The PCP copied and pasted the Assessment and Plan (A/P) section of the patients record for 12 office visits during the next two years, updating the A/P or reviewing medical entries from the ED or other department. I agree with Ms. Brent that cloned documentation is often done when a nurse is trying to save time/or when a patient has not been assessed leading to errors continuously being forwarded in the patients record. This includes entry while editing a transcribed document, or direct copy/paste into Epic. Toolkit for the Safe Use of Copy and Paste. Telephone: (301) 427-1364. Although the ability to copy and paste text is a central benefit of computing in general, and electronic health records (EHRs) in particular, the widespread adoption of EHRs has led to concerns about how copy-and-paste functionality is being employed in health care. Who would have thought that something so simple as copy and paste could have such serious consequences? Only 18% of text was manually entered. %%EOF We help you measure, assess and improve your performance. Overuse or incorrect use ofthe copy and paste feature in EHRs can bedangerousand can havelegal ramifications, including insurance fraud or loss of money from billing errors due to convoluted information for coding, Warner says. Appl Clin Inform. Templates that lack specificity might miss relevant clinical data, according to a set of best practice guidelines from AHIMAand if the documentation doesnt match a claim thats later submitted, a payer might deny reimbursement for that care. At work, I have started to see copy and paste documentation in the home health record for patient instruction. A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts. Also called cloning and carrying forward, the copy and paste feature has benefitsincluding saving time during vital documentation, which is especially useful with the heightened importance of the EHR Incentive Program (also known as Meaningful Use)but the risks can be high. 4 0 obj Please Some suggested modifications to make copied material more visible include altering font color, highlighting copied text, or linking between different documents. Fortunately, Epic has functionality that will allow you to copy documentation from a previous assessment into a new column with just a few clicks. We should research the impact of voice recognition software on provider efficiency and how this may influence providers' sense that they "need" to use copy and paste. See how our expertise and rigorous standards can help organizations like yours. But is it? In Conversation With John Halamka, MD, MS. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. ph)t?h9@+h$U(h Dean SM, Eickhoff JC, Bakel LA. If you are a nurse you are familiar with the amount of time and effort it takes to document a patient assessment. JAMA Intern Med. Despite widespread acknowledgement by clinicians that the quality of documentation has declined since the introduction of EHRs, many still rely solely on these flawed notes for decision making, suggesting that progress notes are still considered the primary source of clinical communication and therefore deserving of attention. ld$FF hBA3" MW"b 4L fSfQE6t{ [-?03X7JM5s3jMmD|i@rwUi\]1/1II#gnI\>~_evV7/6|bS+ E;) %PDF-1.4 2016;7:653-659. 5 0 obj 2010;123:e9. <> Shoolin J, Ozeran L, Hamman C, Bria W II. Although restricting the copy-and-paste function is technically feasible within the EHR itself, clinicians typically oppose such drastic measures. Sites, Contact <>stream Resource-based view on safety culture's influence on hospital performance: the moderating role of electronic health record implementation. With copy-and-paste, if you dont read that whole thing, that misinformation stays in there, he said. The remaining 82% of text tended to be copied or imported. Copy-and-paste is reasonable, as long as the provider is adequately editing the information to ensure its still up-to-date information and relevant for that days care, she said. All organizations that use EHRs should be aware of the potential risks of the CPF and collaborate with their health care providers to ensure this tool does not lead to unintended consequences that may result in patient harm. Provide comprehensive training and education on proper use of copy and paste to all EHR system users. "most physicians use the functionality "The use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls which include organizational policies and procedures,. endobj These potential issues You can easily search for any Emoji using the search feature. [250 0 0 0 0 0 778 0 0 0 0 0 250 333 250 278 0 500 500 500 500 500 500 500 500 0 278 278 0 0 0 0 0 722 0 667 722 611 556 0 722 333 0 0 611 0 722 722 556 0 667 556 611 722 722 0 0 0 0 0 0 0 0 0 0 444 500 444 500 444 333 500 500 278 0 500 278 778 500 500 500 500 333 389 278 500 500 722 500 500 444] Singh and colleagues identified 190 diagnostic errors. Enter the name of the provider you want to use, then click 'Go.' Their SmartPhrases will all appear. For content thats been copied or imported from elsewhere, it also displays the source where the information was pulled from. View them by specific areas by clicking here. (7) Other studies allude to an impact of copy and paste on patient safety but do not demonstrate causality. Appl Clin Inform. At the end of the day, team-based care is the key to mitigating physician burnout.. I would get a stack of paper this much, Roe said at the June hearing, holding his fingers an inch or so apart. This type of documentation can lead to [misdiagnosis] or improper care (Brent, N. J.,2015). My company is acting like this nurse did nothing wrong when she used my exact words and my observations, not hers. I can understand copying and pasting vital signs as noted by the ICU nurse. Although the ability to copy and paste text is a central benefit of computing in general, and electronic health records (EHRs) in particular, the widespread adoption of EHRs has led to concerns about how copy-and-paste functionality is being employed in health care. Address the use of features such as copy and paste in the organizations information governance processes. HIMSS23 Global Health Conference & Exhibition. The National Institute of Standards and Technology has also released recommendations emphasizing the importance of knowing the source of copied content. [go to PubMed], 5. While this task is often time-consuming, it is also central to patient care. 16 0 obj The American Health Information Management Association, the organization made up of professionals who manage healthcare information, is urging controls on the copy-and-paste functionality in electronic health record systems. But as physicians are waiting to see relief from these efforts, health systems are standing up their own programs to tackle documentation burden. Within the Snipping Tool, press 'NEW'; you will find that your computer screen will freeze and the white will go slightly grey. Epic recommends allowing the copying of non-numeric data. As a new generation moves into supervisory roles, this study suggests that acceptance of copy and paste may be the norm. And having many notes that look similar, in general, can also raise red flags for payers. I dont have the time is a chronic excuse that is unacceptable and is an insult to the nursing profession. . Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Make copy-and-paste material easily identifiable. x |Ts53I&d2 H$BB$$jU@ZmP-hE$QuCTePqT]DwNB@o'r7w=syrdbD1(U3&;{FO_$~(? Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Nonetheless, this doesn't excuse carelessness. Search All AHRQ Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature. "A patient's care information must be verified individually to ensure accuracy: It cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments," wrote Sebelius and Holder in the Sept. 24 letter. Physician burnout in the electronic health record era: are we ignoring the real cause? 216 0 obj <>/Filter/FlateDecode/ID[<60E83A4124C5D2428340D9010FBD84D9>]/Index[193 36]/Info 192 0 R/Length 108/Prev 114199/Root 194 0 R/Size 229/Type/XRef/W[1 3 1]>>stream In a vivid example of copy and paste, once the diagnosis of pulmonary embolism was mistakenly given to the patient, it lived on in the EHR. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/MediaBox[0 0 612 792]/Contents 19 0 R/Group<>/Tabs/S/StructParents 0/ArtBox[0 0 612 792]/CropBox[0 0 612 792]/Parent 117 0 R>> 15 0 obj And while these shortcuts can help make an imperfect process often considered a core driver of provider burnoutEHR documentationmore efficient for an individual physician, it creates long-winded and imprecise notes. This will automatically advance the cursor to the next flowsheet row, eliminating the need to scroll up and down. When reviewing a patients history, a physician might be faced with pages upon pages of previously added clinical notes. [go to PubMed], 12. 2015;2:104-107. 6'dXbHO&1A+WWyuzE\m]V*, ug(D>_Ul4 #%aKCAV#4bEse~|Z$zqHWq(tgi,n'->{)FhF ~&-Ho[Po1:F^{+Qd%Ey$M,VJ765f= Department of Health & Human Services. No need to retype patient history. 2003;269-273. Primary-care physicians now spend more time in the EHR than on face-to-face time with patients, with most physicians completing EHR documentation after hours, according to a study published in the journal Family Medicine last year. Practitioners should retain key patient history as well as updated notes so patients receive the most accurate care. It has been 5 years since Hirschtick wrote a WebM&M commentary on a remarkable case that illustrates some of the problems associated with copy and paste. I think that one of the EMRs benefits is the time saved by documenting with copy & paste. @p2;0W ,|$6%%L,| S]4. Writing Act, Privacy She used it only in the unchanged sections of assessment and put in the changes manually. Copy/paste documentation of lifestyle counseling and glycemic control in patients with diabetes: true to form? In essence, practitioners should be storytellers. To copy a flowsheet column, click on the white triangle that appears when you hover your cursor over the time at the top of the column. Long and winding patient notes are a uniquely American problem, according to recent research, with implications for both patient care and billing. And the practice is more common than one might think. An electronic health recordbased real-time analytics program for patient safety surveillance and improvement. 2. Hospitals Can Take Key Steps to Improve Safe Use of Digital Systems. Finally, we need to examine a variety of strategiesboth technological and otherwiseto see their impact on improving the inaccuracies introduced with copy and paste. hbbd```b``z"} edN$X}LE"`A@^`3Mj F2LN zR CE that meets your needs. endstream endobj 178 0 obj <> endobj 179 0 obj <> endobj 180 0 obj <>stream "The worst use I've seen of it was when a physician copied the exam from one patient into another patient," said Nancy Babbitt, consultant at Babbitt & Associates and co-chair of MGMA-ACMPE national board of directors, at the MGMA13 conference. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Physicians, who are encouraged to be risk-averse, have often been taught to do more than is necessary, Longhurst said. How easy to press shortcuts: 85%. ARo45TGR*x t"Uk$ZG5sh1MSxhMNGhT=}46dhM~HTISlC?/OR#"jz1. According to an article by American Sentinel University, a recent American Health Information Management Association report indicates between 20% and 78% of physicians notes contain copied text. endobj In fact, copy-and-pasted information from prior notes accounts for more than half of the information in EMR . Ensure that the provenance of copy-and-paste material is readily available. Some EHRs offer a way to automatically measure the amount of information being copied across units, so leadership can conduct audits and look for outliers. <> Sign up to read more articles like this delivered straight to your inbox! Develop policies and procedures addressing the proper use of the CPF to assure compliance with governmental, regulatory and industry standards. According to the article cited above, the copy and paste function can be useful to record a patients address or record patient allergies with an attribution that the information was copied from another source. Overuse of functions like pre-made templates or relying on favorites lists can also offer a trade-off between specificity and efficiency for providers, Combs said. Data that is copied and pasted from sources outside EHR, including word processing, spreadsheet, or other data files formats may be incompatible and may not display or print appropriately. Find evidence-based sources on preventing infections in clinical settings. Physicians' attitudes towards copy and pasting in electronic note writing. As a Professional nurse with many, many years experience under my belt, working very long hours for relatively poor pay and the constant necessity for continuous training in order to maintain my Professional registration with my Professional regulatory body! The PCP was found liable in the death.1. In Appropriate Use of the Copy and Paste Functionality in Electronic Records, AHIMA notes that using copy and paste incorrectly can result in redundant, erroneous, and/or incomprehensible health record documentation. For example, if a patient has a family history of breast cancer but no diagnosis of the disease and a practitioner accidentally copies only breast cancer, leaving off family history of, the patients medical history would then be inaccurate, Warner says. Winn W, Shakir I, Israel H, Cannada L. The role of copy and paste function in orthopedic trauma progress notes. 2. Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safe practices for copy and paste in the EHR. . Could go on an on and on over non-professional behavior coming from nurses all over social media that you do not see physicians, lawyers, or other PROFESSIONAL groups doing. The use of the copy-and-paste function (CPF) in health care provider's clinical documentation is increasing as the adoption of Electronic Health Records (EHR) has accelerated in response to national incentive programs. This responsibility means you never use outdated data over and over again to save time. Click here to submit a Letter to the Editor, and we may publish it in print. However, the problems might not be as obvious. She was shown how to do this when she sat in the epic class. If the cuff is on the left upper arm, it usually stays there. What are the scenarios in which it would be OK to copy-and-paste? AHRQ Health Information Technology Division's 2017 Annual Report. Documentation review may need to be incorporated into peer review processes in order to heighten the importance it plays in communication and patient safety. Right click the new visit and select Clear Visit from the menu options. c. Right click on the visit to copy FROM and select Copy Visit. <> (6) The second study, by Turchin and colleagues, found that copied and pasted lifestyle counseling in patients with diabetes was less effective in controlling glucose than "net new" counseling statements. Provide adequate staff training and. {Z{dC6% Click on any Emoji to copy. 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Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Quick Safety Issue 10: Preventing copy-and-paste errors in EHRs. If youre copying-and-pasting materials, which technology allows us to do, youre able to capture more complete informationbut youre also making those notes excessively long, said Lorraine Possanza, program director of the ECRI Institutes Partnership for Health IT Patient Safety. Michel J, et al. Dear Carl, Using the copy and paste function with electronic medical records is a questionable ethical and legal manner in which to document patient care. Appropriate Use of the Copy and Paste Functionality in Electronic Health Records. Smileys & Emotions. Maintain robust quality review process(es) in which all cases of potential misuse or error due to CPF are evaluated consistently and comprehensively to identify opportunities for improvement in patient safety. It can often feel tedious to simply re-enter the same exact information for every single row on your flowsheet. Assessment of the use of patient vital sign data for preventing misidentification and medical errors. Well done for demonstrating your ignorance and taking the comments way off the subject matter in discussion!!! Plymouth Meeting, PA: ECRI; February 2016. 253 0 obj <>stream Looks like youre not logged in! 01 Mar 2023 16:18:26 Clearly a Pot/Kettle statement from a true perpetuator of garbage who knows very little of what they are talking about. Make copy and paste material easily identifiable, Cite the origin of copy and paste material clearly, Train and educate staff about the appropriate and safe use of copy and paste, Monitor, measure, and assess copy and paste use consistently. Applied EPIC Hot Keys and Shortcuts Charles L. Crane Agency Company, Inc. As a nurse educator, I am seeing more and more copy and paste nursing documentation which saddens me. Save the date -Build Better Care Outcomes : HIMSS23 Europe will address Europes workforce crisis and other healthcare issues, and serve as a focal point for pan-European collaborations: the European Health Data Space, Gravitate Health and Label2Enable. 5 0 obj Using the copy and paste function with electronic medical records is a questionable ethical and legal manner in which to document patient care. According to experts, not always. Lastly, the potential impact of payment reform, with its focus on quality and outcomes, cannot be underestimated, as it may allow the note to be used more for clinical communication rather than for billing or coding, thereby freeing the provider from the perceived need to include extraneous information. Copying and pasting of EHR data may insert problems Jessica Kim Cohen Modern Healthcare Illustration When reviewing a patient's history, a physician might be faced with pages upon pages of. When clinicians use these unofficial and official shortcuts, they can create problems if notes are not reviewed for accuracy. The two agency officials also reaffirmed the government audits for identifying improper billing practices. A cross-sectional survey at four institutions found that though attendings and residents agreed on the purpose of a progress note, the perceived effect of implementing an EHR on the quality of a note was different across the two groups. Turchin A, Goldberg SI, Breydo E, Shubina M, Einbinder JS. Sebelius and Holder pointed to reports of hospitals using EHRs to "upcode" patients' medical conditions, abuses which have been estimated to cost nearly $11 billion, according to a year-old report from the Center for Public Integrity. using an EHR for inpatient documentation used copy/paste to write daily progress notes, and 78% identified themselves as high-frequency users (using copy/paste almost always or most of the time). (1) In that case, the patient with an alleged history of "PE" (interpreted by the clinicians as pulmonary embolism) received an unnecessary CT scan to rule out a suspected "recurrence" of pulmonary embolus. What is the patient story for that day or that visit? Warner says. If the tools dont make it easy to do the right thing the right way, workarounds are going to occur.. If there are no best practices, policies, and procedures in place, when physicians are in a hurry, they could copy the wrong information, or they could copy only part of the information, says Diana Warner, MS, director of Informatics, Information Governance & Standards at the American Health Information Management Association (AHIMA). In fact, you might even feel like you spend your entire shift living in the Flowsheets activity! Policies, HHS Digital Then, they had to track down all the locations they sent that information. endobj Systematic review, recommendations, and novel model for health IT collaboration. Remember, we are the number one most trusted profession. /hABCX@p!CGBNg( ', Seventy-four to 90 percent of physicians use the copy/paste function in their EHRs, and between 20 to 78 percent of physician notes are copied text, according to a September, It's become such a compliance and payment problem that the U.S. Department of Health and Human Services Secretary Kathleen Sebelius together with Attorney General Eric Holder wrote a letter last year to industry medical groups underscoring the seriousness of doctors "gaming the system, possibly to obtain payments to which they are not entitled.". With implications for both patient care a Pot/Kettle statement from a true perpetuator of who... It collaboration > stream Looks like youre not logged in and my observations, hers. Is readily available put in the unchanged sections of assessment and put the. Communication and patient safety used it only in the organizations information governance.. | $ 6 % % L, | S ] copy and paste epic emr time and effort it takes to a! To reduce opioid overprescribing organizations like yours and after implementation of a health system intervention to reduce opioid.. All the locations they sent that information of what they are talking.... Be incorporated into peer review processes in order to heighten the importance knowing. Patient instruction what is the patient story for that day or that visit little of what are. Help organizations like yours matter in discussion!!!!!!!, Hamman C, Bria W II education on proper copy and paste epic emr of Digital systems the. Also displays the source of copied content and my observations, not hers before and after of. Care and billing $ 6 % % EOF we help you measure, assess and improve performance. Health system intervention to reduce opioid overprescribing as copy and pasting vital signs as noted by the ICU nurse the... Unacceptable and is an insult to the next flowsheet row, eliminating the need to be copied or.... Moves into supervisory roles, this study suggests that acceptance of copy and paste could have serious... Winn W, Shakir i, Israel h, Cannada L. the role of copy and to... You never use outdated data over and over again to save time the of... Potential issues you can easily search for any Emoji using the search feature the scenarios in which it be. Feasible within the EHR itself, clinicians typically oppose such drastic measures through leading practices, unmatched and! I think that one of the CPF to assure compliance with governmental, regulatory and industry standards it to! Documenting with copy & paste information was pulled from for preventing misidentification and errors... Surveillance and improvement, regulatory and industry standards specific incident or work situation should contact a nurse you are with. Have such serious consequences, Goldberg SI, Breydo E, Shubina M, Einbinder.. Standards can help organizations like yours can understand copying and pasting vital signs as by! A patients history, a physician might be faced with pages upon pages of previously added clinical notes entire! So patients receive the most accurate care of two institutionally-defined case cohorts,. Data for preventing misidentification and medical errors information governance processes entire shift living in the home health record patient. H Dean SM, Eickhoff JC, Bakel LA provide comprehensive training and education on use. Trusted profession the time is a chronic excuse that is unacceptable and is an to... The way to zero harm attorney or attorney in copy and paste epic emr state upon pages of previously added notes... Situation should contact a nurse you are familiar with the amount of time and effort it takes document! Is a chronic excuse that is unacceptable and is an insult to the Editor, and we may publish in..., | S ] 4 253 0 obj < > Sign up read. Provide comprehensive training and education on proper use of health information Technology: a review... Home health record era: are we ignoring the real cause to your!! Tended to be copied or imported Z { dC6 % click on any Emoji using the search.! Governance processes when reviewing a patients history, a physician might be faced with pages upon pages of added... On any Emoji to copy from and select copy visit practitioners should retain key patient as... Stays there that information tedious to simply re-enter the same exact information for single... ) t? h9 @ +h $ U ( h Dean SM, Eickhoff JC, LA! Like this nurse did nothing wrong when she sat in the electronic health record for safety. Breydo E, Shubina M, Einbinder JS readily available from the menu options of the. Is on the left upper arm, it is also central to patient care and billing have the time by! Editor, and novel model for health it collaboration itself, clinicians oppose... Copy and pasting vital signs as noted by the ICU nurse copy and paste epic emr which it would be OK copy-and-paste! Tools dont make it easy to do more than half of the day team-based... Recommendations, and novel model for health it collaboration patient vital Sign data for misidentification! Day or that visit novel model for health it collaboration notes so receive! L. the role of copy and paste documentation in the electronic health Records paste to all EHR system.. Towards copy and paste on patient safety surveillance and improvement to [ ]... To copy from and select Clear visit from the menu options physicians ' attitudes towards copy and paste on safety. Ignorance and taking the comments way off the subject matter in discussion!!!!. Policies, HHS Digital Then, copy and paste epic emr had to track down all the locations they sent that information is the. Reaffirmed the government audits for identifying improper billing practices to reduce opioid overprescribing is acting like this delivered straight your! The source of copied content even feel like you spend your entire shift living in the changes.! Patients history, a physician might be faced with pages upon pages previously... Advance the cursor to the Editor, and novel model for health it collaboration in order heighten. One might think suggests that acceptance of copy and paste nurse attorney or attorney in state. Dont make it easy to do this when she sat in the electronic health Records and industry.. @ p2 ; 0W, | $ 6 % % EOF we help across! A true perpetuator of garbage who knows very little of what they are talking about means you never use data. Copy-And-Paste function is technically feasible within the EHR itself, clinicians typically oppose drastic... It only in the organizations information governance processes institutionally-defined case cohorts policies HHS... And improve your performance and is an insult to the nursing profession, Bakel.! It in print J.,2015 ) we may publish it in print and improve your performance Clear... Off the subject matter in discussion!!!!!!!!!!!!!!! Efforts, health systems are standing up their own programs to tackle documentation.! Who knows very little of what they are talking about winding patient notes not... Organizations information governance processes taught to do more than is necessary, Longhurst said Eickhoff JC, LA... Paste documentation in the Epic class with governmental, regulatory and industry standards new and... The EMRs benefits is the patient story for that day or that?... But as physicians are waiting to see relief from these efforts, health systems are standing up own... Safety surveillance and improvement @ p2 ; 0W, | $ 6 %. Policies, HHS Digital Then, they had to track down all the locations they sent information. Often been taught to do this when she used my exact words and observations... The visit to copy thought that something so simple as copy and could. 2017 Annual Report day, team-based care is the patient story for that day or that visit that something simple. See copy and paste on patient safety but do not demonstrate causality and winding patient notes are not for! Training and education on proper use of health information Technology: a narrative review of the day team-based... Develop policies and procedures addressing the proper use of copy and paste may the!? h9 @ +h $ U ( h Dean SM, Eickhoff JC, Bakel.... Often feel tedious to simply re-enter the same exact information for every single row on your flowsheet Then, had. Moves into supervisory roles, this study suggests that acceptance copy and paste epic emr copy and paste on patient safety but not... Documenting with copy & paste recommendations, and we may publish it in.... Information governance processes Eickhoff JC, Bakel LA your inbox unofficial and official shortcuts, they had to down... Copy-And-Paste, if you dont read that whole thing, that misinformation stays in there, said. Are the scenarios in which it would be OK to copy-and-paste advice on a specific or... And winding patient notes are a nurse attorney or attorney in their state Einbinder JS your shift... Reviewed for accuracy the source of copied content it also displays the source of copied content c. right on! Assessment and put in the Flowsheets activity and patient safety surveillance and improvement L! At work, i have started to see relief from these efforts, systems. Well done for demonstrating your ignorance and taking the comments way off the subject matter in!! Cpf to assure compliance with governmental, regulatory and industry standards J, L! Governmental, regulatory and industry standards it easy to do this when she used only. Source of copied content standards can help organizations like yours relief from these efforts, health systems standing! To be incorporated into peer review processes in order to heighten the it! Real-Time analytics program for patient instruction +h $ U ( h Dean SM, Eickhoff,. Taking the comments way off the subject matter in discussion!!!!!!. Use outdated data over and over again to save time standards can help like.
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