HR 5885 IHCommentsClose CommentsPermalink

To promote a better health information system.CommentsClose CommentsPermalink

April 24, 2008

Mr. BURGESS introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concernedCommentsClose CommentsPermalink

To promote a better health information system.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,CommentsClose CommentsPermalink

SECTION 1. SHORT TITLE AND TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the `Health Information Technology Promotion Act of 2008'.CommentsClose CommentsPermalink





(b) Table of Contents- The table of contents of this Act is as follows:CommentsClose CommentsPermalink





Sec. 1. Short title and table of contents.CommentsClose CommentsPermalink





Sec. 2. Preserving privacy and security laws.CommentsClose CommentsPermalink

TITLE I--PROMOTING THE USE OF HEALTH INFORMATION TECHNOLOGY TO BETTER COORDINATE HEALTH CARE

Sec. 101. Safe harbors to antikickback civil penalties and criminal penalties for provision of Health Information Technology and training services.CommentsClose CommentsPermalink





Sec. 102. Exception to limitation on certain physician referrals (under Stark) for provision of Health Information Technology and training services to health care professionals.CommentsClose CommentsPermalink





Sec. 103. Rules of construction regarding use of consortia.CommentsClose CommentsPermalink

TITLE II--ADDITIONAL PROVISIONS

Sec. 201. Promotion of telehealth services.CommentsClose CommentsPermalink





Sec. 202. Study and report on expansion of home health-related telehealth services.CommentsClose CommentsPermalink





Sec. 203. Study and report on store and forward technology for telehealth.CommentsClose CommentsPermalink





Sec. 204. Ensuring health care providers participating in PHSA programs, Medicaid, SCHIP, or the MCH program may maintain health information in electronic form.CommentsClose CommentsPermalink





Sec. 205. Ensuring health care providers participating in the Medicare program may maintain health information in electronic form.CommentsClose CommentsPermalink





Sec. 206. Study and report on State, regional, and community health information exchanges.CommentsClose CommentsPermalink





Sec. 207. Promoting Health Information Technology as a tool for chronic disease management.CommentsClose CommentsPermalink

SEC. 2. PRESERVING PRIVACY AND SECURITY LAWS.

Nothing in this Act (or the amendments made by this Act) shall be construed to affect the scope, substance, or applicability of section 264(c) of the Health Insurance Portability and Accountability Act of 1996 and any regulation issued pursuant to such section.CommentsClose CommentsPermalink

TITLE I--PROMOTING THE USE OF HEALTH INFORMATION TECHNOLOGY TO BETTER COORDINATE HEALTH CARE

SEC. 101. SAFE HARBORS TO ANTIKICKBACK CIVIL PENALTIES AND CRIMINAL PENALTIES FOR PROVISION OF HEALTH INFORMATION TECHNOLOGY AND TRAINING SERVICES.

(a) For Civil Penalties- Section 1128A of the Social Security Act (42 U.S.C. 1320a-7a) is amended--CommentsClose CommentsPermalink





(1) in subsection (b), by adding at the end the following new paragraph:CommentsClose CommentsPermalink





`(4) For purposes of this subsection, inducements to reduce or limit services described in paragraph (1) shall not include the practical or other advantages resulting from health information technology or related installation, maintenance, support, or training services.'; andCommentsClose CommentsPermalink





(2) in subsection (i), by adding at the end the following new paragraph:CommentsClose CommentsPermalink





`(8) The term `health information technology' means hardware, software, license, right, intellectual property, equipment, or other information technology (including new versions, upgrades, and connectivity) designed or provided primarily for the electronic creation, maintenance, or exchange of health information to better coordinate care or improve health care quality, efficiency, or research.'.CommentsClose CommentsPermalink





(b) For Criminal Penalties- Section 1128B of such Act (42 U.S.C. 1320a-7b) is amended--CommentsClose CommentsPermalink





(1) in subsection (b)(3)--CommentsClose CommentsPermalink





(A) in subparagraph (G), by striking `and' at the end;CommentsClose CommentsPermalink





(B) in the subparagraph (H) added by section 237(d) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2213)--CommentsClose CommentsPermalink





(i) by moving such subparagraph 2 ems to the left; andCommentsClose CommentsPermalink





(ii) by striking the period at the end and inserting a semicolon;CommentsClose CommentsPermalink





(C) in the subparagraph (H) added by section 431(a) of such Act (117 Stat. 2287)--CommentsClose CommentsPermalink





(i) by redesignating such subparagraph as subparagraph (I);CommentsClose CommentsPermalink





(ii) by moving such subparagraph 2 ems to the left; andCommentsClose CommentsPermalink





(iii) by striking the period at the end and inserting `; and'; andCommentsClose CommentsPermalink





(D) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





`(J) any nonmonetary remuneration (in the form of health information technology, as defined in section 1128A(i)(8), or related installation, maintenance, support, or training services) made to a person by a specified entity (as defined in subsection (g)) if--CommentsClose CommentsPermalink





`(i) the provision of such remuneration is without an agreement between the parties or legal condition that--CommentsClose CommentsPermalink





`(I) limits or restricts the use of the health information technology to services provided by the physician to individuals receiving services at the specified entity;CommentsClose CommentsPermalink





`(II) limits or restricts the use of the health information technology in conjunction with other health information technology; orCommentsClose CommentsPermalink





`(III) conditions the provision of such remuneration on the referral of patients or business to the specified entity;CommentsClose CommentsPermalink





`(ii) such remuneration is arranged for in a written agreement that is signed by the parties involved (or their representatives) and that specifies the remuneration solicited or received (or offered or paid) and states that the provision of such remuneration is made for the primary purpose of better coordination of care or improvement of health quality, efficiency, or research; andCommentsClose CommentsPermalink





`(iii) the specified entity providing the remuneration (or a representative of such entity) has not taken any action to disable any basic feature of any hardware or software component of such remuneration that would permit interoperability.'; andCommentsClose CommentsPermalink





(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink





`(g) Specified Entity Defined- For purposes of subsection (b)(3)(J), the term `specified entity' means an entity that is a hospital, group practice, prescription drug plan sponsor, a Medicare Advantage organization, or any other such entity specified by the Secretary, considering the goals and objectives of this section, as well as the goals to better coordinate the delivery of health care and to promote the adoption and use of health information technology.'.CommentsClose CommentsPermalink





(c) Effective Date and Effect on State Laws-CommentsClose CommentsPermalink





(1) EFFECTIVE DATE- The amendments made by subsections (a) and (b) shall take effect on the date that is 120 days after the date of the enactment of this Act.CommentsClose CommentsPermalink





(2) PREEMPTION OF STATE LAWS- No State (as defined in section 1101(a) of the Social Security Act (42 U.S.C. 1301(a)) for purposes of title XI of such Act) shall have in effect a State law that imposes a criminal or civil penalty for a transaction described in section 1128A(b)(4) or section 1128B(b)(3)(J) of such Act, as added by subsections (a)(1) and (b), respectively, if the conditions described in the respective provision, with respect to such transaction, are met.CommentsClose CommentsPermalink





(d) Study and Report To Assess Effect of Safe Harbors on Health System-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary of Health and Human Services shall conduct a study to determine the impact of each of the safe harbors described in paragraph (3). In particular, the study shall examine the following:CommentsClose CommentsPermalink





(A) The effectiveness of each safe harbor in increasing the adoption of health information technology.CommentsClose CommentsPermalink





(B) The types of health information technology provided under each safe harbor.CommentsClose CommentsPermalink





(C) The extent to which the financial or other business relationships between providers under each safe harbor have changed as a result of the safe harbor in a way that adversely affects or benefits the health care system or choices available to consumers.CommentsClose CommentsPermalink





(D) The impact of the adoption of health information technology on health care quality, cost, and access under each safe harbor.CommentsClose CommentsPermalink





(2) REPORT- Not later than three years after the effective date described in subsection (c)(1), the Secretary of Health and Human Services shall submit to Congress a report on the study under paragraph (1).CommentsClose CommentsPermalink





(3) SAFE HARBORS DESCRIBED- For purposes of paragraphs (1) and (2), the safe harbors described in this paragraph are--CommentsClose CommentsPermalink





(A) the safe harbor under section 1128A(b)(4) of such Act (42 U.S.C. 1320a-7a(b)(4)), as added by subsection (a)(1); andCommentsClose CommentsPermalink





(B) the safe harbor under section 1128B(b)(3)(J) of such Act (42 U.S.C. 1320a-7b(b)(3)(J)), as added by subsection (b).CommentsClose CommentsPermalink

SEC. 102. EXCEPTION TO LIMITATION ON CERTAIN PHYSICIAN REFERRALS (UNDER STARK) FOR PROVISION OF HEALTH INFORMATION TECHNOLOGY AND TRAINING SERVICES TO HEALTH CARE PROFESSIONALS.

(a) In General- Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)) is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink





`(6) INFORMATION TECHNOLOGY AND TRAINING SERVICES-CommentsClose CommentsPermalink





`(A) IN GENERAL- Any nonmonetary remuneration (in the form of health information technology or related installation, maintenance, support or training services) made by a specified entity to a physician if--CommentsClose CommentsPermalink





`(i) the provision of such remuneration is without an agreement between the parties or legal condition that--CommentsClose CommentsPermalink





`(I) limits or restricts the use of the health information technology to services provided by the physician to individuals receiving services at the specified entity;CommentsClose CommentsPermalink





`(II) limits or restricts the use of the health information technology in conjunction with other health information technology; orCommentsClose CommentsPermalink





`(III) conditions the provision of such remuneration on the referral of patients or business to the specified entity;CommentsClose CommentsPermalink





`(ii) such remuneration is arranged for in a written agreement that is signed by the parties involved (or their representatives) and that specifies the remuneration made and states that the provision of such remuneration is made for the primary purpose of better coordination of care or improvement of health quality, efficiency, or research; andCommentsClose CommentsPermalink





`(iii) the specified entity (or a representative of such entity) has not taken any action to disable any basic feature of any hardware or software component of such remuneration that would permit interoperability.CommentsClose CommentsPermalink





`(B) HEALTH INFORMATION TECHNOLOGY DEFINED- For purposes of this paragraph, the term `health information technology' means hardware, software, license, right, intellectual property, equipment, or other information technology (including new versions, upgrades, and connectivity) designed or provided primarily for the electronic creation, maintenance, or exchange of health information to better coordinate care or improve health care quality, efficiency, or research.CommentsClose CommentsPermalink





`(C) SPECIFIED ENTITY DEFINED- For purposes of this paragraph, the term `specified entity' means an entity that is a hospital, group practice, prescription drug plan sponsor, a Medicare Advantage organization, or any other such entity specified by the Secretary, considering the goals and objectives of this section, as well as the goals to better coordinate the delivery of health care and to promote the adoption and use of health information technology.'.CommentsClose CommentsPermalink





(b) Effective Date; Effect on State Laws-CommentsClose CommentsPermalink





(1) EFFECTIVE DATE- The amendment made by subsection (a) shall take effect on the date that is 120 days after the date of the enactment of this Act.CommentsClose CommentsPermalink





(2) PREEMPTION OF STATE LAWS- No State (as defined in section 1101(a) of the Social Security Act (42 U.S.C. 1301(a)) for purposes of title XI of such Act) shall have in effect a State law that imposes a criminal or civil penalty for a transaction described in section 1877(b)(6) of such Act, as added by subsection (a), if the conditions described in such section, with respect to such transaction, are met.CommentsClose CommentsPermalink





(c) Study and Report To Assess Effect of Exception on Health System-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary of Health and Human Services shall conduct a study to determine the impact of the exception under section 1877(b)(6) of such Act (42 U.S.C. 1395nn(b)(6)), as added by subsection (a). In particular, the study shall examine the following:CommentsClose CommentsPermalink





(A) The effectiveness of the exception in increasing the adoption of health information technology.CommentsClose CommentsPermalink





(B) The types of health information technology provided under the exception.CommentsClose CommentsPermalink





(C) The extent to which the financial or other business relationships between providers under the exception have changed as a result of the exception in a way that adversely affects or benefits the health care system or choices available to consumers.CommentsClose CommentsPermalink





(D) The impact of the adoption of health information technology on health care quality, cost, and access under the exception.CommentsClose CommentsPermalink





(2) REPORT- Not later than three years after the effective date described in subsection (b)(1), the Secretary of Health and Human Services shall submit to Congress a report on the study under paragraph (1).CommentsClose CommentsPermalink

SEC. 103. RULES OF CONSTRUCTION REGARDING USE OF CONSORTIA.

(a) Application to Safe Harbor From Criminal Penalties- Section 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a-7b(b)(3)) is amended by adding after and below subparagraph (J), as added by section 101(b)(1), the following: `For purposes of subparagraph (J), nothing in such subparagraph shall be construed as preventing a specified entity, consistent with the specific requirements of such subparagraph, from forming a consortium composed of health care providers, payers, employers, and other interested entities to collectively purchase and donate health information technology, or from offering health care providers a choice of health information technology products in order to take into account the varying needs of such providers receiving such products.'.CommentsClose CommentsPermalink





(b) Application to Stark Exception- Paragraph (6) of section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as added by section 102(a), is amended by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





`(D) RULE OF CONSTRUCTION- For purposes of subparagraph (A), nothing in such subparagraph shall be construed as preventing a specified entity, consistent with the specific requirements of such subparagraph, from--CommentsClose CommentsPermalink





`(i) forming a consortium composed of health care providers, payers, employers, and other interested entities to collectively purchase and donate health information technology; orCommentsClose CommentsPermalink





`(ii) offering health care providers a choice of health information technology products in order to take into account the varying needs of such providers receiving such products.'.CommentsClose CommentsPermalink

TITLE II--ADDITIONAL PROVISIONS

SEC. 201. PROMOTION OF TELEHEALTH SERVICES.

(a) Facilitating the Provision of Telehealth Services Across State Lines- The Secretary of Health and Human Services shall, in coordination with physicians, health care practitioners, patient advocates, and representatives of States, encourage and facilitate the adoption of State reciprocity agreements for practitioner licensure in order to expedite the provision across State lines of telehealth services.CommentsClose CommentsPermalink





(b) Report- Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report on the actions taken to carry out subsection (a).CommentsClose CommentsPermalink





(c) State Defined- For purposes of this subsection, the term `State' has the meaning given that term for purposes of title XVIII of the Social Security Act.CommentsClose CommentsPermalink

SEC. 202. STUDY AND REPORT ON EXPANSION OF HOME HEALTH-RELATED TELEHEALTH SERVICES.

(a) Study- The Secretary of Health and Human Services shall conduct a study to determine the feasibility, advisability, and the costs of--CommentsClose CommentsPermalink





(1) including coverage and payment for home health-related telehealth services as part of home health services under title XVIII of the Social Security Act; andCommentsClose CommentsPermalink





(2) expanding the list of sites described in paragraph (4)(C)(ii) of section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) to include county mental health clinics or other publicly funded mental health facilities for the purpose of payment under such section for the provision of telehealth services at such clinics or facilities.CommentsClose CommentsPermalink





(b) Specifics of Study- Such study shall demonstrate whether the changes described in paragraphs (1) and (2) of subsection (a) will result in the following:CommentsClose CommentsPermalink





(1) Enhanced health outcomes for individuals with one or more chronic conditions.CommentsClose CommentsPermalink





(2) Health outcomes for individuals furnished telehealth services or home health-related telehealth services that are at least comparable to the health outcomes for individuals furnished similar items and services by a health care provider at the same location of the individual or at the home of the individual, respectively.CommentsClose CommentsPermalink





(3) Facilitation of communication of more accurate clinical information between health care providers.CommentsClose CommentsPermalink





(4) Closer monitoring of individuals by health care providers.CommentsClose CommentsPermalink





(5) Overall reduction in expenditures for health care items and services.CommentsClose CommentsPermalink





(6) Improved access to health care.CommentsClose CommentsPermalink





(c) Home Health-Related Telehealth Services Defined- For purposes of this section, the term `home health-related telehealth services' means technology-based professional consultations, patient monitoring, patient training services, clinical observation, patient assessment, and any other health services that utilize telecommunications technologies. Such term does not include a telecommunication that consists solely of a telephone audio conversation, facsimile, electronic text mail, or consultation between two health care providers.CommentsClose CommentsPermalink





(d) Report- Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report on the study conducted under subsection (a) and shall include in such report such recommendations for legislation or administration action as the Secretary determines appropriate.CommentsClose CommentsPermalink

SEC. 203. STUDY AND REPORT ON STORE AND FORWARD TECHNOLOGY FOR TELEHEALTH.

(a) Study- The Secretary of Health and Human Services, acting through the Director of the Office for the Advancement of Telehealth, shall conduct a study on the use of store and forward technologies (that provide for the asynchronous transmission of health care information in single or multimedia formats) in the provision of telehealth services. Such study shall include an assessment of the feasibility, advisability, and the costs of expanding the use of such technologies for use in the diagnosis and treatment of certain conditions.CommentsClose CommentsPermalink





(b) Report- Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report on the study conducted under subsection (a) and shall include in such report such recommendations for legislation or administration action as the Secretary determines appropriate.CommentsClose CommentsPermalink

SEC. 204. ENSURING HEALTH CARE PROVIDERS PARTICIPATING IN PHSA PROGRAMS, MEDICAID, SCHIP, OR THE MCH PROGRAM MAY MAINTAIN HEALTH INFORMATION IN ELECTRONIC FORM.

Part B of title II of the Public Health Service Act is amended by adding at the end the following new section:CommentsClose CommentsPermalink

`SEC. 249. ENSURING HEALTH CARE PROVIDERS MAY MAINTAIN HEALTH INFORMATION IN ELECTRONIC FORM.

`(a) In General- Any health care provider that participates in a health care program that receives Federal funds under this Act, or under title V, XIX, or XXI of the Social Security Act, shall be deemed as meeting any requirement for the maintenance of data in paper form under such program (whether or not for purposes of management, billing, reporting, reimbursement, or otherwise) if the required data is maintained in an electronic form.CommentsClose CommentsPermalink





`(b) Relation to State Laws- Beginning on the date that is one year after the date of the enactment of this section, subsection (a) shall supersede any contrary provision of State law.CommentsClose CommentsPermalink





`(c) Construction- Nothing in this section shall be construed as--CommentsClose CommentsPermalink





`(1) requiring health care providers to maintain or submit data in electronic form;CommentsClose CommentsPermalink





`(2) preventing a State from permitting health care providers to maintain or submit data in paper form; orCommentsClose CommentsPermalink





`(3) preventing a State from requiring health care providers to maintain or submit data in electronic form.'.CommentsClose CommentsPermalink

SEC. 205. ENSURING HEALTH CARE PROVIDERS PARTICIPATING IN THE MEDICARE PROGRAM MAY MAINTAIN HEALTH INFORMATION IN ELECTRONIC FORM.

Section 1871 of the Social Security Act (42 U.S.C. 1395hh) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





`(g)(1) Any provider of services or supplier shall be deemed as meeting any requirement for the maintenance of data in paper form under this title (whether or not for purposes of management, billing, reporting, reimbursement, or otherwise) if the required data is maintained in an electronic form.CommentsClose CommentsPermalink





`(2) Nothing in this subsection shall be construed as requiring health care providers to maintain or submit data in electronic form.'.CommentsClose CommentsPermalink

SEC. 206. STUDY AND REPORT ON STATE, REGIONAL, AND COMMUNITY HEALTH INFORMATION EXCHANGES.

(a) Study- The Secretary of Health and Human Services shall conduct a study on issues related to the development, operation, and implementation of State, regional, and community health information exchanges. Such study shall include the following, with respect to such health information exchanges:CommentsClose CommentsPermalink





(1) Profiles detailing the current stages of such health information exchanges with respect to the progression of the development, operation, implementation, organization, and governance of such exchanges.CommentsClose CommentsPermalink





(2) The impact of such exchanges on health care quality, safety, and efficiency, including--CommentsClose CommentsPermalink





(A) any impact on the coordination of health information and services across health care providers and other organizations relevant to health care;CommentsClose CommentsPermalink





(B) any impact on the availability of health information at the point-of-care to make timely medical decisions;CommentsClose CommentsPermalink





(C) any benefits with respect to the promotion of wellness, disease prevention, and chronic disease management;CommentsClose CommentsPermalink





(D) any improvement with respect to public health preparedness and response;CommentsClose CommentsPermalink





(E) any impact on the widespread adoption of interoperable health information technology, including electronic health records;CommentsClose CommentsPermalink





(F) any contributions to achieving an Internet-based national health information network;CommentsClose CommentsPermalink





(G) any contribution of health information exchanges to consumer access and to consumers' use of their health information; andCommentsClose CommentsPermalink





(H) any impact on the operation of--CommentsClose CommentsPermalink





(i) the Medicare and Medicaid programs under title XVIII and XIX, respectively, of the Social Security Act;CommentsClose CommentsPermalink





(ii) the State Children's Health Insurance Program (SCHIP) under title XXI of such Act;CommentsClose CommentsPermalink





(iii) disproportionate share hospitals described in section 1923 of such Act;CommentsClose CommentsPermalink





(iv) Federally-qualified health centers; orCommentsClose CommentsPermalink





(v) managed care plans, if a significant number of the plan's enrollees are beneficiaries in the Medicaid program or State Children's Health Insurance Program under title XIX or XXI, respectively, of such Act.CommentsClose CommentsPermalink





(3) Best practice models for financing, incentivizing, and sustaining such health information exchanges.CommentsClose CommentsPermalink





(4) Information identifying the common principles, policies, tools, and standards used (or proposed) in the public and private sectors to support the development, operation, and implementation of such health information exchanges.CommentsClose CommentsPermalink





(5) A description of any areas in which Federal Government leadership is needed to support growth and sustainability of such health information exchanges.CommentsClose CommentsPermalink





(b) Report- Not later than one year after the date of enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report on the study described in subsection (a), including such recommendations as the Secretary determines appropriate to facilitate the development, operation, and implementation of health information exchanges.CommentsClose CommentsPermalink

SEC. 207. PROMOTING HEALTH INFORMATION TECHNOLOGY AS A TOOL FOR CHRONIC DISEASE MANAGEMENT.

(a) In General- The Secretary of Health and Human Services shall establish a two-year project to demonstrate the impact of health information technology on disease management for individuals entitled to medical assistance under a State plan under title XIX of the Social Security Act.CommentsClose CommentsPermalink





(b) Structure of Project- The project under subsection (a) shall--CommentsClose CommentsPermalink





(1) create a web-based virtual case management tool that provides access to best practices for managing chronic disease; andCommentsClose CommentsPermalink





(2) provide chronic disease patients and caregivers access to their own medical records and to a single source of information on chronic disease.CommentsClose CommentsPermalink





(c) Competition- Not later than the date that is 90 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall seek proposals from States to carry out the project under subsection (a). The Secretary shall select not less than four of such proposals submitted, and at least one proposal selected shall include a regional approach that features access to an integrated hospital information system in at least two adjoining States and that permits the measurement of health outcomes.CommentsClose CommentsPermalink





(d) Report- Not later than the date that is 90 days after the last day of the project under subsection (a), the Secretary of Health and Human Services shall submit to Congress a report on such project and shall include in such report the amount of any cost-savings resulting from the project and such recommendations for legislation or administrative action as the Secretary determines appropriate.CommentsClose CommentsPermalink