Human Factors Can Assist with Appropriate Implementation of Health Information Technology

April 29, 2009 by · 3 Comments
Filed under: health care, human factors 

On February 17, 2009, President Obama signed into law the American Recovery and Reinvestment Act (ARRA) of 2009 (13.4 MB, .pdf).  Its’ stated purpose, among other things, is “to provide investments needed to increase economic efficiency by spurring technological advances in science and health” (p. 2).  The act consists of several provisions, including title XIII – Health Information Technology (a.k.a., “Health Information Technology for Economic and Clinical Health Act” [HITECH Act]).  According to the ARRA:

“‘health information technology’ means hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information.” (p. 115)

“‘qualified electronic health record’ means an electronic record of health-related information on an individual that-”(A) includes patient demographic and clinical health information, such as medical history and problem lists; and ”(B) has the capacity-”(i) to provide clinical decision support; ”(ii) to support physician order entry; ”(iii) to capture and query information relevant to health care quality; and ”(iv) to exchange electronic health information with, and integrate such information from other sources.” (p. 115)

“‘certified EHR technology’ means a qualified electronic health record that is certified pursuant to section 3001(c)(5) as meeting standards adopted under section 3004 that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals).” (p. 114)

The ARRA authorizes $19 billion (Blumenthal, 2009) in funding between 2011 and 2015 to facilitate health information technology acquisition and implementation.  Of this amount, $17 billion is allocated for Medicare and Medicaid reimbursement incentives to physicians and hospitals “for adoption and meaningful use of certified EHR technology” (ARRA, 2009, p. 353).  Eligible physicians can receive up to $44,000 in incentive payments starting in 2011 (p. 354), while eligible hospitals will receive a base amount of $2,000,000 (p. 363).  The remaining $2 billion is allocated to Office of the National Coordinator (ONC) for Health Information Technology “to carry out title XIII of this Act” (p. 65).

Electronic health record systems, one type of health information technology, are a main focus of the HITECH Act.  Although, as of yet, there is no standardized definition for electronic health record systems (Jha, et al., 2006), some agreement has been reached on the core functionalities they should possess.  Specifically, eight categories (see Institute of Medicine (2003) for more detail) have been identified, including:

  • health information & data;
  • results management;
  • order entry & management;
  • decision support;
  • electronic communication & connectivity;
  • patient support;
  • administrative processes; and
  • reporting & population health management. (p. 7)

Moreover, the “core EHR system functionalities” should meet five criteria:

  • improve patient safety;
  • support the delivery of effective patient care;
  • facilitate management of chronic conditions;
  • improve efficiency; and
  • feasibility of implementation (Institute of Medicine, 2003, pp. 5-6).

This sentiment is reflected in the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology homepage, where it states they can:

  • improve health care quality;
  • prevent medical errors;
  • reduce health care costs;
  • increase administrative efficiencies;
  • decrease paperwork; and
  • expand access to affordable care.

Although appropriately implemented EHR systems have the potential to increase the efficiency, quality, and safety of health care (Chaudhry, et al., 2006), while decreasing associated costs (Girosi, Meili, & Scoville, 2005), adoption in the U.S. is still very low (DesRoches, et al., 2008; Jha, et al., 2006).  In a recent survey of 3049 acute care general hospitals, it was determined that only “1.5% (95% confidence interval [CI], 1.1 to 2.0) of U.S. hospitals had a comprehensive electronic-records system implemented across all major clinical units and an additional 7.6% (95% CI, 6.8 to 8.1) had a basic system that included functionalities for physicians’ notes and nursing assessments in at least one clinical unit (Jha, et al., 2009, p. 1631).

Given the low adoption rates, it’s important to understand possible barriers that are preventing increased implementation.  Reported barriers (Blumenthal, 2009; Hoffman & Podgurski, 2008; Jha, et al., 2009; Wang, et al., 2005), include:

  • lack of funding for purchase & maintenance;
  • resistance from physicians & hospital staff;
  • inadequate information technology staff; and
  • hospital type (e.g., non-profit, for-profit, public, private, etc.) & size.

Moreover, besides barriers, there are also several potential negative consequences for improper implementation (Han, et al., 2005; Hoffman & Podgurski, 2008; Weimar, 2009), including:

  • increased adverse & sentinel events;
  • decreased patient & staff safety;
  • increased litigation;
  • increased physician & staff frustration; and
  • privacy & security concerns of sensitive electronic information.

Although electronic health record systems have great potential, their implementation is often viewed as a mixed blessing.  The promises of new systems, software, and equipment are rarely realized.  Systems that looked good during the initial sale presentation are likely to create as many problems as they solve.  Even when systems undergo some level of evaluation, their implementation is all too often associated with surprises that require changes in work methods and processes.  To capitalize on the potential of electronic health record systems, it is incumbent on health care personnel to scrutinize needs, evaluate systems, assess impacts on personnel, establish work procedures, offer training, and provide technical support and maintenance.  With the number of available choices, barriers to implementations, negative consequences if improperly implemented, not to mention the limited time and resources health care personnel can devote to such an endeavor, they need a proven method to facilitate the selection and implementation process.  One way makes use of methods from the discipline of human factors and ergonomics.

What is Human Factors and Ergonomics?

Human factors and ergonomics is a unique scientific discipline that systematically applies the knowledge of human abilities and limitations to the design of systems with the goal of optimizing the interaction between people and other system elements to enhance safety, performance, and satisfaction.  In simpler terms, human factors focuses on designing the world to better accommodate people.

Human factors and ergonomics are relevant anywhere people work within systems, whether they are social or technical in nature – such as health care.  With regard to the procurement of electronic health record systems, it entails determining if the technology conforms to basic human factors principles and whether it will negatively influence the system (patients, hospital staff, other equipment, etc.) to which it will be integrated.   Increasing numbers of health care organizations are turning to human factors as a means of facilitating the process used to specify, evaluate, procure and implement new technology.

Benefits

The patient-centered systems approached used by human factors and ergonomics practitioners can provide health care organizations with a systematic process when purchasing and implementing electronic health record systems.  Using established human factors methods can:

  • increase patient and staff safety;
  • decrease numbers of adverse events;
  • minimize the potential for new hazards to be introduced into the system;
  • improve staff acceptance;
  • increase work efficiency;
  • better integrate with existing technology;
  • decrease training time needed to reach competency; and
  • minimize the need for modifications, “work arounds,” and/or shortcuts

Solutions

Human factors and ergonomics practitioners use a variety of methods when evaluating, designing, or procuring technology.  Two general human factors approaches can be used to analyze potential electronic health record systems prior to procurement and implementation: expert reviews and usability testing.

Expert Reviews

Expert reviews consist of a human factors and ergonomics expert assessing the electronic health record system to diagnose potential problems that might arise from the technology itself or after its integration in the health care organization’s system.  One of its strengths is that it allows the expert to “weed out” electronic health record systems that have poor usability.  Moreover, it seeks to identify if they conform to established human factors principles, including:

  • assuring systems are easy and natural to use;
  • maintaining consistency when possible;
  • making things visible;
  • providing appropriate feedback;
  • minimizing reliance on users memory; and
  • allowing for reversal of action.

Examples of expert reviews include heuristic evaluations, guideline reviews, and cognitive walkthroughs.

Usability Testing

Usability testing consists of having people from the target audience (i.e., physicians, nurses, staff, etc.) identify potential problems while performing typical tasks with the electronic health record system.  The steps required to complete a usability test include writing a test plan, designing the test, performing a dry run, recruiting users, conducting the test, analyzing the results, and determining the appropriate action to take.

Final Thoughts

Health care organizations are encouraged to incorporate both heuristic evaluations and usability tests to identify potential problems with the introduction of new electronic health records systems.  Heuristic evaluations are useful for identifying usability issues of electronic health records systems prior to integration.  However, heuristic evaluations cannot capture all the potential usability issues for new electronic health records systems or the level of staff acceptance and increased work efficiency.  Thus, it is necessary to also perform usability testing with health care personnel.  While both methods have their place, when used in tandem, they can have the greatest impact and success.  Using these methods also helps determine whether the electronic health records system effectively serves the goals of the organization (e.g., decreased medical errors, increased patient safety, etc.).  Finally, human factors & ergonomics methods are designed to help health care organizations maximize their ROI by increasing the positive and reducing the negative impact new electronic health records systems create.

Interested readers are encouraged to review the paper, “Assessing Devices from the User’s Perspective,” (4 MB, .pdf) that I co-authored with Curt Braun and was published in the September 2008 issue of Materials Management in Health Care, to learn more about this topic.

References

American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, 123 Stat. 115 (2009).

Blumenthal, D. (2009).  Stimulating the adoption of health information technology.  The New England Journal of Medicine, 360, 1477-1479.

Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., Morton, S.C., & Shekelle, P.G. (2006).  Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care.  Annals of Internal Medicine, 144, 742-752.

DesRoches, C.M., Campbell, E.G., Rao, S.R., Donelan, K., Ferris, T.G., Jha, A., Kaushal, R., Levy, D.E., Rosenbaum, S., Shields, A.E., & Blumenthal, D. (2008).  Electronic health records in ambulatory care – A national survey of physicians.  The New England Journal of Medicine, 359, 50-60.

Girosi, F., Meili, R., & Scoville, R. (2005).  Extrapolating evidence of health information technology savings and costs. Santa Monica, CA: RAND Corporation.  Retrieved April 26, 2009, from: http://www.rand.org/pubs/monographs/2005/RAND_MG410.pdf

Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., Clark, R.S.B., Watson, R.S., Nguyen, T.C., Bayir, H., & Orr, R.A. (2005).  Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.  Pediatrics, 116, 1506-1512.

Hoffman, S., & Podgurski, A. (2008).  Finding a cure: The case for regulation and oversight of electronic health record systems.  Harvard Journal of Law & Technology, 22, 103-165.

Institute of Medicine. (2003).  Key capabilities of an electronic health record system. Washington, DC: The National Academies Press.

Jha, A.K., DesRoches, C.M., Campbell, E.G., Donelan, K., Rao, S.R., Ferris, T.G., Shields, A., Rosenbaum, S., & Blumenthal, D. (2009).  Use of electronic health records in U.S. hospitals.  The New England Journal of Medicine, 360, 1628-1638.

Jha, A.K., Ferris, T.G., Donelan, K., DesRoches, C., Shields, A., Rosenbaum, S., & Blumenthal, D. (2006).  How common are electronic health records in the United States?  A summary of the evidence.  Health Affairs, 25, w496-w507.

Office of the National Coordinator for Health Information Technology – http://healthit.hhs.gov

Shaver, E.F., & Braun, C.C. (2008, September).  Assessing devices from the user’s perspective.  Materials Management in Health Care, 30-34.

Wang, B.B., Wan, T.T.H., Burke, D.E., Bazzoli, G.J., & Lin, B.Y.J. (2005).  Factors influencing health information adoption in American hospitals.  Health Care Management Review, 30, 44-51.

Weinmar, C. (2009, March-April).  Electronic health care advances, physician frustration grows.  Physician Executive Journal, 8-15.

Print This Post Print This Post

Multidisciplinary Approaches to Problem Solving and Human Factors

April 27, 2009 by · Leave a Comment
Filed under: human factors 

The May-June 2009 issue of The Futurist includes an article by Bruce L. Tow and David A. Gilliam of SynOvation Solutions entitled “Synthesis: An Interdisciplinary Discipline.”  The article highlights, in a world that has become increasingly populated by specialists, the need to more fully embrace a multidisciplinary approach to solving problems.

The article introduces readers to several new terms, including:

  • Bridge – “A Bridge is a person who, while primarily employed as a specialist, formally or informally does Synthesis whenever possible when engaged in a multidisciplinary endeavor.” (p. 45)
  • Gatekeeper – “A gatekeeper is a person who (formally or informally) acts as an information conduit for others, helping them get quick and effective access to both technical and organizational information in order to resolve problems effectively.” (p. 45)
  • Synthesist – “A Synthesist is a person who has made a profession out of the art and science of combining or spanning multiple conventional disciplines or specialties.” (p. 45)

Moreover, it also raises several important points, including:

  • “Specialists create unique vocabularies to allow them to communicate more effectively among themselves, but this trend further restricts their ability to communicate with others outside their specialty.” (p. 44)
  • “…it is increasingly difficult to achieve effective communication between specialists.” (p. 44)
  • “…we have an enormous number of multidisciplinary gaps containing real problems that require – but cannot receive – proper attention.” (p. 45)
  • “The more specialization that exists, the greater the need will be for Bridges.” (p. 45)
  • “Businesspeople should be alert to opportunities to use Synthesis to achieve a competitive edge in the marketplace.” (p. 47)

As I read the article, several thoughts came to mind.  First, I was reminded of the following quote by Robert A. Heinlein:

“A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects.”

Second, I realize that my educational background, professional work, and personal interests strongly align with their definitions of a “Bridge” and “Gatekeeper.”  Moreover, as time goes on, I envision my work will transition more towards that of a “Synthesist.”

Finally, the authors note that “signs of Synthesis already exist in many professions, including: systems engineers and industrial engineers” (p. 46).  Given the overlap of those two engineering subdisciplines with human factors and ergonomics, I would argue that many of our professionals already have embraced the concept of Synthesis in their professional work.  But, human factors and ergonomics professionals should strive to find additional opportunities for doing so in the future – something I’ve called for in a previous post.

Print This Post Print This Post

Human Factors and K-12 Education

April 24, 2009 by · 1 Comment
Filed under: built environment, design, education, human factors 

According to the Organization for Economic Co-Operation and Development (OECD, 2008), in 2005, the United States spent, on average, $12,788 per student for their education – more than any of the other 29 member countries (p. 218).  Even with such a substantial investment, the high school graduation rate was only 70.6 percent for the same year (Swanson, 2009 April, p. 1).  Moreover, when compared with the scholastic performance of 15 year old children from 57 countries, the US ranked 29th in science (p. 58) and 35th in mathematics (p. 318) (OECD, 2007).  Given such disappointing statistics, it’s obvious that better innovative solutions are needed to increase the effectiveness of the U.S. elementary and secondary education system.  One way is to utilize solutions from the discipline of human factors and ergonomics.

Human factors and ergonomics is a unique scientific discipline that systematically applies the knowledge of human abilities and limitations to the design of systems with the goal of optimizing the interaction between people and other system elements to enhance safety, performance, and satisfaction.  In simpler terms, human factors focuses on designing the world to better accommodate people.

Human factors and ergonomics are relevant anywhere people work within systems, whether they are social or technical in nature.  In the case of K-12 education, it focuses on using a student-centered systems approach to optimize the elements of the educational learning system.  The basic elements include:

  • people (e.g., students, teachers, administrators, parents, etc.);
  • equipment (e.g., desks, chairs, books, computers, school supplies, etc.);
  • workspaces (e.g., chair-desks, tables, computer stations, etc.);
  • tasks/work (e.g., learning, playing, teaching, etc.);
  • facilities/environment (e.g., classrooms, laboratories, gymnasiums, playgrounds, buildings, campuses, etc.); and
  • organizations

The history of educational ergonomics, “…the teaching of ergonomics and the design of environments where ergonomics teaching and learning might occur…” (Woodcock, 2007), extends to the 1970s with Kao’s seminal publication “On Educational Ergonomics.”  He identified its goals to be “…educational efficiency, improvement, and excellence…” (Kao, 1976, p. 668).  Since that time, work performed in this area has fallen into two general categories: (1) teaching about the discipline of human factors and ergonomics and (2) designing the educational learning system to fit the needs of students.  With regards to the latter, according to Smith (2007, p. 1532), there are nine educational design factors that could impact student learning, including:

  • Academic curriculum and programme;
  • Learning resources (textbooks, audiovisual materials, media);
  • Classroom technology;
  • Classroom and building ergonomics;
  • Class design;
  • Macroergonomics of the educational system;
  • Teaching factors;
  • Personal factors; and
  • Community & family factors.

Specific examples include:

  • Redesigning chairs & desks to fit the anthropometrics of children;
  • Identifying multimedia modes that accommodate auditory and visual learners;
  • Using virtual reality and simulation to facilitate education and training; and
  • Investigating the influence of built environment features such as lighting, air quality, wall colors, and spatial orientation on learning.

Although significant headway has been made to identify design factors that will positively impact the educational learning system, additional research and application are still needed.  The interested reader is encouraged to review the following resources to learn more about educational ergonomics:

Publications

Kao, H.S.R. (1976).  On educational ergonomics.  Ergonomics, 19, 667-681.

Legg, S. (2007).  Ergonomics in schools.  Ergonomics, 50, 1523-1529.

Legg, S. & Jacobs, K. (2008).  Ergonomics for schools.  Work, 31, 489-493.

Smith, T.J. (2007).  The ergonomics of learning: Educational design and learning performance.  Ergonomics, 50, 1530-1546.

Stone, N.J. (2008).  Human factors and education: Evolution and contributions.  Human Factors, 50, 534-539.

Woodcock, A. (2007).  Ergonomics, education and children: A personal view.  Ergonomics, 50, 1547-1560.

Websites

http://www.ergonomics4schools.com/

http://www.moveit.org.nz/

http://www.iea.cc/ergonomics4children/

References

OEDC (2007).  PISATM 2006 science competencies for tomorrow’s world: Volume 1 – analysis.  Paris, France: Organization for Economic Co-Operation and Development.  Retrieved April 22, 2009, from: http://www.oecd.org/dataoecd/30/17/39703267.pdf

OEDC (2008).  Education at a glance 2008: OECD indicators. Paris, France: Organization for Economic Co-Operation and Development.  Retrieved April 22, 2009, from: http://www.oecd.org/edu/eag2008

Swanson, C.B. (2009, April).  Cities in crisis 2009: Closing the graduation gap. Bethesda, Maryland: Editorial Projects in Education, Inc.  Retrieved April 24, 2009, from: http://www.americaspromise.org/uploadedFiles/AmericasPromiseAlliance/Dropout_Crisis/Cities_In_Crisis_Report_2009.pdf

Print This Post Print This Post

The DoD SBIR Solicitation Requests Human Factors Research

April 20, 2009 by · Leave a Comment
Filed under: human factors, research 

Today, the Department of Defense (DoD) announced the pre-release of its 2009.2 Small Business Innovation Research (SBIR) solicitation.  The solicitation includes topics from the Army, Navy, Defense Advances Research Projects Agency (DARPA), Defense Microelectronics Activity (DMEA), Defense Threat Reduction Agency (DTRA), and Office of the Secretary of Defense (OSD). Several human factors-related topics were listed in the 400+ page solicitation, including:

  • UAV Sensor Controller for Manned Aircraft (A09-016) – Define, design and develop an innovative sensor control interface for US Army aircrew members operating in manned aircraft to easily and intuitively operate the sensor systems on Unmanned Air Vehicles (UAVs).
  • End-User Development of Robust Part-Task Pilot Models for Simulated ATC (A09-018) – Develop capabilities that allow for rapid, end-user scripting of robust behavior models that can bridge the gap between simulation-specific Computer Generated Forces (CGFs) interfaces and human Air Traffic Control (ATC).
  • Any-Time Cognition for Network Centric Environments (A09-087) – Design, develop and demonstrate the algorithms and software components required to enable anytime cognition of the warfighter or team to improve distributed collaboration and decision making in network centric operations.
  • Context Based Data Abstraction (A09-088) – Develop a generalized computer software system that is able to reduce the amount of data required to successfully perform a given task by producing an abstract model of the data, populating the model with real world data, and then using the model to perform the task.
  • Context-Aware Visualization for Tactical Multi-Tasking (N092-125) – Develop a software technology that reduces context switching for multi-tasking human operators using visualization tools in a tactical setting.
  • Training Cognitive Situational Awareness for Multi-Platform Command and Control (N092-136) – Develop methodology and tools to measure and train cognitive skills necessary to maintain USW Strike Group Situational Awareness. Develop a metrics assessment tool to provide “in-action” feedback on situation awareness and decision-making.
  • Similarity Measures for Persona/Human Networks (N092-149) – To develop an application that enhances the identification of at-risk actors and/or networks using robust closeness or similarity metrics. Human persona and networks can be described in terms of their past behavior, current activities, and external forces influencing its behavior. Signatures of at-risk groups can be described in similar terms. The objective of the topic is to automate the detection of at-risk personas and human networks through N-dimensional clustering and comparison to individuals or groups considered to be at-risk.
  • Decision Support Aiding for Human-Systems Acquisition (N092-150) – To develop a decision support tool that will allow system acquisition decision makers the ability to assess whether a proposed system addresses relevant Human-Systems Integration elements and how these elements impact Total Ownership Costs.
  • Algorithmic Behavior Forecasting (OSD09-HS3) – The objective of this topic is to develop a tool that will an provide accurate forecast into the cultural and social behaviors of a domestic or foreign target population to enable more accurate and effective decision making.
  • Using Serious Games for Socio-Cultural Scenario Training (OSD09-HS4) – The objective of this topic is to develop a low cost, portable Serious Game-based tool that will quickly train Warfighters on a wide range of Human, Social, Cultural and Behavioral knowledge.
  • Discovery of Human Activity from Video (OSD09-SP5) – Automated analysis of surveillance data would greatly empower our own forces. Large numbers of video sensors exist in urban environments. Technology is needed to recognize human activity, perform context analysis and interpret criminal or terrorist behavior. Of particular value for understanding behavior, is context analysis using individual and environment interactions over a sliding window of time.

Print This Post Print This Post

Idaho Innovation Council: Take Away Thoughts from the Initial Meeting

April 16, 2009 by · Leave a Comment
Filed under: human factors, Idaho, innovation 

On Tuesday, I attended the first quarterly meeting of the recently formed Idaho Innovation Council.  According to the Idaho Business Review, it’s “…a group that will advise the Idaho Department of Commerce, other state agencies and universities on ways to leverage the state’s technological innovations into economic growth.”  The council members, who were appointed by Governor C.L. “Butch” Otter, include:

Governor Otter was also in attendance for part of the meeting to outline his vision and direction for the council.  Some of the comments he made include:

  • His vision for the council is that it will identify (and interpret) best practices in technology transfer and commercialization from universities and businesses. The council will communicate their findings in order to provide Idaho with a competitive advantage upon implementation.
  • Technological advances are outrunning our ability to efficiently make the transfer where Idaho currently is to where we need to be in the future.
  • Idaho has to conform to the needs of the market in order to be competitive with the world.
  • The focus should include increasing efficiencies. Two areas mentioned include – energy and education.

Although I only attended the first half of the meeting, I was able to glean several things, including:

  • The council will focus on technology transfer and commercialization. Specifically, to identify what obstacles (e.g., current policies, procedures, etc.) need to be removed in order to streamline the process of commercializing potential products, services, etc.
  • The council has a more expansive mandate than its previous incarnation – the Science & Technology Advisory Council.
  • The focus will be on the application of existing ideas; not so much on the development of new ideas.
  • The LinkedIn Group will be used to foster discussions with members between quarterly meetings. Moreover, they hope to leverage this medium to increase participation from interested individuals who are located in more rural areas of the state.

As I reflected on the substance of the meeting, I was reminded of articles I’ve read from the human factors and ergonomics domain that stress how appropriately designed products, services, and processes facilitate technology transfer and commercialization, including:

  • Burns, C.M., Vicente, K.J., Christoffersen, K., & Pawlak, W.S. (1997). Towards viable, useful and usable human factors design guidance. Applied Ergonomics, 28, 311-322.
  • Dekker, S.W.A., & Nyce, J.M. (2004). How can ergonomics influence design? Moving from research findings to future systems. Ergonomics, 47, 1624-1639.
  • Gillian, D.J. (2001). Usability science. 1: Foundations. International Journal of Human-Computer Interaction, 13, 351-372.
  • Woods, D., & Dekker, S. (2000). Anticipating the effects of technological change: A new era of dynamics for human factors. Theoretical Issues in Ergonomics Science, 1, 272-282.

Print This Post Print This Post

Next Page »