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News 11/28/17

November 28, 2017 News Comments Off on News 11/28/17

Top News

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CNBC looks to break into the healthcare conference business with an event focused on investing in healthcare innovation. Healthy Returns will take place March 28 in New York City.

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The media company, which seems to have increased its healthcare technology coverage since bringing on reporter Chrissy Farr in April, has appointed such health IT luminaries as Eric Topol, MD and 23andMe founder and CEO Anne Wojcicki to its conference advisory board. The conference website seems sparse on programming right now. No doubt the media outlet is looking to attract new advertisers with related digital and televised content.


Webinars

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November 30 (Thursday) 1:00 ET. “Making Clinical Communications Work in Your Complex Environment.” Sponsored by: PatientSafe Solutions. Presenters: Steve Shirley, VP/CIO, Parkview Medical Center; Richard Cruthirds, CIO, Peterson Health. Selecting, implementing, and managing a mobile clinical communications platform is a complex and sometimes painful undertaking. With multiple technologies, stakeholders, and disciplines involved, a comprehensive approach is required to ensure success. Hear two hospital CIOs share their first-hand experience, lessons learned, and demonstrated results from deploying an enterprise-wide mobile clinical communications solution.

December 5 (Tuesday) 2:00 ET. “Cornerstones of Order Set Optimization: Trusted Evidence.” Sponsored by: Wolters Kluwer. Updating order sets with new medical evidence is crucial to improving outcomes, but coordinating maintenance for hundreds of order sets with dozens of stakeholders is a huge logistical challenge. For most hospitals, managing order set content is labor intensive and the internal processes supporting it are far too inefficient. Evidence-based order sets are only as good as their content, which is why regular review and updates are essential. This webinar explores the relationship between clinical content and patient care with an eye toward building trust among the clinical staff. Plus, we will demonstrate a new evidence alignment tool that can easily incorporate the most current medical content into your order sets, regardless of format, including Cerner Power Plans and Epic SmartSets.

Previous webinars are on our YouTube channel. Contact Lorre for information.


Announcements and Implementations

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Onduo will integrate digital insulin recommendations from Voluntis with its virtual diabetes platform, which helps diabetics manage their conditions via wireless glucose monitors, software, and personalized coaching. Onduo got its start last year as a joint venture between Verily and Sanofi.


People

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InfoMC promotes Jeff Branagh to COO.

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Healthcare consulting firm Sullivan, Cotter, and Associates hires Mark Rumans, MD (Vidant Health) as CMO.

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Doctor on Demand founder Adam Jackson (Dopamine Labs) joins cryptocurrency-based investment firm Cambrian Asset Management as CTO.

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ZappRx brings on James Cornicelli (UCB Biopharma) as VP of corporate strategy, and Rich Kramer (Upfront Healthcare) as VP of commercial operations.


Telemedicine

Telemedicine is the top use case for embedded video across all industries, according to a small Vidyo survey of executives and engineers.


Government and Politics

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A New Hampshire judge rules that 84-year-old Anna Konopka, MD cannot renew her medical license. She claims that state regulators forced her to give up her license over her unwillingness to use a computer and, as a result, her inability to comply with the state’s mandatory PDMP policies. The license hand-over also seems to be connected to a recent disciplinary hearing with the state licensing board brought on by several patient complaints of inappropriate treatment.


Research and Innovation

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Google researchers develop software for the Google Pixel smartphone that can detect when a second set of eyes is looking at the phone’s screen. The researchers contend their gaze-detection software may be ideal for reading sensitive information or watching video in a public space.


Other

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Facebook will roll out its suicide-detection software to countries beyond the US, where it began piloting the technology in March. The AI-based software alerts specially trained Facebook staff in real time when a user posts suicidal messages, who then contact local authorities. First responders have checked in on people over 100 times in the last month based on Facebook software alerts.

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#GivingTuesday: The AMA continues to accept donations for practices affected by this year’s spate of natural disasters. The AMA Foundation’s Physician Disaster Recovery Fund has already given out $75,000 to practices impacted by Hurricanes Harvey, Irma, and Maria; and $150,000 to general relief efforts in Florida and Louisiana.

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Specialty EHR and PM vendor WebPT encourages users to donate to Rehab Therapists Give Back, a charity also working to help providers affected by recent hurricanes and wildfires.


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Jenn, Mr. H, Lorre

More news: HIStalk, HIStalk Connect.

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News 11/27/17

November 27, 2017 News Comments Off on News 11/27/17

Top News

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Reuters reports that DaVita is considering selling its physician network business, DaVita Medical Group, in light of sluggish Medicare Advantage payments, high healthcare costs, and a recent $5 million operating loss that likely contributed to the elimination of 350 non-clinical positions. DMG is reportedly worth $4 billion.


HIStalk Practice Musings

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The holiday shopping season is upon us once again, with Cyber Monday forecast to be the biggest online shopping day in US history. Adobe Analytics expects today’s Web-based shopping to total close to $6 billion, (versus Black Friday’s $5 billion). Unlike years past, I got out and about on Friday for several in-store purchases, but did the majority of my shopping online. My sole tech purchase (from Amazon) was an Ozobots coding starter pack, which I’m fairly certain family members of all ages will enjoy. I’ve seen them in action at several community STEM events and no one seemed able to resist taking a crack at their colorful coding. If you’re in need of STEM-related toys and activities, check out interim CIO and consultant Sue Schade’s list of “STEM Gift Ideas for 2017.”


Webinars

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November 30 (Thursday) 1:00 ET. “Making Clinical Communications Work in Your Complex Environment.” Sponsored by: PatientSafe Solutions. Presenters: Steve Shirley, VP/CIO, Parkview Medical Center; Richard Cruthirds, CIO, Peterson Health. Selecting, implementing, and managing a mobile clinical communications platform is a complex and sometimes painful undertaking. With multiple technologies, stakeholders, and disciplines involved, a comprehensive approach is required to ensure success. Hear two hospital CIOs share their first-hand experience, lessons learned, and demonstrated results from deploying an enterprise-wide mobile clinical communications solution.

December 5 (Tuesday) 2:00 ET. “Cornerstones of Order Set Optimization: Trusted Evidence.” Sponsored by: Wolters Kluwer. Updating order sets with new medical evidence is crucial to improving outcomes, but coordinating maintenance for hundreds of order sets with dozens of stakeholders is a huge logistical challenge. For most hospitals, managing order set content is labor intensive and the internal processes supporting it are far too inefficient. Evidence-based order sets are only as good as their content, which is why regular review and updates are essential. This webinar explores the relationship between clinical content and patient care with an eye toward building trust among the clinical staff. Plus, we will demonstrate a new evidence alignment tool that can easily incorporate the most current medical content into your order sets, regardless of format, including Cerner Power Plans and Epic SmartSets.

Previous webinars are on our YouTube channel. Contact Lorre for information.


Announcements and Implementations

MyMipsScore makes HIPAA Secure Now!’s security risk analysis available as part of its app that helps physicians participating in MIPS aggregate, calculate, and analyze quality data across 271 measures.


People

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Marc Levine (JDA Software Group) will join Athenahealth as EVP, CFO, and treasurer.

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Radiology provider ONRAD hires David Engert (Nighthawk Radiology) as president and CEO.


Telemedicine

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StickyJ Medical ID will provide TelaCare customers with medical ID jewelry that includes the telemedicine company’s ViewMyID website address and patient serial number for easy health-data lookup by first responders.

NPR looks at the role telemedicine plays in opioid addiction treatment, highlighting the challenges well-meaning physicians face when attempting to incorporate virtual visits into treatment plans that include many unbillable hours for counseling sessions and briefer check-ins. Jay Joshi, MD of Prestige Clinics (IN) occasionally uses telemedicine to prescribe addiction medication, but prioritizes face-to-face visits. “You’re not going to get a good system of healthcare for primary care in these high-risk areas unless you invest time and energy into these patients,” he explains.


Research and Innovation

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This study reveals that consumers are increasingly turning to voice assistants like Alexa and Google Home for healthcare information and advice. Nearly 50 percent of the 1,000 respondents have used such technology to ask about symptoms (70 percent of users), wellness tips (59 percent), or to connect to a healthcare provider (48 percent).

University of South Carolina researchers find that a 2014 statewide mandate requiring all physicians to check the state’s PDMP before prescribing opioids to Medicaid patients has resulted in a 29-percent drop in such prescriptions. The mandate was expanded to include all patients earlier this year – a smart move given that CDC stats show that physicians in South Carolina write more opioid prescriptions annually than there are residents in the state.


Other

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The local paper looks at the unique things Midwest Regional Health Services (NE) is doing to retain its patient-centered medical home status and quality certifications. Efforts include posting physician quality measures on waiting room walls, organizing 12 week-long healthy living groups, and offering a ladies’ day that includes routine screenings, manicures, and make-and-go foot scrubs. The independent primary care practice has created consulting company Celtic Healthcare Solutions to help other practices transition to the PCMH model.

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More Cyber Monday tidings: McAfee releases its list of most hackable gifts, with laptops, tablets, and smartphones taking top honors. Drones, digital assistants, and connected toys and appliances also make an appearance. The company has created a pretty cute campaign aimed at educating consumers about securing their digital gifts.

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Folks have 18 days left to sign up for coverage at Healthcare.gov. Enrollment for this year is predicted (optimistically, some contend, due to the halved sign-up period) to top out at just under 10 million. If you really want to get into the weeds of ACA sign-up analysis, check out Chris Conover’s mind-bending arithmetic, which has lead him to conclude that, “Obamacare Exchange enrollments continue to perform well below expectations” (despite headlines that say otherwise).


Contacts

Jenn, Mr. H, Lorre

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice updates.
Contact us online.
Become a sponsor.

Jenn_125

News 11/22/17

November 22, 2017 News Comments Off on News 11/22/17

Top News

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San Francisco-based Ginger.io launches subscription-based mental healthcare services that include AI-powered coaching and virtual consults. The company seems to have left behind its focus on partnering with health systems to help passively monitor the mental health of patients enrolled in various programs. Ginger.io has raised over $28 million since opening for business in 2011.


Webinars

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November 30 (Thursday) 1:00 ET. “Making Clinical Communications Work in Your Complex Environment.” Sponsored by: PatientSafe Solutions. Presenters: Steve Shirley, VP/CIO, Parkview Medical Center; Richard Cruthirds, CIO, Peterson Health. Selecting, implementing, and managing a mobile clinical communications platform is a complex and sometimes painful undertaking. With multiple technologies, stakeholders, and disciplines involved, a comprehensive approach is required to ensure success. Hear two hospital CIOs share their first-hand experience, lessons learned, and demonstrated results from deploying an enterprise-wide mobile clinical communications solution.

December 5 (Tuesday) 2:00 ET. “Cornerstones of Order Set Optimization: Trusted Evidence.” Sponsored by: Wolters Kluwer. Updating order sets with new medical evidence is crucial to improving outcomes, but coordinating maintenance for hundreds of order sets with dozens of stakeholders is a huge logistical challenge. For most hospitals, managing order set content is labor intensive and the internal processes supporting it are far too inefficient. Evidence-based order sets are only as good as their content, which is why regular review and updates are essential. This webinar explores the relationship between clinical content and patient care with an eye toward building trust among the clinical staff. Plus, we will demonstrate a new evidence alignment tool that can easily incorporate the most current medical content into your order sets, regardless of format, including Cerner Power Plans and Epic SmartSets.

Previous webinars are on our YouTube channel. Contact Lorre for information.


People

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Jack Karabees (Consult A Doctor) joins EpicMD as president and VP of sales.


Government and Politics

Financial records released earlier this week show that HHS Secretary nominee and former pharma executive Alex Azar profited considerably during his time at Eli Lily. He was paid nearly $2 million during his final year at the company, and has amassed a financial portfolio valued at $20.6 million. After leaving Eli Lily at the end of last year, Azar went on to start healthcare consulting company Seraphim Strategies, valued at between $15,000 and $50,000. Azar is due to be confirmed November 29.


Research and Innovation

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Blind triplet brothers Nick, Steven and Leo Cantos use smart glasses from Aira to “see” with the help of remote agents who narrate in real time what the camera-equipped glasses capture. The San Diego-based startup launched in April as a subscription-based service that offers 100 minutes of agent time with $89 a month.

An observational study involving 17 physicians and 42 patients suffering from overactive bladder finds that conversations about the condition were predominantly physician-centric, with physicians doing most of the talking and asking only yes-or-no questions that did little to advance patient understanding of the condition or its treatment.


Telemedicine

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University of Arizona Telemedicine Program staffers give thanks for increasing support from CMS for telemedicine, expansion of the Interstate Medical Licensure Compact, and FDA approval of telepathology technology developed by ATP founder Ronald Weinstein, MD in 1987. The university has been one of the first to incorporate telemedicine education into its medical school curriculum.


Other

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Family physicians share what they are thankful for ahead of Thanksgiving, with the majority pointing to the willingness of their colleagues to share their time and expertise.

“I am so grateful for partnership with my colleagues,” writes Melissa Hemphill, MD. “We share the same goals – strong resident education, excellent patient care, and clinician wellness. To meet those goals, we must work together to share the load. That load might be a scheduling issue, a simple task such as completing paperwork, or a complex one such as creating a curriculum for residents. In each case, working together makes the work easier, faster and more enjoyable. Beyond lightening the load, the teamwork in my practice allows us to build trust and mutual support among our faculty. It makes my practice feel like a family. We care about, and take care of, each other. I could not be more grateful for my work partners.”

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The American College of Emergency Physicians offers tips on avoiding Thanksgiving-related trips to the ER. Last year, over 36,000 people went to the ER for knife injuries, food poisoning, burns, and heartburn and indigestion. I find it amusing, given the copious amounts of food and napping I plan on taking advantage of, that they include exercise safety tips for those that plan on participating in a “traditional Thanksgiving sporting event.”

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This article reminds family members that talking about health histories over a hearty Thanksgiving meal is a great way to share concerns and proactively learn about issues that may crop up in the future. The strategy was first introduced by former US Surgeon General Richard Carmona, MD who dubbed Thanksgiving National Family History Day. HHS has created the My Family Health Portrait tool to assist family members with organizing and sharing their family’s health data.


Contacts

Jenn, Mr. H, Lorre

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice updates.
Contact us online.
Become a sponsor.

Jenn_125

News 11/21/17

November 21, 2017 News Comments Off on News 11/21/17

Top News

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An MGMA poll of 1,029 physicians finds that 61 percent educate their patients about opioid misuse, primarily through face-to-face conversations followed by a combination of in-person appointments and printed or digital materials. Twelve percent of survey respondents reported not offering their patients any type of education on the dangers of opioids – a stat that seems worth taking a deeper dive into given that the latest figures from White House estimate the cost of the opioid crisis to be $504 billion – 2.8 percent of GDP.

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Data released yesterday from the Council of Economic Advisers also shows that drug overdoses are the leading cause of injury death in the US, surpassing traffic crashes or gun-related deaths; and that over 64,000 people died from drug overdoses last year, representing 175 deaths per day. While physician conversations with patients about the dangers of opioid misuse may impact the statistics above, mandating such chats or adding EHR alerts to prompt them takes us into the realm of hindered workflows and the increasing intrusiveness of technology – both aspects of practice that physicians are looking to move – if not run – away from.


Webinars

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November 30 (Thursday) 1:00 ET. “Making Clinical Communications Work in Your Complex Environment.” Sponsored by: PatientSafe Solutions. Presenters: Steve Shirley, VP/CIO, Parkview Medical Center; Richard Cruthirds, CIO, Peterson Health. Selecting, implementing, and managing a mobile clinical communications platform is a complex and sometimes painful undertaking. With multiple technologies, stakeholders, and disciplines involved, a comprehensive approach is required to ensure success. Hear two hospital CIOs share their first-hand experience, lessons learned, and demonstrated results from deploying an enterprise-wide mobile clinical communications solution.

December 5 (Tuesday) 2:00 ET. “Cornerstones of Order Set Optimization: Trusted Evidence.” Sponsored by: Wolters Kluwer. Updating order sets with new medical evidence is crucial to improving outcomes, but coordinating maintenance for hundreds of order sets with dozens of stakeholders is a huge logistical challenge. For most hospitals, managing order set content is labor intensive and the internal processes supporting it are far too inefficient. Evidence-based order sets are only as good as their content, which is why regular review and updates are essential. This webinar explores the relationship between clinical content and patient care with an eye toward building trust among the clinical staff. Plus, we will demonstrate a new evidence alignment tool that can easily incorporate the most current medical content into your order sets, regardless of format, including Cerner Power Plans and Epic SmartSets.

Previous webinars are on our YouTube channel. Contact Lorre for information.


Announcements and Implementations

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Practice management company Stratifi Health selects patient risk stratification and care coordination technology from Innovaccer to better enable its population health management offerings.

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Regional Medical Imaging (MI) rolls out Royal Solutions Group’s RoyalMD portal to help providers keep up with orders, exam status, testing and imaging results, and peer-to-peer communication.


Acquisitions, Funding, Business, and Stock

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Specialty-focused healthcare IT company Nextech sees an employee increase of more than 10 percent after hiring over 80 employees in 2017. The Tampa, FL-based company got its start in 1997 and now offers EHR, PM, and RCM software and services for dermatology, ophthalmology (via its MDIntelleSys acquisition in 2014), and plastic surgery (via its Supramed acquisition in 2016).


People

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Agility Health promotes Joseph Laurent to corporate secretary.


Telemedicine

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A California State University economics professor believes telemedicine may be the answer to the state’s Medi-Cal provider access problem – a situation that has grown worse over the years thanks to nearly stagnant reimbursement rates for in-person visits that have result in physician dropping Medi-Cal patients all together. The 2017-18 budgets calls for a 2.5-percent increase – the first since 2001. “The Legislature should end the requirement that out-of-state physicians secure a California license to provide telemedicine care to Medi-Cal patients,” writes Shirley Svorny. “Not only would such as change expand options for Medi-Cal recipients, it would let the state experiment with interstate telemedicine, which has the potential to make healthcare more accessible and less costly for all Californians.”


Government and Politics

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CMS CMO Kate Goodrich, MD announces the Measures Inventory Tool, an interactive Web-based list of measures that are in development, in use, or no longer around. Goodrich, who is also director of the CMS Center for Clinical Standards and Quality, explains that what was once available only via Excel spreadsheet now enables providers to more easily identify and coordinate measurement efforts across care settings and patient populations.

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Surgeon General Jerome Adams, MD tells local public radio that the federal government is committed to fighting the opioid epidemic, despite President Trump’s decision to declare a public health emergency over the epidemic rather than a funding-friendly national state of emergency. In addition to providing $800 million for prevention treatment and naloxone for first responders, the Trump administration has already addressed nine initial recommendations set forth by the opioid commission in March, and is working through another 50 made by the commission in its final report earlier this fall.

“While folks are frustrated,” Adams says, “and I understand that they’re frustrated because we’ve got over 150 people dying every day from overdoses, we’ve had our foot on the gas from day one that I’ve been in this position, and even before, the president came out and said, this is his top health priority. We will get there, I’m confident we will, but we will only get there working together.”


Research and Innovation

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Kaiser Permanente physicians in Southern California reduce antibiotic prescriptions for sinus infections by 22 percent using EHR messages to alert them to alternative courses of treatment. Nearly 90 percent of patients with such infections receive an antibiotic, despite guidelines that suggestion against it.


Other

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PeakMed (CO) adds house calls (of a sort) to its list of membership-based family medicine services with the launch of Mobile LifeCenters. The four-wheeled clinics will visit PeakMed’s employer customers to offer employees on-site access to care for common ailments. The company began offering in-home visits several months ago.


Contacts

Jenn, Mr. H, Lorre

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice updates.
Contact us online.
Become a sponsor.

Jenn_125

News 11/20/17

November 20, 2017 News Comments Off on News 11/20/17

Top News

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Waiting-room messaging company Outcome Health offers employees voluntary buyouts as it continues to face media scrutiny over investor lawsuits related to overpromised and under-delivered advertisement metrics, layoffs, and a pending move to a new multi-million dollar headquarters in downtown Chicago that seems risky in light of its ongoing troubles. In a statement to employees over the weekend, the company stressed its leadership understands “these are challenging times and that the ongoing scrutiny in the media may not be the right fit for everyone …. Outcome Health’s founders believe strongly in the long-term success of the business and that’s why they are seeking to reinvest their own money into the company.”

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In addition, the AMA has pulled its pre-diabetes PSAs from Outcome Health’s rotation, and Harvard Health Publishing has canceled its arrangement with the company. To top it all off (for now), the Chicago Tribune reports that misleading sales tactics have dogged the company (fka ContextMedia) for years. Between 2010 and 2016, Outcome Health found itself involved with several lawsuits brought by competitors like Healthy Advice and Accent Health (which it acquired in 2016) over unethical practices that included lying about competitors, misleading potential customers, and gaining competitive intelligence in a highly suspect fashion.


Webinars

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November 30 (Thursday) 1:00 ET. “Making Clinical Communications Work in Your Complex Environment.” Sponsored by: PatientSafe Solutions. Presenters: Steve Shirley, VP/CIO, Parkview Medical Center; Richard Cruthirds, CIO, Peterson Health. Selecting, implementing, and managing a mobile clinical communications platform is a complex and sometimes painful undertaking. With multiple technologies, stakeholders, and disciplines involved, a comprehensive approach is required to ensure success. Hear two hospital CIOs share their first-hand experience, lessons learned, and demonstrated results from deploying an enterprise-wide mobile clinical communications solution.

December 5 (Tuesday) 2:00 ET. “Cornerstones of Order Set Optimization: Trusted Evidence.” Sponsored by: Wolters Kluwer. Updating order sets with new medical evidence is crucial to improving outcomes, but coordinating maintenance for hundreds of order sets with dozens of stakeholders is a huge logistical challenge. For most hospitals, managing order set content is labor intensive and the internal processes supporting it are far too inefficient. Evidence-based order sets are only as good as their content, which is why regular review and updates are essential. This webinar explores the relationship between clinical content and patient care with an eye toward building trust among the clinical staff. Plus, we will demonstrate a new evidence alignment tool that can easily incorporate the most current medical content into your order sets, regardless of format, including Cerner Power Plans and Epic SmartSets.

Previous webinars are on our YouTube channel. Contact Lorre for information.


Announcements and Implementations

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Express Scripts will supply patients enrolled in its Pulmonary Care Value Program with Propeller Health’s smart inhaler and companion app to help manage their asthma or COPD. An earlier pilot program helped patients improve asthma medication adherence and decrease emergency situations.

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Harris Healthcare subsidiary Amazing Charts incorporates OptimizeRx’s digital prescription savings and pharmacy messaging into its EHR.


Acquisitions, Funding, Business, and Stock

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Drchrono entices physicians to sign up for its subscription-based EHR services with new iPads.


Government and Politics

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HHS Acting Secretary Eric Hargan appoints Leslie Lenert, MD (Medical University of South Carolina), Clem McDonald, MD (Lister Hill National Center for Biomedical Communications), and Robert Wah, MD (DXC Technology) to the Health IT Advisory Committee.

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The American Institutes for Research will help CMS identify, test, and deploy patient-reported outcomes measures for practices participating in the Comprehensive Primary Care Plus program. It will also assist practices with patient experience survey implementation, analytics, and results reporting.


Telemedicine

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The FDA approves telemedicine visits for Nucleus Cochlear Implant System patients who need adjustments made to their implants. “Being able to have a qualified audiologist program the device via telemedicine from a remote location can greatly reduce the burden to patients and their families, especially those who must travel great distances or need frequent adjustments,” says Malvina Eydelman, MD director of the Division of Ophthalmic, and Ear, Nose, and Throat Devices in the FDA’s Center for Devices and Radiological Health.


Research and Innovation

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Auto manufacturers look into incorporating health sensors into vehicles to help prevent accidents related to heart attacks or diabetic conditions. Companies like Toyota, Ford, Honda, and GM are specifically looking at developing systems that can trigger cars to pull off the road and call for help in the event of an emergencies that drivers might at first be unaware of.


Other

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Texas-based physician Laurence Chu, MD laments the demise of SoapWare EHR, technology he has used at his small practice since 2004, and the arduous process he will have to undergo to find a replacement. (The company apparently announced it will discontinue service at the end of February via a two-sentence message within the user portal.) “By far, the greatest problem will be the transfer of patient data,” he explains. “While basic information can be moved to the new database, much of the data will lose its original dynamic usefulness. I will lose the ability to retrieve historic analysis of patient care and past visits. I am surprised vendors have not overcome this critical need.”


Sponsor Updates

  • Medicity publishes a new report, “HIE Preparedness: Learning from Recent Health Care Disasters.”
  • Healthwise will exhibit at the Next Generation Patient Experience November 28 in San Diego.

Blog Posts


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Jenn, Mr. H, Lorre

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice updates.
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