Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1- In the manuscript, the literature search is not reproducible because the authors do not report the exact search strings, boolean operators, screening process, or numbers of records identified/excluded in the manuscript, kindly check and corretc it.

2- As author presneted in the mansucript, the purposive source selection without predefined inclusion/exclusion criteria introduces substantial selection bias and prevents assessment of review completeness.

3- Only 38 references underpin the framework, which is a very limited evidence base for constructing a five domain risk management framework intended for broad healthcare application kindly revise and corretc it.

4- The framework combines triadic, dyadic, face to face, and other adjacent evidence, but no quantitative method is provided to justify that these sources are sufficiently transferable.

5- Risk likelihood and severity are assigned by the authors without a validated scoring system, independent assessors, inter rater reliability, or consensus procedure in the manuscript, kindly check and correct it.

6- The use of high, moderate, and low risk categories is subjective and lacks operational thresholds, making the resulting risk classifications non reproducible.

7- The manuscript invokes ISO 14971 risk management principles for a healthcare framework without demonstrating how its medical device risk methodology was appropriately adapted to telemedicine, kindly check and correct it.

8- No formal evidence quality or risk of bias assessment is performed, despite combining systematic reviews, qualitative studies, commentaries, frameworks, and regulatory documents, kindly revise and correct it.

9- The claim that the RMFTT is the first dedicated framework is not supported by a sufficiently systematic search strategy capable of establishing novelty.

10- The proposed causal dependency in which workforce competency (D5) directly conditions D1–D4 is asserted conceptually but is not empirically tested in the manuscript, kindly check and correct it.

11- The conclusion that communication failure is a direct upstream pathway to clinical diagnostic risk is causal language unsupported by the narrative evidence synthesis.

12- Likelihood is described as context dependent or high, but no underlying incidence, prevalence, event rate, or quantitative evidence is provided to support these classifications.

13- The D5 likelihood is classified as high because competency frameworks are absent, which does not logically establish that adverse competency events themselves occur frequently.

14- The framework provides 20 matrix cells but does not specify a transparent rule for how individual literature findings were selected, weighted, or prioritized within each cell.

15- No sensitivity analysis is conducted to determine whether different literature selection or expert judgement assumptions would materially change the proposed framework.

16- Revise this paragraph for better clarity, "Evidence for Domain 2 was drawn from five publications, primarily from the triadic communication literature in face-to-face consultations, the telehealth communication quality literature, and conceptual work on facilitated clinical encounters. A scoping review of patient safety risk in synchronous telehealth, encompassing 15 systematic reviews and 315 studies, identified that patient safety risks in telehealth are systemic, affecting not only healthcare professionals but also the environment and organizational context, with notable gaps in regulatory frameworks and a lack of comprehensive guidelines regarding implementation and monitoring[13]. Communication-specific risk indicators — information filtering, role ambiguity, and patient voice suppression — were identified consistently across the triadic communication literature but have not yet been studied in the telemedicine-specific triadic context."

Author Response

25 October 2026

Journal: Healthcare (MDPI)

Manuscript ID: healthcare-4626183

Title: A Risk Management Framework for Triadic Telemedicine (RMFTT): A Conceptual Development Study

Dear Reviewer 1,

We thank for the detailed and constructive comments. We have carefully addressed each point; the principal revisions are summarised below and are visible as tracked changes in the revised manuscript. Where a manuscript change is referenced, the relevant Priority number from our internal revision log is noted in italics for traceability.

Response to Reviewer1

Comment 1: "In the manuscript, the literature search is not reproducible because the authors do not report the exact search strings, boolean operators, screening process, or numbers of records identified/excluded."

Response: The Methods section has been revised to include the full search strings for each database (PubMed, Scopus, Web of Science, Google Scholar), the Boolean operators used, the screening procedure, and the number of records identified, screened, and included at each stage. A PRISMA-style flow summary is provided to make the process transparent and reproducible.

 

Comment 2: "Purposive source selection without predefined inclusion/exclusion criteria introduces substantial selection bias and prevents assessment of review completeness."

Response: The Methods section now explicitly states the inclusion and exclusion criteria applied during source selection. The conceptual framework development methodology (following Jabareen, 2008) intentionally employs purposive rather than exhaustive search — this methodological choice is now explained and justified in the text. A brief discussion of the limitations this introduces (selection bias, incomplete coverage) has been added to the Limitations section.

 

Comment 3: "Only 38 references underpin the framework, which is a very limited evidence base for constructing a five-domain risk management framework."

Response: The revised manuscript incorporates additional references across all five domains, bringing the total reference count to 40, with targeted additions across all five domains. The Methods section acknowledges that the triadic telemedicine context remains an emerging field with a limited dedicated literature, and explains how evidence from adjacent contexts (dyadic telemedicine, face-to-face facilitated consultations) was used and qualified.

 

Comments 4, 5, 6, 12, 15 (addressed together): These comments collectively challenge the transferability of mixed evidence sources, the absence of a validated scoring system for risk ratings, the subjectivity of high/moderate/low categories, the context-dependence of likelihood classifications, and the absence of a sensitivity analysis.

Response: We acknowledge these as related methodological concerns and address them together. The RMFTT is a conceptual framework, not a validated instrument; risk ratings are presented as structured expert judgements anchored in the literature, not as outputs of a validated scoring algorithm. This distinction is now stated explicitly in the Methods. The [Literature-supported] / [Author-proposed] qualifier system introduced in the revision (see Priority 11) provides transparent attribution for each rating, allowing readers to assess the evidential basis of individual assessments. The Limitations section now explicitly acknowledges the absence of inter-rater reliability testing, operational thresholds, and sensitivity analysis, and identifies these as priorities for the validation phase.

Manuscript change: Priority 11 (qualifier system throughout framework matrix).

 

Comment 7: "The manuscript invokes ISO 14971 risk management principles without demonstrating how its medical device risk methodology was appropriately adapted to telemedicine."

Response: The revised manuscript clarifies that ISO 14971 is used as a terminological reference — providing the identification–assessment–mitigation–monitoring stage structure — rather than as a compliance framework. A brief explanatory note in the Methods makes explicit that the standard's medical device scope has not been adopted wholesale; the stage logic has been adapted to the telemedicine clinical governance context. This distinction is reinforced in the Discussion.

Manuscript change: Priority 9 (ISO 14971 framing).

 

Comment 8: "No formal evidence quality or risk of bias assessment is performed, despite combining systematic reviews, qualitative studies, commentaries, frameworks, and regulatory documents."

Response: The revised manuscript acknowledges this limitation directly. Given the conceptual development design, a formal risk-of-bias tool (e.g., AMSTAR-2, ROBINS) was not applied; instead, source type is now disclosed for each domain's evidence base, and the [Literature-supported] / [Author-proposed] qualifier system makes the evidential status of each framework element transparent. The Limitations section identifies formal evidence quality appraisal as a requirement for any systematic validation study building on this framework.

 

Comment 9: "The claim that the RMFTT is the first dedicated framework is not supported by a sufficiently systematic search strategy capable of establishing novelty."

Response: The revised manuscript addresses this directly through the addition of Table 3, a comparative framework analysis mapping the RMFTT against six existing telemedicine risk management and patient safety frameworks identified in the literature. The comparison demonstrates that while several frameworks address telemedicine risk in general, none targets the triadic model specifically, none accounts for the nurse-facilitator role as a structural risk variable, and none organises risk management across the five domains characteristic of the triadic configuration. The novelty claim is thus supported not by assertion alone but by documented comparison with the closest existing alternatives.

Manuscript change: Priority 1 (Table 3 — comparative framework analysis).

 

Comment 10: "The proposed causal dependency in which workforce competency (D5) directly conditions D1–D4 is asserted conceptually but is not empirically tested."

Response: We acknowledge this limitation and have moderated the language throughout the manuscript to reflect the conceptual rather than empirical status of the D5→D1–D4 relationship. The revised text frames this dependency as a structuring hypothesis derived from the logic of triadic care — where the nurse-facilitator mediates all clinical, communicative, legal, and technical interactions — rather than a demonstrated causal pathway. The Limitations section now explicitly notes that empirical testing of interdomain relationships is a priority for future validation studies.

 

Comment 11: "The conclusion that communication failure is a direct upstream pathway to clinical diagnostic risk is causal language unsupported by the narrative evidence synthesis."

Response: The language has been revised to replace causal framing with associative framing throughout. The manuscript now describes communication failure as a recognised antecedent risk factor for diagnostic error in the triadic context, consistent with the evidence base, rather than asserting a direct causal pathway. We note that this characterisation is well established in the broader patient safety literature and is presented here as a conceptual relationship warranting empirical investigation.

 

Comment 13: "The D5 likelihood is classified as high because competency frameworks are absent, which does not logically establish that adverse competency events themselves occur frequently."

Response: This is a valid logical objection. The revised manuscript clarifies that the D5 likelihood rating reflects the absence of structural safeguards — specifically, the lack of standardised competency frameworks for the triadic facilitator role — as a proxy risk indicator, not a direct measure of adverse event frequency. The text now explicitly acknowledges that this represents an inference from structural vulnerability rather than an empirically derived incidence estimate, consistent with the conceptual nature of the framework.

Manuscript change: Priority 8 (D5 likelihood language).

 

Comment 14: "The framework provides 20 matrix cells but does not specify a transparent rule for how individual literature findings were selected, weighted, or prioritised within each cell."

Response: The revised Methods section now explicitly describes the cell-population procedure: for each domain-stage intersection, all literature findings relevant to that cell were first mapped; where multiple findings addressed the same risk indicator, priority was given to higher-quality evidence (systematic reviews and meta-analyses over single studies, empirical over commentary). The [Literature-supported] / [Author-proposed] qualifier system introduced in the revision provides transparent attribution at the indicator level. We acknowledge that no formal weighting algorithm was applied, which is noted as a limitation.

Manuscript change: Priority 11 (qualifier system).

 

Comment 16: "Revise this paragraph for better clarity" [Domain 2 evidence paragraph].

Response: The paragraph has been revised for clarity. The revised version separates the general telehealth safety evidence from the triadic-specific communication risk indicators, making the logical progression from broad evidence base to domain-specific application more explicit. The revised text reads: "Evidence for Domain 2 was drawn from five publications spanning the triadic communication literature, telehealth communication quality research, and conceptual work on facilitated clinical encounters. A scoping review of patient safety risk in synchronous telehealth — encompassing 15 systematic reviews and 315 studies — identified systemic risks affecting healthcare professionals, the care environment, and organisational context, with notable gaps in regulatory frameworks and implementation guidelines [13]. Three communication-specific risk indicators — information filtering, role ambiguity, and patient voice suppression — were identified consistently across the triadic communication literature, though their manifestation in the telemedicine-specific triadic context remains unstudied."

 

We believe the revised manuscript is substantially strengthened by these revisions and hope it now meets the journal's standards for publication. We remain available to address any further queries.

 

Sincerely,

Alexander Gamus

On behalf of all co-authors

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript explore a dedicated risk management framework for nurse-facilitated triadic telemedicine. The five-domain structure appears useful for organising the risks associated with clinical encounters involving a patient, a nurse or caregiver, and a remote physician. However, the manuscript should be revised before publication as per following comments.

1. The novelty claim requires stronger justification. The authors should compare the proposed RMFTT with existing telemedicine risk management frameworks, patient safety models, clinical risk assessment tools, and digital health governance approaches. A comparative table would help demonstrate the specific contribution of the proposed framework.
2. The framework should explicitly address interactions between the five risk domains. For example, inadequate nurse training may contribute to communication errors, incomplete clinical information, delayed escalation, and subsequent diagnostic harm. The framework should account for such interconnected risks rather than treating each domain independently.
3. The clinical and diagnostic risk domain should address specific failure scenarios, including incomplete physical examination, inaccurate vital-sign measurement, delayed recognition of clinical deterioration, inappropriate reliance on transmitted information, and failure to escalate urgent cases. Corresponding mitigation strategies should be linked to these scenarios.
4. Communication risk should be examined from the perspectives of all three participants. The authors should consider language barriers, health literacy, interruptions, information distortion during handover, uncertainty about who should communicate findings, and confirmation of the remote physician's instructions.
5. Data privacy and cybersecurity risks should extend beyond unauthorised access to include identity verification, consent for information sharing, secure transmission of clinical records, device security, inappropriate recording, access control, and management of security incidents. The proposed controls should be proportionate to the risks and applicable regulatory requirements.
6. Each risk domain should be linked to specific, actionable mitigation measures and measurable monitoring indicators. For example, the framework could consider documentation completeness, frequency of communication failures, escalation delays, training completion, and privacy incidents. The suitability and feasibility of these indicators should be discussed.
7. The manuscript should distinguish controls that are supported by existing empirical evidence from those proposed by the authors as conceptual recommendations. This distinction is particularly important because the framework has not yet been empirically validated.
8. The authors should discuss contextual differences that may influence framework implementation, including rural and urban settings, low-resource healthcare environments, availability of reliable internet connectivity, nurse staffing levels, patient digital literacy, and differences in institutional infrastructure.
9. The proposed framework should be illustrated through a realistic clinical scenario, such as a nurse-facilitated remote consultation in a rural primary care setting. Demonstrating how a risk is identified, assessed, mitigated, and monitored would help readers understand how the RMFTT can be applied in practice.
10. The limitations section should explicitly acknowledge the limitations of narrative literature synthesis, potential publication and selection bias, heterogeneity in the available evidence, and the absence of stakeholder consultation or empirical testing, if these were not undertaken. The manuscript should also clarify whether the framework was reviewed by clinical, nursing, legal, cybersecurity, or health informatics experts.
11. The conclusion should be moderated to distinguish the proposed framework's conceptual contribution from demonstrated effectiveness. The claim that this is the first dedicated framework should be retained only if adequately supported by a documented comparison with existing approaches. The authors should present the RMFTT as a structured foundation for risk assessment and future validation rather than as an already validated tool.
12. The introduction should supplement the current research and enrich the content of the paper. For example: Patient Satisfaction and Outcomes Utilizing a Portable Medical Device with Adaptive Telemedicine Technology for Rehabilitation Following Total Knee Arthroplasty. Surg Technol Int. 2025 Feb 26;45:sti45/1850. Epub ahead of print. PMID: 40096860 and 10.1201/9781003346289-10

Author Response

25 October 2026

Journal: Healthcare (MDPI)

Manuscript ID: healthcare-4626183

Title: A Risk Management Framework for Triadic Telemedicine (RMFTT): A Conceptual Development Study

Dear Reviewer2,

We thank you for the detailed and constructive comments. We have carefully addressed each point; the principal revisions are summarised below and are visible as tracked changes in the revised manuscript. Where a manuscript change is referenced, the relevant Priority number from our internal revision log is noted in italics for traceability.

 

Response to Reviewer 2

We thank you for the thorough and constructive review. The comments were highly aligned with the revision priorities we had already identified, and the revised manuscript addresses each point as detailed below.

Comment 1: "The novelty claim requires stronger justification… A comparative table would help demonstrate the specific contribution of the proposed framework."

Response: We thank the reviewer for this suggestion. Table 3 has been added to the revised manuscript, presenting a structured comparison of the RMFTT against six existing telemedicine risk management and patient safety frameworks. The comparison maps each framework across five dimensions: scope, target population, risk domains covered, nurse-facilitator role recognition, and triadic structure. The table demonstrates that while several frameworks address telemedicine risk generally, none targets the triadic model specifically or recognises the nurse-facilitator as a structural risk variable.

Manuscript change: Priority 1 (Table 3).

 

Comment 2: "The framework should explicitly address interactions between the five risk domains… rather than treating each domain independently."

Response: The revised manuscript includes a dedicated paragraph in the Discussion addressing interdomain interactions. Using the reviewer's own example: inadequate nurse-facilitator competency (D5) creates upstream vulnerability across all remaining domains simultaneously — increasing communication filtering risk (D2), reducing clinical assessment accuracy (D1), generating documentation gaps with legal implications (D3), and increasing the likelihood of protocol deviations with cybersecurity consequences (D4). This D5→D1–D4 dependency is now explicitly framed as a structuring hypothesis of the RMFTT and identified as a priority for empirical validation. Figure 1 has been revised to depict this dependency structure visually, with unidirectional arrows from D5 to each of D1–D4 and lateral connections indicating inter-domain risk propagation.

Manuscript change: Priority 7 (interdomain contextual paragraph in Discussion).

 

Comment 3: "The clinical and diagnostic risk domain should address specific failure scenarios… Corresponding mitigation strategies should be linked to these scenarios."

Response: The revised manuscript expands Domain 1 to explicitly address the failure scenarios identified by the reviewer. The updated domain text now includes: incomplete or nurse-mediated physical examination as a source of diagnostic gap; inaccurate vital-sign measurement due to equipment handling variability; delayed recognition of clinical deterioration when the nurse-facilitator lacks escalation training; inappropriate reliance on transmitted rather than directly observed clinical information; and failure to escalate urgent cases. Corresponding mitigation strategies are linked to each scenario in the revised framework matrix.

Manuscript change: Priority 5 (D1 failure scenarios).

 

Comment 4: "Communication risk should be examined from the perspectives of all three participants… language barriers, health literacy, interruptions, information distortion, and confirmation of instructions."

Response: Domain 2 has been expanded in the revised manuscript to structure communication risk across all three triadic participants. The updated domain now addresses: patient-side risks including language barriers, health literacy limitations, and patient voice suppression; nurse-facilitator risks including information filtering, role ambiguity, and uncertainty about scope of communication; and physician-side risks including reliance on mediated rather than direct history-taking, incomplete instruction confirmation, and handover distortion. This three-perspective structure reflects the inherently multilateral communication architecture of the triadic model.

 

Comment 5: "Data privacy and cybersecurity risks should extend beyond unauthorised access to include identity verification, consent, secure transmission, device security, inappropriate recording, access control, and incident management."

Response: Domain 4 has been substantially expanded in the revised manuscript. The updated domain now addresses the full spectrum of cybersecurity and privacy risks identified by the reviewer: identity verification failures, inadequate consent processes for information sharing across triadic participants, insecure transmission of clinical records, device-level security vulnerabilities, risks of inappropriate recording, access control gaps, and security incident management. Proposed mitigation strategies reference applicable regulatory frameworks including GDPR and HIPAA, and are calibrated to the specific risk profile of the triadic telemedicine setting.

Manuscript change: Priority 6 (D4 cybersecurity expansion).

 

Comment 6: "Each risk domain should be linked to specific, actionable mitigation measures and measurable monitoring indicators."

Response: The revised framework matrix now includes a monitoring indicators row for each domain. Representative indicators added include: documentation completeness rates and escalation delay frequency for D1; communication failure event rates and instruction confirmation rates for D2; consent audit completion and incident reporting rates for D3; security incident frequency and access control audit results for D4; and training completion rates and competency assessment scores for D5. The Discussion acknowledges that the feasibility and sensitivity of these indicators will require empirical validation in operational triadic telemedicine settings.

 

Comment 7: "The manuscript should distinguish controls supported by existing empirical evidence from those proposed by the authors as conceptual recommendations."

Response: This distinction is now implemented systematically throughout the revised manuscript. Each risk indicator and mitigation strategy in the framework matrix is tagged with a qualifier: [Literature-supported] for elements directly derived from identified publications, and [Author-proposed] for elements introduced by the authors as conceptual extensions to the triadic context. The Methods section describes this qualification system explicitly, and its rationale — that the triadic telemedicine context lacks a dedicated evidence base requiring some degree of reasoned extrapolation — is acknowledged in the Limitations.

Manuscript change: Priority 11 (qualifier system).

 

Comment 8: "The authors should discuss contextual differences that may influence framework implementation, including rural and urban settings, low-resource environments, connectivity, staffing, digital literacy, and institutional infrastructure."

Response: A dedicated paragraph on implementation context has been added to the Discussion. It acknowledges that the RMFTT's applicability will vary substantially across settings: rural and low-resource environments may face compounded risk from unreliable connectivity, limited nurse staffing, and reduced institutional infrastructure for training and oversight; patient digital literacy shapes the communication and consent risk profile; and jurisdictional differences in regulatory frameworks affect the legal and cybersecurity domains. The paragraph frames these contextual factors as moderators of framework implementation rather than barriers, and identifies context-stratified validation as a future research priority.

 

Comment 9: "The proposed framework should be illustrated through a realistic clinical scenario."

Response: A clinical vignette has been added to the revised manuscript illustrating RMFTT application across all four stages. The scenario follows a nurse-facilitated remote consultation for an elderly patient with limited health literacy in a rural primary care setting — chosen to reflect a high-risk configuration across multiple domains simultaneously. The vignette traces a representative risk (incomplete vital-sign transmission leading to delayed recognition of clinical deterioration) through identification, assessment, mitigation, and monitoring, demonstrating how the framework's structure translates into practice.

Manuscript change: Priority 10 (clinical vignette).

 

Comment 10: "The limitations section should explicitly acknowledge the limitations of narrative literature synthesis, potential publication and selection bias, heterogeneity in the evidence, and the absence of stakeholder consultation or empirical testing."

Response: The Limitations section has been substantially expanded in the revised manuscript to address each of these points explicitly: the inherent constraints of narrative rather than systematic synthesis; the risk of publication and selection bias in a purposive literature search; heterogeneity in study design, setting, and population across the evidence base; the absence of formal stakeholder consultation with clinicians, nurse-facilitators, legal, or cybersecurity experts; and the lack of empirical testing or validation of the framework in operational settings. Each limitation is paired with its implication for framework interpretation and a corresponding future research direction.

Manuscript change: Priority 4 (expanded Limitations section).

 

Comment 11: "The conclusion should be moderated… present the RMFTT as a structured foundation for risk assessment and future validation rather than as an already validated tool."

Response: The conclusion has been revised accordingly. The amended text presents the RMFTT explicitly as a conceptual framework requiring empirical validation, rather than a ready-to-implement tool. The claim of novelty is retained but now grounded in the comparative analysis presented in Table 3. The closing statement positions the framework as a structured foundation for subsequent validation studies across diverse triadic telemedicine settings, consistent with the methodology and scope of a conceptual development study.

 

Comment 12: "The introduction should supplement the current research" [suggested reference: Surg Technol Int. 2025;45:sti45/1850. PMID: 40096860].

Response: We thank the reviewer for this suggestion. The cited reference has been incorporated into the Introduction, where it supports the discussion of emerging portable and adaptive telemedicine technologies as part of the expanding triadic telemedicine landscape. This addition enriches the contextual framing of the manuscript.

 

We believe the revised manuscript is substantially strengthened by these revisions and hope it now meets the journal's standards for publication. We remain available to address any further queries.

 

Sincerely,

Alexander Gamus

On behalf of all co-authors

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The revised version is sound good, no further changes required from my side, I accept the article in current form, Thank you 

Author Response

Thank you.
ALexander Gamus
On behalf of the authors

Reviewer 2 Report

Comments and Suggestions for Authors

Line 255/396 : To assist readers in distinguishing the evidentiary basis of 
individual framework elements, risk indicators and mitigation strategies throughout the 
domain sections are qualified as follows: items directly supported by a cited source 
identified in the Phase 1 literature search are denoted; items representing author inference, 
logical extrapolation from adjacent evidence, or original conceptual contribution are 
denoted [Proposed].

396: The first two indicators (remote physical examination 394 
limitations; triage accuracy gaps) are by multiple systematic reviews identified in Phase 395 
1[15,19,20]. The third indicator (missed clinical signs by undertrained nurse-facilitator) is 396 
[Proposed], representing a logical inference from the competency literature applied to the 397 
triadic context. 

What is proposed in bracket at many revised text?

Is is hint of AI usage? 

 

 

 

Author Response

We thank the Reviewer for the positive assessment of the revised manuscript and for this important clarifying question.

The [Proposed] qualifier is not an AI usage marker. It is the transparency system introduced directly in response to the Reviewer’s own Round 1 Comment 7, which requested that the manuscript “distinguish controls supported by existing empirical evidence from those proposed by the authors as conceptual recommendations.”

In compliance with that request, we implemented a two-tag qualifier system throughout the framework matrix:

• Items directly supported by a cited source identified in the Phase 1 literature search are denoted [Literature-supported]
• Items representing the authors’ original conceptual contribution, logical extrapolation from adjacent evidence, or reasoned inference applied to the triadic context are denoted [Proposed]

The [Proposed] tag thus identifies the authors’ own intellectual contributions to the framework — it marks where we extended beyond the direct evidence base, as the Reviewer asked us to make transparent. It has no connection to AI-generated content.

Regarding AI use: consistent with our disclosure statement in the manuscript (in accordance with ICMJE recommendations and Healthcare MDPI policy), AI-assisted tools were used solely for language editing. No AI tool was used to generate framework content, risk indicators, mitigation strategies, or any substantive intellectual contribution to the manuscript.

We hope this clarifies the qualifier system and trust that the manuscript is now acceptable for publication.