MedMij:V2019.01 FHIR PDFA
{{#customtitle:MedMij FHIR Implementation Guide: PDF/A 2.0.1}}
Inhoud
- 1 Introduction
- 2 Actors and transactions involved
- 3 Use case: Find and retrieve existing PDF/A document(s)
- 4 Use case: Send PDF/A document(s)
- 5 Annex: Document history
Introduction
MedMij specifies the format PDF/A for exchanging unstructured documents containing health information. Forum Standaardisatie is a Dutch governmental organization that aims to stimulate the use of open standards. PDF/A is one of the standards that is recommended by Forum Standaardisatie. More information regarding PDF/A can be found here: https://www.forumstandaardisatie.nl/standaard/pdf-a1.
To achieve exchange of PDF/A files, MedMij adopts as much as possible from the Mobile access to Health Documents (MHD) profile from Integrating the Healthcare Enterprise (IHE) that defines a RESTful/HTTP interface to an XDS environment using HL7 FHIR STU3 resources. The MHD profile is written to be content agnostic and as such is suitable for much more than PDF/A. For this use case, we have limited the scope to PDF/A. The next section summarizes MHD and contains references to IHE MHD specification. The following sections provides an adaptation of the MHD profile to specify exchange of PDF/A documents in a MedMij context.
IHE MHD specification
Mobile access to Health Documents (MHD) profile defines a simple HTTP RESTful interface to an XDS like environment, based on HL7 FHIR. It describes four transactions:
- submit submission sets, folders, new documents, and document metadata from the mobile device to a document receiver (Provide Document Bundle),
- find submission sets matching query parameters (Find Document Manifest),
- find document entries containing metadata based on query parameters (Find Document Reference),
- retrieve a copy of a specific document (Retrieve Document).
These transactions leverage the document content and format agnostic metadata concepts from XDS but simplify them for access by constrained environments such as mobile devices, or other resource-constrained systems. The MHD profile does not replace XDS. It can be used to allow mobile devices, or other resource-constrained systems, access to an XDS health information exchange.[1]
Wiki: Mobile acces to Health Document (MHD)
Document: MHD Supplement (Rev 2.4 July 24, 2018)
Additional Supplement: Appendix Z on HL7 FHIR (Rev 1.2 July 21, 2017)
Actors and transactions involved
Table 1 shows the relevant actors, systems and FHIR capability statements in a MedMij context. The capability statements demonstrate the minimum requirements to be conformant to the full MHD specifications.
| Persons | Systems | FHIR Capability Statements | |||
|---|---|---|---|---|---|
| Name | Description | Name | Description | Name | Description |
| Patient | The user of a personal healthcare environment. | PHR | Personal health record |  CapabilityStatement: Client
|
PDFA FHIR Client requirements |
| Healthcare Provider | The user of a XIS | XIS | Healthcare information system | CapabilityStatement: Server
|
PDFA FHIR Server requirements |
Table 1. Actors, systems and FHIR capability statements
Table 2 shows the MHD actors and transactions in perspective of the systems used in a MedMij context.
| Person | System | MHD Actors | MHD Transactions |
|---|---|---|---|
| Patient | |||
| PHR | |||
| Document Consumer | Find Document Manifests [ITI-66] | ||
| Find Document References [ITI-67] | |||
| Retrieve Document [ITI-68] | |||
| Document Source | Provide Document Bundle [ITI-65] | ||
| Healthcare provider | |||
| XIS | |||
| Document Responder | Find Document Manifests [ITI-66] | ||
| Find Document References [ITI-67] | |||
| Retrieve Document [ITI-68] | |||
| Document Recipient | Provide Document Bundle [ITI-65] |
Use case: Find and retrieve existing PDF/A document(s)
Introduction
This section summarizes the IHE MHD profile to find and retrieve PDF/A documents in a MedMij context.
This FHIR implementation guide assumes that the PHR system is able to make a connection to the right XIS that contains the patient's information. It does not provide information on finding the right XIS nor does it provide information about security. Moreover, each transaction is performed in the context of a specific authenticated patient, for whose context (token) has been established using the authentication mechanisms described in the 'Afsprakenstelsel'. Each XIS Gateway is required to perform filtering based on the patient associated with the context for the request, so only the records associated with the authenticated patient are returned. For this reason, search parameters should not be included for patient identification.
Actors and transactions involved
Table 1 shows the relevant actors, systems and FHIR capability statements in a MedMij context. The capability statements demonstrate the minimum requirements to be conformant to the full MHD specifications.
| Persons | Systems | FHIR Capability Statements | |||
|---|---|---|---|---|---|
| Name | Description | Name | Description | Name | Description |
| Patient | The user of a personal healthcare environment. | PHR | Personal health record | CapabilityStatement: Client
|
PDFA FHIR Client requirements |
| Healthcare Provider | The user of a XIS | XIS | Healthcare information system | CapabilityStatement: Server
|
PDFA FHIR Server requirements |
Table 1. Actors, systems and FHIR capability statements
Table 2 shows the MHD actors and transactions in perspective of the systems used in a MedMij context.
| Person | System | MHD Actors | MHD Transactions |
|---|---|---|---|
| Patient | |||
| PHR | |||
| Document Consumer | Find Document Manifest | ||
| Find Document Reference | |||
| Retrieve Document | |||
| Healthcare provider | |||
| XIS | |||
| Document Responder | Find Document Manifest | ||
| Find Document Reference | |||
| Retrieve Document |
Table 2. MHD actors and transactions in perspective of systems in a MedMij context
Transactions in scope
- Find Document Manifests – This transaction is used to issue parameterized queries that result in a list of Document Manifest resources.
- Find Document References – This transaction is used to issue parameterized queries that produce a list of Document Reference resources.
- Retrieve Document – This transaction is used to get documents.
Document Consumer shall implement at least one transaction: Find Document Manifests, Find Document References, or Retrieve Document. Document Responder shall implement all transactions.
Transactions out of scope
The MHD profile specifies how to send documents from a Document Source to a Document Receiver using the Provide Document Bundle transaction. However, sending PDF/A documents is currently out of scope for the MedMij context. The 'Afsprakenstelsel' first focuses on pulling data from a XIS to a PHR before considering push transactions. In the future, specifications of sending PDF/A documents from a PHR will be added.
Find and retrieve existing PDF/A document(s)
Find PDF/A or PDF/A collection
Discovery of PDF/A documents is done with the MHD defined transaction 'Find Document Reference' or 'Find Document Manifest.' The Find Document Reference retrieves FHIR DocumentReference Resources that represents a single reference to document per resource, for example, one PDF/A file. The Find Document Manifest retrieves FHIR DocumentManifest Resources. A DocumentManifest Resource gathers a set of DocumentReference Resources into a single package together with metadata that applies to the collection.
The Document Consumer requests DocumentReference or DocumentManifest Resources, matching a set of criteria, from the Document Responder. The Document Responder returns DocumentReference or DocumentManifest Resources that match the search criteria provided by the Document Consumer.
Request message
Search
The Document Consumer executes an HTTP GET conform to the FHIR RESTfull and search specification. A search query would have the following format.
GET [base]DocumentReference?[parameters]{&_format=[mime-type]}
GET [base]DocumentManifest?[parameters]{&_format=[mime-type]}
Example query to search for DocumentReferences of type Discharge summary with a current status.
GET http://example.org/fhir/DocumentReference?type=http://loinc.org|18842-5&status=current
Search Parameters The Document Consumer shall include search parameter status. The Document Consumer may supply, and the Document Responder shall be capable of processing, all query parameters listed below. These search parameters are a selection of the defined search parameters by the HL7 FHIR specification (search parameters: DocumentReference, DocumentManifest). See also the HL7 FHIR STU3 specification for searching.
| DocumentReference | DocumentManifest | ||||
|---|---|---|---|---|---|
| Name | Type | Description | Name | Type | Description |
| indexed | date | When this document reference was created | created | date | When this document manifest created |
| author (author.given and author.family) | string | Who and/or what authored the document | author (author.given and author.family) | string | Who and/or what authored the manifest |
| type | token | Kind of document (LOINC if possible) | type | token | Kind of document set |
| class | token | Categorization of document | source | uri | The source system/application/software |
| status | token | current / superseded | status | token | current / superseded |
| setting | token | Additional details about where the content was created (e.g. clinical specialty) | |||
| period | date | Time of service that is being documented | |||
| facility | token | Kind of facility where patient was seen | |||
| event | token | Main clinical acts documented | |||
| securitylabel | token | Document security-tags | |||
| format | token | Format/content rules for the document | |||
| related-id | token | Identifier of related objects or events | |||
The PDF/A use cases within MedMij especially use of the search parameters indexed and status for DocumentReference and created and status for DocumentManifest.
Response message
The Document Responder shall process the query to discover the DocumentReference or DocumentManifest entries that match the search parameters given. The Document Responder returns an HTTP Status code appropriate to the processing as well as a Bundle including the matching DocumentReference or DocumentManifest Resources. When the Document Responder needs to report an error or warning, it shall use HTTP error response codes and should include a FHIR OperationOutcome with more details on the failure or warning. If the request message is processed successfully, whether or not any DocumentReference or DocumentManifest Resources are found, the HTTP status code shall be 200.
- The Document Responder shall place into the 'DocumentReference.content.attachment.url' element a full URL that can be used by the Document Consumer to retrieve the document using Retrieve Document transaction.
- The Document Responder shall only include references which are resolved through the Document Responder to maintain control over the authentication and authorization. The Document Responder shall only serve DocumentReference or DocumentManifest resources that contain a reference which the Document Consumer may resolve.
- The Document Responder shall return only PDF/A documents and shall place into the 'DocumentReference.content.attachment.contentType' element the value 'application/pdf'.
Example of a response message
Example of a Bundle with 11 DocumentReference Resources. Only the first DocumentReference is displayed.
<Bundle xmlns="http://hl7.org/fhir">
<id value="c0beb362-efc7-4cb9-b35a-c6cea0742156" />
<meta>
<versionId value="1498fcb4-af9c-404f-b445-e6634619df55" />
<lastUpdated value="2017-10-25T11:25:00.336+00:00" />
</meta>
<type value="searchset" />
<total value="11" />
<link>
<relation value="self" />
<url value="http://vonk.furore.com/DocumentReference?status=current" />
</link>
<entry>
<fullUrl value="http://vonk.furore.com/DocumentReference/c4f22730-bb5a-4f12-b4ef-c7bde0784426" />
<resource>
<DocumentReference xmlns="http://hl7.org/fhir">
<id value="example-pdfa-documentreference2" />
<meta>
<profile value="http://ihe.net/fhir/StructureDefinition/IHE.MHD.Query.Minimal.DocumentReference"/>
</meta>
<contained>
<Practitioner>
<id value="p1"/>
<name>
<family value="Kneder"/>
<given value="B.">
<extension url="http://hl7.org/fhir/StructureDefinition/iso21090-EN-qualifier">
<valueCode value="IN"/>
</extension>
</given>
</name>
</Practitioner>
</contained>
<masterIdentifier>
<system value="urn:ietf:rfc:3986" />
<value value="urn:oid:1.2.276.0.7230010.3.1.2.1787205428.3024.1522314975.220899" />
</masterIdentifier>
<identifier>
<system value="http://example-xis.org/fhir/NamingSystem/DocumentReferenceID"/>
<value value="963369"/>
</identifier>
<status value="current" />
<type>
<coding>
<system value="http://loinc.org/" />
<code value="34781-5" />
<display value="Infectious disease Consult note" />
</coding>
</type>
<class>
<coding>
<system value="http://loinc.org/" />
<code value="11488-4" />
<display value="Consult Note" />
</coding>
</class>
<subject>
<reference value="Patient/example-pdfa-kwalificatie1" />
</subject>
<indexed value="2017-04-08T15:26:01+01:00" />
<author>
<reference value="#p1" />
</author>
<description value="Infectious disease Consult note" />
<securityLabel>
<coding>
<system value="http://hl7.org/fhir/v3/Confidentiality" />
<code value="V" />
<display value="very restricted" />
</coding>
</securityLabel>
<content>
<attachment>
<contentType value="application/pdf" />
<language value="en" />
<url value="http://example-test-server.org/fhir/Binary/example-pdfa-binary2" />
<title value="Example PDF - Infectious disease Consult note"/>
</attachment>
</content>
</DocumentReference>
</resource>
<search>
<mode value="match" />
</search>
</entry>
.......
Retrieve PDF/A document
After obtaining the location of the PDF/A document in the DocumentReference.content.attachment.url, the Document Consumer requests the document from the Document Responder. The Document Responder sequentially serves the PDF/A document to the Document Consumer. The context that was established in the initial request shall also apply when retrieving/serving the document contents.
Request Message
This message is an HTTP GET request to retrieve the document. See an example below.
GET http://example:9556/svc/fhir/Binary/1e404af3-077f-4bee-b7a6-a9be97e1ce32
The Document Consumer may provide an HTTP Accept header, according to the semantics of the HTTP protocols (see RFC2616, Section 14.1). The only MIME type assured to be returned is the MIME type indicated in the 'DocumentReference.content.attachment.contentType'. Within MedMij this is set to 'application/pdf'. The HTTP If-Unmodified-Since header shall not be included in the GET request
Response Message
The Document Responder shall process the request message. The Document Responder returns an HTTP Status code appropriate to the processing as well as the content of the requested PDF/A document in the HTTP message-body.
The document may be placed inside a FHIR Binary resource if it is useful to handle pure binary content using the same framework as other resources. Binary resources behave slightly differently from all other resources on the RESTful API. Specifically, when a read request is made for the binary resource that doesn't explicitly specify the FHIR content types "application/fhir+xml" or "application/fhir+json", then the content should be returned using the content type stated in the resource. e.g. if the content type in the resource is "application/pdf", then the content should be returned as a PDF directly.[2]
When the Document Responder needs to report an error or warning, it shall use HTTP error response codes and should include a OperationOutcome with more details on the failure or warning. If the Retrieve Document message is processed successfully the HTTP status code shall be 200.
Example of a response message
<Binary>
<id value="1e404af3-077f-4bee-b7a6-a9be97e1ce32" />
<meta>
<versionId value="948f3653-c9a3-4831-bae5-f629319c194f" />
<lastUpdated value="2017-09-20T17:55:14.098+00:00" />
</meta>
<contentType value="application/pdf" />
<content value="JVBERi0xLjUNJeLjz9MNCjU1I........"/>
</Binary>
Interactions, operations, search parameters
Interactions
The following logical interactions are needed for this use case:
Operations
There are no defined operations for this use case.
Search parameters
The following search parameter types need to be supported for this use case. No search result parameters need to be supported.
Search parameter types:
List of StructureDefinitions
IHE has defined StructureDefinitions and other Conformance resources applicable to this use case. The FHIR Implementation Guide on the IHE MHD wiki lists these StructureDefinitions.
Find and retrieve existing PDF/A document transaction uses the following StructureDefinitions:
- DocumentReference from Query with Minimal Metadata (canonical URL http://ihe.net/fhir/StructureDefinition/IHE.MHD.Query.Minimal.DocumentReference)
- DocumentManifest (canonical URL http://ihe.net/fhir/StructureDefinition/IHE.MHD.DocumentManifest)
- Optionally: DocumentReference from Query with Comprehensive Metadata (canonical URL: http://ihe.net/fhir/StructureDefinition/IHE.MHD.Query.Comprehensive.DocumentReference). This StructureDefinition has more mandatory field compared to Minimal Metadata and is used for XDS environments.
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|
The IHE StructureDefinitions restrict the use of the .created element. This is a known issue and will be addressed in the R4 release of the profiles. This issue (CP-ITI-1100) can be found on the IHE MHD wiki. Therefore the indexed element is used to capture creation time. |
Next to the IHE MHD StructureDefinitions, MedMij uses the following HCIM StructureDefinitions for the response message.
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|
MedMij uses the FHIR Packaging mechanism. This conveniently bundles all examples, profiles and other conformance resources you need into a single download. For more background information see the the FHIR implementation guide. This version of the information standard depends on Nictiz package 1.3.x. Please note that the direct links to the various conformance resources below will take you to the latest version, which might not match the package version. At time of writing, there is no way to render the conformance resource as found in the package. This is on the roadmap for Simplifier. |
| ZIB name NL | ZIB name EN | FHIR Resource | |
| Patient | Patient | Patient | http://fhir.nl/fhir/StructureDefinition/nl-core-patient |
| Zorgverlener | HealthProfessional | Practitioner | http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner |
| Zorgaanbieder | HealthcareProvider | Organization | http://fhir.nl/fhir/StructureDefinition/nl-core-organization |
| - | - | DocumentManifest | http://ihe.net/fhir/StructureDefinition/IHE.MHD.DocumentManifest |
| - | - | DocumentReference | http://ihe.net/fhir/StructureDefinition/IHE.MHD.Query.Minimal.DocumentReference |
Use case: Send PDF/A document(s)
Introduction
This section summarizes the IHE MHD profile to Send PDF/A document(s) in a MedMij context.
This FHIR implementation guide assumes that the PHR system is able to make a connection to the right XIS that contains the patient's information. It does not provide information on finding the right XIS nor does it provide information about security. Moreover, each transaction is performed in the context of a specific authenticated patient, for whose context (token) has been established using the authentication mechanisms described in the 'Afsprakenstelsel'. Each XIS Gateway is required to perform filtering based on the patient associated with the context for the request, so only the records associated with the authenticated patient are returned. For this reason, search parameters should not be included for patient identification.
Actors
| Person | System | MHD Actors | MHD Transactions |
|---|---|---|---|
| Patient | PHR | Document Source | Provide Document Bundle [ITI-65] |
| Healthcare provider | XIS | Document Recipient | Provide Document Bundle [ITI-65] |
Send PDFA
PHR: Request message
When the patient (PHR) wants to send one or more PDF/A documents, it issues a send PDFA request message.
The PHR initiates a FHIR transaction using a create action by sending an HTTP POST request, composed of a FHIR Bundle resource containing one DocumentManifest resource, one or more DocumentReference resources, one or more Binary resources, one Patient resource, and zero or more Practitioner resources to the XIS recipient. References to the FHIR specification for the required transaction and POST requests are given in the interactions, operations and search parameters section below.
The PHR executes an HTTP POST against the XIS's base endpoint as shown below.
POST [base] {?_format=[mime-type]}
Read more:
The resources in the message SHALL be a valid instance of the listed StructureDefinitions below. All resources SHALL include their related profile canonical URL in the meta.profile element in order to show compliance.
Example - Bundle structure
<?xml version="1.0" encoding="UTF-8"?>
<Bundle xmlns="http://hl7.org/fhir">
<type value="transaction"/>
<entry>
<fullUrl value="urn:uuid:96cf0274-9b2c-4bdc-b4c4-cb46f7a07097"/>
<resource>
<Patient xmlns="http://hl7.org/fhir">
<!-- SNIP -->
</Patient>
</resource>
<request>
<method value="POST"/>
<url value="Patient"/>
</request>
</entry>
<entry>
<fullUrl value="urn:uuid:278764fb-06b6-4f4f-8cef-4abaa3682111"/>
<resource>
<DocumentManifest xmlns="http://hl7.org/fhir">
<!-- SNIP -->
</DocumentManifest>
</resource>
<request>
<method value="POST"/>
<url value="DocumentManifest"/>
</request>
</entry>
<entry>
<fullUrl value="urn:uuid:2aa911db-9117-4e4b-97e4-d2f09dd28111"/>
<resource>
<DocumentReference xmlns="http://hl7.org/fhir">
<!-- SNIP -->
</DocumentReference>
</resource>
<request>
<method value="POST"/>
<url value="DocumentReference"/>
</request>
</entry>
<entry>
<fullUrl value="urn:uuid:6d035264-66ac-4df2-8bf8-d9a9bbf46111"/>
<resource>
<Binary xmlns="http://hl7.org/fhir" >
<!-- SNIP -->
</Binary>
</resource>
<request>
<method value="POST"/>
<url value="Binary"/>
</request>
</entry>
</Bundle>
XIS: Response message
The target XIS returns an HTTP Status code appropriate to the processing outcome and returns a Bundle, of type transaction-response, that contains one entry for each entry in the request, in the same order, with the outcome of processing the entry.
The target XIS SHALL return a Bundle with type set to transaction-response that contains one entry for each entry in the request, in the same order, with the outcome of processing the entry.
A client may use the returned Bundle to track the outcomes of processing the entry, and the identities assigned to the resources by the server. Each entry element SHALL contain a response element which details the outcome of processing the entry - the HTTP status code, and the location and ETag header values, which are used for identifying and versioning the resources. In addition, a resource may be included in the entry, as specified by the Prefer header.
Handling Errors
When the resource syntax or data is incorrect or invalid, and cannot be used to create a new resource, the server returns a 400 Bad Request HTTP status code. When the server rejects the content of the resource because of business rules, the server returns a 422 Unprocessable Entity error HTTP status code. In either case, the server SHOULD include a response body containing an OperationOutcome with detailed error messages describing the reason for the error, and perform a rollback of the creation of any previous entries.
Common HTTP Status codes returned on FHIR-related errors (in addition to normal HTTP errors related to security, header and content type negotiation issues):
- 400 Bad Request - resource could not be parsed or failed basic FHIR validation rules
- 404 Not Found - resource type not supported, or not a FHIR end-point
- 422 Unprocessable Entity - the proposed resource violated applicable FHIR profiles or server business rules. This should be accompanied by an OperationOutcome resource providing additional detail
Read more:
Interactions, operations, search parameters
Interactions
The following logical interactions are needed for this use case:
Operations
There are no defined operations for this use case.
Search parameters
No search parameters are needed for this use case.
List of StructureDefinitions
IHE has defined StructureDefinitions applicable to this use case. Although the IHE MHD Profile text (the published PDF) is Normative these conformance resources are labelled as Informative. Not all IHE MHD profiles are implementable as-is for the send use case because of errors that IHE does not intend to resolve in FHIR STU3, but instead, require updating to FHIR R4. MedMij is not ready upgrading to FHIR R4 for just this use case and has implemented the necessary fixes in the IHE FHIR STU3 profiles to support this use case. The IHE MHD profiles 'IHE.MHD.DocumentManifest' and 'IHE.MHD.ProvideDocumentBundle.Minimal' are therefore copied, adjusted for the known issues and released under Nictiz. The table below shows the IHE MHD profiles used for the Providing Document Bundle transaction and the relevant HCIM profiles.
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MedMij uses the FHIR Packaging mechanism. This conveniently bundles all examples, profiles and other conformance resources you need into a single download. For more background information see the the FHIR implementation guide. This version of the information standard depends on Nictiz package 1.3.x. Please note that the direct links to the various conformance resources below will take you to the latest version, which might not match the package version. At time of writing, there is no way to render the conformance resource as found in the package. This is on the roadmap for Simplifier. |
| ZIB name NL | ZIB name EN | FHIR Resource | URL profile |
|---|---|---|---|
| Patient | Patient | Patient | http://fhir.nl/fhir/StructureDefinition/nl-core-patient |
| Zorgverlener | HealthProfessional | Practitioner | http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner |
| PractitionerRole | http://fhir.nl/fhir/StructureDefinition/nl-core-practitionerrole | ||
| Zorgaanbieder | HealthcareProvider | Organization | http://fhir.nl/fhir/StructureDefinition/nl-core-organization |
| - | - | Bundle * | http://nictiz.nl/fhir/StructureDefinition/IHE.MHD.ProvideDocumentBundle.Minimal |
| - | - | DocumentManifest * | http://nictiz.nl/fhir/StructureDefinition/IHE.MHD.DocumentManifest |
| - | - | DocumentReference | http://nictiz.nl/fhir/StructureDefinition/IHE.MHD.Provide.Minimal.DocumentReference |
| - | - | List | http://nictiz.nl/fhir/StructureDefinition/IHE.MHD.List |
'* Adjusted version of IHE MHD profiles by Nictiz.
Annex: Document history
Release notes
Release notes can be found on the functional design page.
History
| Release | Date | Description |
|---|---|---|
| 2019.01 | 02-10-2019 |
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| 2019.01 | 30-09-2019 |
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| 01-08-2019 |
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| 29-07-2019 |
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| 01-07-2019 |
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| 09-05-2019 |
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| 2019.01 | 11-03-2019 |
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| 2019.01 | 11-03-2019 |
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| 2018.06 | 15-10-2018 |
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