may earn from privately funded patients could have some negative impacts, for instance, on tackling health inequalities and ensuring good provider behaviour.
TL;DR: The development 10 years after the implementation of decentralisation of the financial responsibility for pharmaceuticals in Sweden seems to be more robust in terms of capping costs while the population based model includes a higher level of service to the patient.
Abstract: Background Risk sharing mechanisms in health care balance between need and demand within the financial limits, acceptable from medical, political and ethical perspectives. Subsidising outpatients' medicines is part of the risk sharing. In order to stimulate a more cost-effective use of resources decentralisation of the financial responsibility for pharmaceuticals was introduced in Sweden in 2002. In this study we explored the development 10 years after the implementation. Method The Swedish counties are responsible for all financing and provision of health care. In this study nine representative counties were included, each with its own set of models for devolution of financial responsibilities. Information was collected from written sources and supplemented by interviews with high level officials and administrators in each county. Results Two main models were found; in the population based model the responsibility for subsidising pharmaceuticals is decentralised to the primary care units and their responsibility follows listed patients regardless of prescriber. In the other model each prescriber is financially responsible for own prescribing. In addition, over time mixed models were developed. Conclusions Incentives for cost containment on an organisational level seem to be highly effective although there is no individual economic return involved. The prescriber based model seems to be more robust in terms of capping costs while the population based includes a higher level of service to the patient. The choices of principles were based on norms and responses from the users, and were not actively assessed by the counties in terms of cost efficiency.
TL;DR: A retrospective study of the big budget National Programme for IT (NPFIT) in the UK is seen through the lens of the national newspapers and analysed via the Cynefin model, suggesting that gaps between media reporting and success factors are captured by the less tangible aspects of theCynefin framework.
Abstract: This paper describes a retrospective study of the big budget National Programme for IT (NPFIT) in the UK. The project is seen through the lens of the national newspapers and analysed via the Cynefin model. A set of success factors in health information system (IS) initiatives are derived from the literature, 584 newspaper stories drawn from the period October 2002, when the NPFIT programme began, until the end of 2012, are analysed using a multi method approach to identify gaps between real information systems issues and reporting. Results suggest that gaps between media reporting and success factors are captured by the less tangible (complex and chaotic) aspects of the Cynefin framework. Further, newspaper articles skirted around many human aspects of system development that were prominent in the IS literature such as of change management and user acceptance. The most commonly reported domain moved from known to chaotic as the project progressed.
TL;DR: The results of a field test indicate that NFC is almost as simple as filling out a paper-based questionnaire, and the information quality of each patient's health status could be improved.
Abstract: We present an electronic data capture (EDC) system based on Near Field Communication (NFC). NFC is an easy way for self-reporting of health status information. As traditional paper-based questionnaires are time- and cost-consuming and may be affected by low patient compliance, our EDC system allows patient monitoring and electronic data acquisition directly from the patient's home. It enables real time representation and analysis of patient data and thus allows direct medical intervention by physicians. The results of a field test indicate that NFC is almost as simple as filling out a paper-based questionnaire. During the study patients used the prototype autonomously and with minimal errors. Further, NFC technology was perceived as very intuitive and the information quality of each patient's health status could be improved. Based on the findings we derive recommendations for future research and applications of NFC based electronic data capture systems.
TL;DR: The results revealed that the OBESE model simulates the CBT outcome satisfactorily and simulation experiments demonstrated that it could be applied as a predictive tool for evaluating the outcome of CBT weight reduction program.
Abstract: The objective of our study was to construct the obesity (OBESE) model based on the method of response function (MRF) approach which allows predicting the impact of the pre-treatment meanings of subjects' psychological variables on the outcome of CBT weight management program. A total of 104 patients (32 males and 72 females, mean age was 37.6±6.7 years) participated in the CBT weight management program. Control group was included. The data on psychological variables were used for the construction of the OBESE model, evaluation of its parameters and providing simulation experiments. Results The results revealed that the OBESE model simulates the CBT outcome satisfactorily and simulation experiments demonstrated that it could be applied as a predictive tool for evaluating the outcome of CBT weight reduction program. The OBESE model could be applied as a helpful tool for health technology assessment undertaking to evaluate the evidence on combined cognitive-behavioral therapy to reduce weight.
TL;DR: Among the paired-matched gastrectomy, colectomy, and anterior resection groups, LS was associated with fewer complications and earlier recovery of postoperative oral intake, and laparoscopic anterior resections and colectomies were associated with less frequent BI deterioration.
Abstract: Objectives Laparoscopic abdominal surgery (LS) has been prevailing over open surgery (OS). However, its functional outcomes in the aging generation have not been sufficiently examined. We compared changes in physical status and earlier resumption of oral intake between LS and OS. Methods Using the Japanese administrative database, we matched variables affecting LS and compared them between LS and OS patients. During the 6-month period from July to December of 2006–2010, we examined the data from data from surviving patients of ≥15 year old who underwent isolated gastrectomy, colectomy, or anterior resection. Functional status was estimated by the Barthel index (BI) at admission and discharge. Outcomes were postoperative complications, BI deterioration, change in BI, and day of recommencing postoperative oral intake. Results We identified 30,763 gastrectomies (laparoscopic: 7297), 31,958 colectomies (laparoscopic: 9364), and 12,545 anterior resections (laparoscopic: 4351). Variation in LS indications was observed in patient and hospital mixes. Among the paired-matched gastrectomy, colectomy, and anterior resection groups, LS was associated with fewer complications and earlier recovery of postoperative oral intake. Laparoscopic anterior resection (LAR) and colectomy were associated with less frequent BI deterioration. Longer operative time was associated with more complications, which then influenced BI deterioration in patients who underwent anterior resection. Conclusions Shorter operative time for LAR was associated with less functional deterioration than for laparoscopic gastrectomy and colectomy. Physicians should consider the appropriate indications for LS by concurrently avoiding unnecessary longer operations and their associated complications. More investment in teaching the skills necessary for LAR is recommended.