Telehealth will be come a fact with the new Healthcare laws but as a Doctor or patient does it really work and can you trust the technology behind it? To find out read this report from Fierce Health IT and find out the facts behind this new form of healthcare.

1. 
Thank you to
our Sponsor:
FierceHealthIT
FierceHealthIT.com
More than a fad, telehealth can save lives,
reduce costs, improve patient access to care
and increase market share for participating
organizations. Remote consults dramatically
expand the range of services available to
patients in rural parts of the country. “Telehealth
reduces mortality, hospitalizations, duration
of stay and improves drug adherence. If you
had any drug that had the outcome measures
demonstrated by telehealth, you would have
a blockbuster,” Chris Wasden, global health
innovation leader for the consultancy PwC, tells
FierceHealthIT in an interview for this eBook.
Still, there are challenges: Reimbursement
and sustainability most notable among them.
In this eBook, FierceHealthIT interviewed
healthcare leaders and industry experts from
around the country on how they overcame those
challenges and reaped the rewards of successful,
profitable and sustainable telehealth programs.
Read on to learn:
• ow to ensure rapid adoption of telehealth
H
across departments and how to marshal
physician champions to the cause.
• ow telemedicine supports some of the
H
nation’s most seriously injured warriors and
military physicians in remote locations.
Telehealth Monitoring:
• ow to operationalize telehealth so it is just
H
one more way to provide excellent care
to patients, no matter where they are.
Creating Profitable, Sustainable Programs
• ow to devise sustainable programs—
H
and which telehealth services experts
say will see the most growth.
3
Across the Country,
Telehealth Reimbursement
Grows
1
August 2 012
5
How to Create a
Sustainable Telehealth
Program
6
Telehealth and Mobile
Technology
*Sponsored Content*
7
QA: with Peter Kung,
UCLA Health System’s
Director of Innovative
Technologies
9
Case Study: Children’s
Healthcare of Atlanta and
Coffee Regional
Medical Center
• ow to take advantage of recent
H
reimbursement changes and why operating
at a loss today may actually be a good
strategy to prepare for future success
by gienna shaw
Editor-in-chief /// Fiercehealthit
sep tember 2 013
2

2. FierceHealthIT
FierceHealthIT.com
Across the Country, Telehealth
Reimbursement Grows
By Anne t te M. Boyle and Brenda L. Moone y
Reimbursement—or
lack thereof—remains one
of the sticking points for
providers that want to expand
telemedicine services. But
there’s been more progress
in the last year than in the
previous decade,” says Chris
Wasden, global healthcare
innovation leader for PwC,
the New York City-based
consultancy.
In mid-July, the Centers
for Medicare Medicaid
Services (CMS) proposed a
change to the 2014 Medicare
Physician Fee Schedule that
would expand payment for
telehealth services. CMS
currently covers telemedicine
visits for residents outside of
a metropolitan statistical area
at the same rate as in-person
visits. The proposed change
would extend coverage to
anyone living in a rural census
tract, as defined by the Office
of Rural Health Policy, and
would review that coverage
on an annual basis, providing
continuity of care for areas
that lose rural status during
the calendar year, according to
the National Telehealth Policy
Resource Center. In addition, CMS
proposed coverage for transitional
care management services in
selected cases.
States that pay
Also in July, Missouri passed
legislation requiring private insurers
to cover any services provided
remotely that they would cover for
in-person visits. Previously, patients
had to live more than 50 miles
away from providers to qualify for
telemedicine coverage.
Kentucky also expanded Medicaid
telemedicine coverage to include
a wide range of therapies and
monitoring as well as evaluation
or management consultations
by physicians, advanced practice
nurses, optometrists and
chiropractors.
Earlier in the year, Arizona
mandated coverage of remotely
provided services starting in 2015 for
trauma, burn, cardiology, infectious
diseases, dermatology and
neurology in the state’s rural areas.
According to the American
Telemedicine Association, 20
states require private insurers to
cover telemedicine services and 10
mandate Medicaid coverage for at
least some services.
“There’s been more progress in the last
year than in the previous decade.”
Chris Wasden, global healthcare
innovation leader, PwC, New York City
3
sep tember 2 013
But in states that do provide
payment through Medicaid, the
reimbursement rates still pose
financial challenges, according to
Michael McConnell, medical director
of the telemedicine program at
Children’s Healthcare of Atlanta
(CHOA). “State of Georgia Medicaid
reimburses at about 15 cents on
the dollar,” he said. “That’s not
sustainable if you have a fully
Medicaid population served by
telemedicine.”
Debra Lister, M.D., medical
director at the Coffee Regional
Medical Center Telemedicine
Program in Douglas, Ga., notes that
reimbursement differs between
presentation and consulting sites.
“Don’t expect to start off making
a bundle of money at presentation
sites. Specialists are supposed to
“We’re planning for a future state, where
we’re rewarded for delivering healthcare
more efficiently and get paid for keeping
people healthy.”
Michael McConnell, medical director, Children’s
Healthcare of Atlanta Telemedicine Program
be reimbursed by Georgia law what
they would be paid for seeing a
patient in the office. With private
insurance and Medicare, they do
pretty well. Medicaid has historically
paid poorly, but it has improved
a great deal in recent years.
Unfortunately, that’s where most of
the need is.”
Service lines that pay
Some services get high
reimbursement rates across the
board. “If you include radiologists
reading chest x-rays from remote
sites as telemedicine, that’s very
efficient and there is no issue with
reimbursement.” says McConnell.
Across the country, teleradiology is
one of the most commonly provided
telehealth services and has little
incremental cost.
“Most radiology imaging
equipment has digital capability
and embedded picture archiving
and communication systems,” says
Jon Linkous, chief executive officer
of the American Telemedicine
Association. “The cost for
technology is minor compared to
what it used to be.”
Pressure to reduce healthcare
costs and the move away from
fee-for-service payment bode well
for telemedicine, says Wasden.
These trends “create pressure
on legislatures and healthcare
organizations to change the system
and focus on delivering care in space
instead of place.”
CHOA has built out its
telemedicine program based on the
expectation that the reimbursement
model will change. “Right now, it’s
a labor of love,” says McConnell.
“We’re planning for a future state,
where we’re rewarded for delivering
healthcare more efficiently and get
paid for keeping people healthy.” l
sep tember 2 013
4

3. FierceHealthIT
FierceHealthIT.com
How to Create a Sustainable
Telehealth Program
By Anne t te M. Boyle and Brenda L. Moone y
The secret to success? Keep
it simple.
Telehealth works, but how
do you maintain a profitable
program over the long run?
Chris Wasden, global health
innovation leader for PwC,
says he thinks he knows the
answer: Make the telehealth
model as easy for physicians as
prescribing a drug.
“Telehealth reduces
mortality, hospitalizations,
duration of stay and improves
drug adherence. If you had
any drug that had the outcome
measures demonstrated by
telehealth, you would have
a blockbuster,” he says.
“To make telehealth more
successful and sustainable,
it needs to mimic the
prescription model. We’re
seeing movement in
this direction with health
monitoring solutions, where
a physician has been able to
order the product, send the
patient home” and arrange
for in-home training. “And the
physician sets the frequency at
which updates are received.”
the practice of medicine can be done
remotely without video,” he says.
“Telemedicine can be additive. Most
organizations that provide remote
monitoring use tablets that also have
video capability, so that’s available if
necessary.”
Eliminating video circumvents the
challenges posed by the absence of
broadband capability in many rural
areas. “Telehealth data is collected
in kilobytes,” says Wasden. “In
rural situations, you’re fine using
Telehealth and
Mobile Technology
GSM connectivity [Global System
for Mobile communications], which
telehealth companies can buy at
a wholesale rate of about $5 per
month.”
Strategy drives successful
programs
For the more intensive telemedicine
programs, sustainability starts
with integrating the service into
physician workflow and organization
strategy, says Jon Linkous, chief
executive officer of the American
Telemedicine Association (ATA).
“Many telemedicine programs
start as pilots, funded by grants.
That’s a good beginning, but not
continued on page 11
“If you had any drug that had the outcome
measures demonstrated by telehealth,
you would have a blockbuster.”
Chris Wasden, global healthcare innovation
leader, PwC, New York City
by Michelle Bruno
Bringing patients closer to care
Healthcare providers are investing
time and resources into remote
health monitoring. By 2017,
telehealth is projected to reach
1.8 million patients worldwidei
and the number of remote
monitoring devices with integrated
communication capabilities is
projected to grow to 9.4 million
connections globally.ii
There are several reasons why
the practice of telehealth is gaining
such momentum. The rising cost
of in-facility care is only part of the
story.
Reducing patient
readmission rates
Readmissions are among the leading
problems facing the U.S. health
care system. Research shows
that 15-25% of people who are
discharged from the hospital will be
readmitted to the hospital within 30
days or less.iii In fact, The Centers
for Medicare Medicaid Services is
now penalizing hospitals with high
rates of readmission for patients
with certain conditions. Telehealth
can help.
Streamlining patient care
A telehealth practice helps doctors
monitor patients.
Patients can
transmit information,
such as blood
pressure or blood
glucose levels, via
smartphone app or web portal.
Based on this data, caregivers can
quickly and knowledgeably make
recommendations, or change the
patient’s care regimen.
Increasing access to
health services
Mobile technologies, such as
videoconferencing, store-andforward imaging and streaming
media help healthcare providers
meet the needs of underserved
people—including disabled, elderly
and rural patients—who cannot
easily access medical care facilities.
Mobile networks help support
the two-way communication
necessary for patients and providers
to exchange information over the
Internet, when meeting in person
isn’t possible.
Improving self-care
management
The proliferation of mobile
applications and connected devices
helps patients help themselves. For
example, telehealth programs can
result in significant improvement
in self-care behaviors, like daily
weighing, medication management,
exercise adherence, fluid and alcohol
restriction, salt restriction or stress
reduction, for the intervention of
Sponsored Content
heart failure patients.iv
Providing timely access to a
patient’s medical histories
The secure, online storage of
medical records facilitates prompt
data-driven decisions by providing
up-to-date patient health
information at the point of care.
By accessing centralized data,
providers can validate drug
interactions and help protect patients
from medical errors.v
Developing solutions for a
health-conscious future
Technology helps medical
professionals provide treatment
services and empowers patients
to become engaged in their health
care. Reliable, secure broadband
connections make telehealth
possible. With our 3G, 4G LTE
and fiber-optic networks; cloud
computing and enterprise-level
security, Verizon provides the
infrastructure that connects patients
to the care they need and healthcare
providers to the patients they serve.
To discover more, contact your
Verizon business specialist, or
visit us at verizonenterprise.com/
healthcare.l
Video creates
unnecessary barriers
Telehealth, or remote
care without video, notes
Wasden, offers much
greater opportunities than
telemedicine, which requires
video consults. “Over half of
5
sep tember 2 013
i
The World Market for Telehealth, an Analysis of Demand Dynamics. InMedica. 2012.
ii
mHealth and Home Monitoring. Berg Insight. 2013.
iii
Center for Healthcare Quality and Payment Reform. http://www.chqpr.org/readmissions.html
iv
Impact of Telehealth on Patient Self-Management of Heart Failure: a review of literature. Journal of Cardiovascular Nursing. 2012.
v
http://www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes
sep tember 2 013
6

4. FierceHealthIT
FierceHealthIT.com
QA: with Peter Kung,
UCLA Health System’s
Director of Innovative
Technologies
and must be able to integrate
telehealth into clinical workflow.
At the enterprise level, if you tie
telehealth to technology, you will
always be behind. You need to
create a telehealth service platform
that has the right contracting and
right payers in place, so you can
deliver sustainable service and
incentivize physicians to embrace
technology from an operational point
of view.
By Anne t te M. Boyle
How a hybrid model paves the way for
value-based paymentS
 A leader in the use of telemedicine, the University
of California at Los Angeles (UCLA) Health System
offers remote consultation and monitoring in nearly
every service line. With more than 2,000 physicians
and 800 beds in four hospitals on two campuses, the
organization’s telemedicine services include neurology
and stroke care, radiology, neonatal intensive care,
family medicine, surgery and a variety of pediatric
specialties. FierceHealthIT spoke to Peter Kung, director
of innovative technologies at UCLA Health System,
about the key decisions that make telemedicine an
integral part of the organization’s service delivery system
and what must change so it can succeed long-term.
FierceHealthIT: UCLA has
telemedicine and telehealth
embedded in nearly all of its
departments. What drove the
widespread adoption?
Peter Kung: Initially, various
departments received
individual grants that allowed
them to start to provide
services. In 2006 and 2007
telemedicine really took hold,
as funding from California’s
Proposition 1D provided
financing for the equipment
and networks needed to carry
out our value of delivering
quality healthcare regardless of
geographic location. We took
a different approach than most
other large health systems,
7
sep tember 2 013
which start with a centralized
telehealth office and a single service
and expand from there.
Executive leadership here knew
telehealth could be very disruptive
and that a massive pivot in delivery
can be difficult. Instead of a topdown approach, we implemented
a decentralized model that enabled
telemedicine to spread through
various departments quickly,
based on the interest and ability of
physicians who wanted to take on
If you tie telehealth to
technology, you will always
be behind.
the responsibility and find new ways
to deliver care.
FHIT: What’s the difference
between telehealth and
telemedicine?
PK: While we frequently use the
terms interchangeably, telemedicine
refers to diagnosis and treatment
using remote technology.
Telehealth is the larger umbrella
term; it includes telemedicine as
well as prevention and disease
management.
FHIT: What steps must an
organization take to make telehealth
services work?
PK: At the department level, you
have to have the right technology
FHIT: A recent study in Telemedicine
and e-Health found that University of
California-Davis Children’s Hospital
doubled its referrals and saw a 60
percent increase in revenue from
patient transfers after implementing
a telemedicine network. Are
you seeing a similar return on
investment (ROI) for UCLA?
PK: I absolutely agree that we see
that kind of increase in referrals.
The main ROI we see now,
however, is a halo effect. We are
expanding our reach, partnering
with organizations outside our
community, and achieving our three
missions as an academic medical
center of research and teaching as
well as treatment. If you look at ROI
today just from a fee for service
model driven by volume, there’s
tremendous variability by state and
by service. Within our departments,
different specialties require different
equipment. We didn’t want them to
worry about taking on the financial
risk. Leadership secured funding
and supported the program, so our
physicians felt comfortable diving
into telehealth, regardless of the
short-term ROI.
and develop a hybrid model for
telehealth. The platform will move
us from focusing on the next great
gizmo to honing in on the right
technology, payers, contracts and
workflow across our departments so
we can continue to offer telehealth
programs to patients for years to
come.
The hybrid model will leverage
our current system and extensive
capabilities and enable us to better
coordinate our programs, reduce
costs and streamline management.
This new structure will position
us to respond to the movement
toward reimbursement for improving
population health and away from
pure volume and fee for service.
The telehealth program will
expand in response to those new
financial incentives and to achieve
our vision of providing quality
healthcare regardless of geography.
Already, we are building out our
network in rural California. We
support military service members
nationally through Operation Mend.
We provide pathology consultations
and training in China and we’re also
expanding programs elsewhere
in Asia, into South America, and
starting to do cancer education
in Africa. l
FHIT: What’s next?
PK: We have two goals for the
coming year: Put the platform
in place to sustain the program
sep tember 2 013
8

5. FierceHealthIT
FierceHealthIT.com
Case Study: Children’s
Healthcare of Atlanta and
Coffee Regional Medical Center
By Anne t te M. Boyle and Brenda L. Moone y
Organizations create a
telemedicine partnership to
improve pediatric care in
rural Georgia
For years, physicians in rural
Douglas, Ga. struggled to find
nearby specialists to whom
they could refer patients,
particularly children. The
closest pediatric cardiologist
practiced in Macon, more
than two hours away. To see
other specialists, children had
to travel 200 miles to Atlanta.
Poverty further compounded
lack of access.
“We frequently have people
cancel clinic appointments
because the car is out of
gas and they can’t afford
to buy enough to get the
10 miles to see us,” says
Debra Lister, M.D., medical
director of the telemedicine
program at Coffee Regional
Medical Center (CRMC), the
only hospital in Douglas and
surrounding Coffee County.
Connecting specialists
and patients
To improve access to
specialists, in 2007 CRMC
joined the Georgia Partnership
for TeleHealth (GPT), a
statewide network initially
funded by an $11.5 million
grant from WellPoint, Inc. and
$100 million in rural capital
9
sep tember 2 013
bonds. Early on, the hospital’s
telemedicine program enabled
neurologists at the Medical
College of Georgia in Augusta and
cardiologists in Atlanta to examine
patients with strokes or heart attacks
in the emergency department
through a teleconferencing link;
pulmonologists could evaluate
patients using the telemedicine
suite in the hospital’s walk-in clinic.
Consistent access to pediatric
specialists, however, remained
elusive.
In 2009, Children’s Healthcare
of Atlanta (CHOA) launched a pilot
program to offer subspecialty
services outside the Atlanta
metropolitan area through GPT.
Over the next three years, the
three-hospital, 529-bed organization
expanded its telemedicine
program to include 25 physicians
in 14 pediatric subspecialties,
including autism, cardiology, child
protection, endocrinology, fetal
echocardiography, nephrology,
neurosurgery, orthopedics and
pulmonology. CHOA provides
consultations to 43 sites,
including hospitals, public
health departments, schools
and department of family and
children’s services offices.
“Now specialists can see
children who otherwise would
never have been able to come to
their offices,” says Lister. Local
physicians like the program, too, not
only because their patients receive
appropriate care but also because
they can better manage the care
patients receive.
With Mobile technology,
docTorS caN hEAR A hEARtbEAt
a hUNdrEd miLES aWay
.
{ PO W E R F UL ANSW E R S }
Keeping care in the
community
“Our families are very grateful not
to have to travel far and our local
doctors like that they have more
control of their patients’ care.
When we referred patients out of
town for consultations, often the
physician would refer the child to
other specialists close to them—
even if we had that specialty in
Douglas,” Lister says. “We are
very conscientious about sending
reports from consults to primary care
physicians. We act as a go-between
continued on page 12
the technology to help transform healthcare. healthcare providers are continually looking for ways
to improve patient care. The innovative minds at Verizon have teamed up with some of the smartest
companies around to create solutions that help doctors treat patients remotely. Wireless applications
allow medical practitioners to view critical patient data on the Verizon 4G LTE network. it all helps to
improve healthcare delivery for people and increase efficiency for providers.
because the world’s biggest challenges deserve even bigger solutions.
Solutions for healthcare: verizon.com/healthcare
4G LTE is available in more than 500 markets in the U.S. Network details coverage maps at vzw.com. © 2013 Verizon Wireless.
sep tember 2 013
10

6. FierceHealthIT
FierceHealthIT.com
continued from page 5
sustainable,” he says.
For telemedicine to work well,
Linkous says “it must be integrated
into care; part of the standard
procedures for the organization.”
With more than 200 telehealth
networks connecting more than
3,000 healthcare organizations,
according to the ATA, knowing what
makes programs successful could
profoundly affect healthcare across
the country.
Healthcare organizations provide
telemedicine services for many
different reasons, says Linkous. “A
hospital may look at telemedicine
as a way to boost visibility of clinics
and eventually raise the number of
referrals. They may do it to reduce
readmissions, related to upcoming
financial penalties or to increase
market footprint.”
Equipment costs create few
barriers
For organizations interested in
telehealth programs, the cost
of equipment is no longer a
barrier. “Reimbursements don’t
cover equipment, but these days
technology costs are relatively
minor,” says Linkous. “Unless you’re
talking about assisted surgery,
you don’t need bells and whistles.
Monitoring and conferencing
equipment are not expensive
systems. The decision to offer
telemedicine services shouldn’t be
based on cost of the technology or
software today.”
Presenting sites providing
therapies that do not require scopes
“Unless you’re talking about assisted
surgery, you don’t need bells and whistles.”
Jon Linkous, chief executive officer, American
Telemedicine Association
11 sep tember 2 013
or other examination equipment can
get by with a laptop and $1,500 in
software. A fully loaded cart with
a variety of scopes and full video
capability runs about $27,000, says
Sherrie Williams, director of state
projects for the Georgia Partnership
for TeleHealth.
Equipment requirements vary
by service offerings. “Different
diseases need different technology,”
says Wasden. “Programs fail when
they lack a level of sensitivity and
specificity. One size does not fit all.”
Teleradiology, the most common
telemedicine service, uses images
transmitted through communication
lines built into most equipment.
Teleneurology for stroke patients
requires full video conferencing.
Remote monitoring of intensive care
beds, a rapidly growing field, relies
more on ongoing data transmission
rather than episodic video consults.
Chronic disease monitoring
poised for growth
Online consultation and webbased monitoring of chronic health
conditions offer the greatest
opportunities for growth, says
Linkous. “Hospitals may provide
1,000 or 2,000 consults to rural
areas each year; with web-based
programs, they can provide that
many in a week,” he says.
A new source of funding may
speed widespread adoption of
telehealth initiatives, adds Linkous.
“About 20% of large employers say
that they are looking at offering webbased programs in the workplace or
through employer-sponsored plans.
Factories or large office buildings
could make telehealth services
available through a nursing office or
you may see companies allowing
employees to use their desktop
computers to obtain services.” l
continued from page 9
to keep everything going smoothly
during and after a telemedicine visit.”
For CHOA, keeping care local
achieves multiple goals. “We
rarely ask families to bring a child
to Atlanta; our goal is to support
the healthcare professionals in the
community. If we were seeing
a patient in Coffee County, for
example, who needed multiple
tests, the labs there would do the
work and get the revenue,” says
D.D. Fritch-Levens, R.N., director
of the contact center for CHOA.
In other instances, CHOA has
proactively identified patients who
travel significant distances and asked
them whether they would prefer
a telemedicine consult at a more
convenient presenting site.
“We can’t put bricks and mortar
everywhere in the state. With
telemedicine we don’t need to.
We can partner with communities
and local physicians to increase
pediatric medical knowledge,” adds
Fritch-Levens. In keeping with that
objective, CHOA recently completed
a three-part series on pediatric
cardiology offered to physicians
and mid-level practitioners through
telemedicine links and plans
sessions on pediatric nursing and
pulmonology.
Getting started
Lister advises healthcare
organizations considering adding or
expanding telemedicine services to
find someone within their practice
or hospital who thinks it is a good
idea and is willing to promote it.
Presenting sites should “canvas
local doctors and find out what
they need, what services they have
trouble getting patients into.” Expect
the service to evolve, she adds.
“Our families are very grateful not to have to
travel far and our local doctors like that they
have more control of their patients’ care.”
Debra Lister, M.D., medical director, Coffee
Regional Medical Center Telemedicine Program
“Initially, we had more requests for
dermatology consults than anything
else.” Now, pediatric subspecialties
comprise three of the top four most
requested services.
Fritch-Levens echoes the
importance of finding internal
champions. “The will to do this
must come from the clinic side.
The organization may plan to offer
one service, but if that specialty or
department is not interested in doing
it, and doesn’t have someone with
passion to spearhead it, it simply
won’t succeed,” she says. “There
are too many competing priorities.”
Making it work
To make it easy for physicians to
work telemedicine consults into
their daily schedule, Fritch-Levens
advocates putting telemedicine
facilities inside clinics or bringing
wireless capability to the bedside.
Making remote consults part of the
regular workflow also helps. Initially
physicians would set aside available
time and wait in the telemedicine
suite for presenting sites to initiate
visits, but for most practices, that
led to underutilization. “On a typical
clinic day, a physician sees 15-18
patients; on a busy telemedicine day,
he might see four,” says Michael
McConnell, medical director, CHOA
telemedicine. “We’re trying to work
telemedicine into the daily workflow
of the clinic now. A doctor might
have patients scheduled at 9:00,
9:30 and 10:00 for in-person visits
and at 10:30 talk to someone via a
telemedicine link and be back in the
clinic for an 11:00 appointment.”
Fritch-Levens notes that some
sites queue all their patients who
need a particular type of consultation
on one day, and the specialist books
the entire day in the telemedicine
suite. This structure works especially
well to continue care for patients
when a specialist closes a practice in
a rural location.
Measuring success
Increasing efficiency improves
the economics of the program,
but ultimately, CRMC and CHOA
each consider the work part of
their missions. For both hospitals,
reimbursement, while steadily
improving, does not fully cover the
costs of the service.
“The program gives Children’s
a voice in communities that we
didn’t have before. It allows us to
intervene in children’s health in
a positive, impactful way,” says
Fritch-Levens. “Recently, we did a
consult with a teenage girl who had
severe shortness of breath. She’d
been treated for asthma and wasn’t
improving. A pulmonologist remotely
diagnosed her with pulmonary
hypertension and she was in the
ICU that night. She has a long road
ahead, but now she’s getting the
right treatment.”
“Improving care, saving lives—
that’s really the whole point of the
system,” says Lister. l
sep tember 2 013
12