A blog covering the health/care ecosystem and people.

Notwithstanding the head of the AMA recently referring to digital health technologies as “snake oil,” it appears that one-half of physicians is keen on digital health. And scale, not age, matters when it comes to doctors using digital health tools. The American Medical Association (AMA) surveyed physicians on their use of digital health tools, finding that primary care physicians (PCPs) and doctors working in larger and more complex practices tend to be more digital. In Physicians’ motivations and requirements for adopting digital clinical tools, the AMA’s digital health study, “Physicians are optimistic about digital health innovation and its game-changing potential

Managing stress, weight, mental health, sleep, and heart function are among the top-most desired reasons already-connected health consumers are interested in further connecting their health, according to The 2016 HealthMine Digital Health Report. The most popular tools people use to digitally manage their health deal with fitness and exercise (among 50% of connected health consumers), food and nutrition (for 46%), and weight loss (for 39%). 3 in 4 people who use digital health tools say they have improved their health by connecting to these tools. 57% of digital health users also say going health-digital has lowered their healthcare costs. The survey

Consumers are open to technology-enabled healthcare, but look to providers to ensure quality and privacy of patients’ personal health information, according to Will Patients and Caregivers Embrace Tech-Enabled Healthcare?, based on the Deloitte 2016 Survey of US Health Care Consumers. Seven in 10 consumers would use at least one of the technologies Deloitte served up in its study, with telemedicine at the top of the list: 49% of people favor telemedicine for post-surgical care, 48% for chronic disease management, 36% for care while traveling, and 32% for minor health issues. While Millennials are generally keener across-the-board for tech-enabled health care,

“In the developed world, patient disengagement has become the new killer disease — not the lack of diagnostic devices, trained physicians or efficacious treatment options,” argues Andrea LaFountain, PhD, in her book, How Patients Think. Disbanding prescription drugs in advance of doctors’ instructions, postponing lab and diagnostic tests, and avoiding daily blood glucose testing when managing diabetes are just some examples of “how patients think” about health care and the many tasks involved in caring for oneself and the health of loved ones. But better understanding how patients think — technically speaking, the cognitive neuropsychology underneath the thinking — can

When a person dons a piece of wearable technology, they first look to engage with some aspect of health or fitness before they seek entertainment. To satisfy that demand side of the market equation, we’re seeing a stream of devices, platforms, and corporate strategies trying to reach the wearable tech consumer. Today, Philips announced its expanding strategy for digital health, launching devices to help people, in Philips’ words, measure, monitor, and stay motivated for personal health. The company is offering a health smartwatch, a weight scale, an ear thermometer, and two blood pressure monitors (for wrist and upper arm), all

Health care payment responsibility continues to shift from employers to employee-patients, More of those patients are morphing into financially burdened health consumers, according to TransUnion, the credit agency and financial risk information company, in the TransUnion Healthcare Report published in June 2016. Patients saw a 13% increase in their health insurance deductible and out-of-pocket (OOP) maximum costs between 2014 and 2015. At the same time, the average base salary in the U.S. grew 3% in 2015, SHRM estimated. Thus, deductibles and OOP costs grew for consumers more than 4 times faster than the average base salary from 2014 to 2015.  In

Technology alone won’t improve health care in America, especially in people with chronic health problems don’t want to use it. Furthermore, too many clinicians who have invested in digital health technologies (namely, electronic health records systems), aren’t fully taking advantage of what they have. This and other health care realities are explored in Better Together: Patient Expectations and the Accountability Gap, based on a consumer survey conducted by Nielsen Strategic Health Perspectives for the Council of Accountable Physician Practices, an affiliate of the American Medical Group Foundation. The survey polled 30,007 consumers in March 2016, and combined physician data culled from Nielsen’s

Digital platforms and tools are fast-advancing in all industries, and especially in health and health care. But it’s people-first, and digital PLUS analog, based on Accenture’s latest forecast of five macro technology trends. The five forces are: Intelligent automation – 70% of health executives expect to invest more in artificial intelligence; Liquid workforce – 42% of health/care workers are expected to be contractors or free agents within organizations within 3 years’ Platform economy – 10x growth is expected in application programming interfaces (APIs) in the next five years, which will enable data to liquidly move across healthcare platforms Predictable disruption

Virtual healthcare – call it telemedicine, remote monitoring, or the umbrella term, telehealth – is coming of age. And it’s a form of healthcare that a growing percentage of consumers in the U.S. want. I’m in Branson, Missouri, today, meeting with the State’s Hospital Association to talk about consumers in the growing DIY health/care economy. So “telehealth,” broadly defined, is part of my message. This week Xerox announced its survey results focused on consumers’ interests in telehealth. “Xerox helps healthcare providers serve patients anytime, anywhere,” the press release starts. Convenience, cost-savings, and the ability to consult physicians quickly and get e-refills are

At the start of 2016, the current installed base of wearable activity tracking devices was just over 33 million in the U.S. This consumer market penetration is expected to grow by 11% in 2016, according to the Consumer Technology Association (CTA) forecast published in the 18th Annual Consumer Technology Ownership and Market Potential Study. Wearable tech comprises a very small piece of the larger consumer technology market, led by TVs, smartphones, headphones (wired), DVD players, and notebook/laptop/netbook computers, the four largest rectangles in the graphic. However, there is growth momentum for emerging consumer tech segments such as portable wireless speakers,

The first health news I read this morning in my Google Alerts was a press release explaining that Nokia planned to acquire Withings for EU170 (about $190mm). As an early adopter and devoted user of the Withings Smart Body Analyzer, I took this news quite personally. “What will Nokia be doing with my beloved Withings?” I asked myself via Twitter early this morning. As if on cue, a public relations pro with whom I’ve been collegial for many years contacted me to see if I’d like to talk with the Founder and CEO of Withings, Cédric Hutchings, and Ramzi Haidamus,

Older workers and retirees in the U.S. are most pleased with their healthcare experiences and have the fewest problems accessing  services and benefits. But, “younger workers [are] least comfortable navigating U.S. healthcare system,” which is the title of a press release summarizing results of a survey conducted among 1,536 U.S. adults by the Harris Poll for Accolade in September 2015. Results of this Accolade Consumer Healthcare Experience Index poll were published on April 12, 2016. Accolade, a healthcare concierge company serving employers, insurers and health systems, studied the experiences of people covered by health insurance to learn about the differences across age

April 7 is World Health Day, and the World Health Organization (WHO) has named #diabetes the big public health challenge for 2016. What’s striking about this year’s World Health Day is the “Stay Super” public health ad campaign that WHO has developed featuring figures of super-people. THINK: Superman and Wonderwoman meet Doctors Welby, Kildare, and McDreamy. I’ve included several of the posters in the blog today to show how engaging health messaging works well when it works. The materials can be downloaded at this link. This week also saw the publication of America’s Health Rankings, spotlighting the impact of unhealthy behaviors.

In the growing era of consumer-driven health, a growing list of options for receiving care are available to consumers. And people are liking new-new sites of care that are more convenient, cheaper, price-transparent, and digitally-enabled. Think of these new-new sites as “new front doors,” according to Oliver Wyman in their report, The New Front Door to Healthcare is Here. The traditional “doors” to primary and urgent care have been the doctor’s office, hospital ambulatory clinics, and the emergency room. Today, the growing locations for retail clinics and urgent care centers are giving consumers more visible and convenient choices for seeking

Today is International Women’s Day. Being a woman is a social determinant of health (for the worse). To mark the occasion of the Day, The International Labour Organization (ILO) published a report on women and work yesterday, finding that in the 178 countries studied, inequality between women and men persists across labor markets. And while there’s been progress in women’s education over the past twenty years, this hasn’t resulted in women advancing career paths and wage equality. It struck me this morning, reading both (paper versions of) the Wall Street Journal and the Financial Times that the latter had two FT-sponsored ads marking

La salute prima de tutto! Health is first of all!  I am on holiday with my favorite person in the world, my husband, and we are Italophiles. He comes by that bias genetically, and I through loving him and sharing so many joyful, enchanting experiences in la Bella Italia over our many years of marriage. The day before flying to Italy, Dr. Michael Painter, Senior Program Officer of the Robert Wood Johnson Foundation, posted a link on his Facebook page to this wonderful explanation of why Italy ranks as the second-healthiest country in the world, just after Singapore. The rankings

People – patients, caregivers, health consumers all – have begun to use the digital tools they use in daily life for booking taxis, managing money, seeking information — for their health. This is the growing adoption of Personal Health IT (PHIT), and it’s a growing aspect of the annual HIMSS Conference that the planet’s health IT folk will attend from 29th February until 4th March in Las Vegas. I talk about the phenomenon of PHIT and #HIMSS16 in The State of Health IT to Engage the New Health Consumer, a summary of the driving forces of the trend and opportunities

“It depends” is the hedge-phrase that characterizes how Americans see disclosing personal information versus keeping private information private, according to the consumer survey report, Privacy and Information Sharing, published by the Pew Research Center (PRC) in January 2016. U.S. adults see a privacy trade-off, living in the convenience-context of 21st century digital economy in exchange for some form of value. The “it depends” is a factor of what kind of data is geing collected, especially by third parties, how long that data area retained, for what use — vis-à-vis what a person is trading in return which could be a hard dollar

As we concluded our panel on The Wizards of Maternal Health kicking off today’s launch of the 2016 Digital Health Summit, co-located with the 2016 CES (Consumer Electronics Show) in Las Vegas, our diverse team concurred that there’s more than enough “technology” on the convention floor. The challenge now for health is to make connections between the islands of devices, and generate meaningful data and culturally contextual information and support for consumers (patients, caregivers, people) and health providers. Here at the CES, it’s all about the supply side of the equation – for health, that means digital health tools, wearables,

The rate of infant mortality — that is, babies dying in their first year of life — in the United States ranks lowest among the world’s developed countries, and below some less wealthy nations, as well. Shiny new things for digital health will be launching at the 2016 CES, the Consumer Electronics Show, in Las Vegas this week. And in the midst of virtual reality devices, connected cars, drones, and 4K TVs, I’ll be moderating a panel to kick off the Digital Health Summit at CES on Thursday focusing on The Wizards of Maternal Health — and how digital +

It’s time to get the tea leaves out and mash up trends in my world of health, health care, technology, policy and people for 2016. We’ll start with the central player: people, consumers, patients, caregivers all. Health consumerism on the rise.  People – call us patients, consumers, caregivers – will take on even more financial and clinical decision making risk in 2016. Growing penetration of high-deductible and consumer-driven health plans will push (not just nudge) people into the role of health care consumers, and the emerging businesses and programs serving the transparency market for price and quality will gain traction

Adoption of telehealth, remote health monitoring, patient engagement platforms, mobile and digital health applications, and the emergence of the Internet of Things in health care will all be bolstered in 2016 based on health care providers’ having to do more with less (money, labor, resources). The value-based healthcare world — the migration of payment “from volume to value” — requires greater investment in information and communications technology that moves care to lower-cost sites, with lower-priced labor (as appropriate), and shifting greater clinical self-care and financial skin-in-the-game to patients. My annual health IT forecast was published yesterday in iHealthBeat, 2016: Technology

By 2020, according to the World Economic Forum, more than 5 billion people and 30 billion “things” will be connected to the Internet — cars, refrigerators, TVs, washing machines and coffeemakers, among those 5 bn folks’ electronic stuff. But so will medical devices, activity trackers, and a host of sensor-enabled “things” to help people and clinicians optimize health and manage illness. The Internet of Things (IoT) phenomenon, which is already penetrating households with energy management and security applications, is reaching health care. One of the pioneers in this connected health market is Dr. Joseph Kvedar, who leads the Center for

The 2015 holiday shopper can find activity trackers for gifting discounted as much as 50% and more over Thanksgiving weekend. In greater Philadelphia, the Thursday print newspaper ads were chock full of examples from Best Buy, Dick’s Sporting Goods, Kohl’s, Target, and Walmart, among others. Among the many “Doorbusters” and deep discounts were a Misfit Flash tracker for $14.99 at Best Buy (a 50% discount), a Fitbit Zip at both Kohl’s and Walmart for $39 ($20 off the manufacturers’ suggested retail price), and a Fitbit Flex at Dick’s Sporting Goods for $49.95 — 50% off full retail. That trackers are

Consumers may demand connected experiences in daily living, but there have been many barriers to health care industry stakeholders delivering on that expectation: among them, privacy and security concerns, and provider resistance. This demand-and-supply chasm is noted in Deloitte’s Center for Health Solutions’ latest look into the healthcare landscape, Accelerating the adoption of connected health. The objectives of connected health, or cHealth, are: To improve digital connectivity among consumers, providers, health plans and life sciences companies To facilitate self-managed care in a secure environment that protects privacy To deliver care outside of traditional institutional settings To enable chronic care management

The fastest-growing category of products and services at Health 2.0 is consumer-facing digital health, and a panel of companies demonstrated various flavors of the New Retail Health. One of the most prominent companies featured in Health 2.0’s conferences from the inception has been MyFitnessPal (MFP), a long-time helpful tool I’ve used to manage my own health-life. Under Armour acquired MFP earlier this year, which I covered here in Health Populi. Under Armour’s original mission was to make all athletes better. With the company’s acquisition of MyFitnessPal, Under Armour continued its morphing from a textile and sports gear company to a

Of the over 165,000 mobile health (mHealth) apps available in the Apple iTunes and Google Play (Android) stores, 36 are responsible for one-half of all downloads, based on IMS Institute‘s latest research into Patient Adoption of mHealth: Use, Evidence and Remaining Barriers to Mainstream Adoption published today. This report updates IMS Institute’s 2013 report on mHealth, covered here in Health Populi. For the 2015 research, IMS Institute looked at the state of mHealth apps, number and type, uptake and usage, evidence of the impact apps have on patient care, and consideration of barriers and progress made for apps becoming a

Health is everywhere, where we live, work, play, pray and shop. So while I’m in Chicago staying off The Magnificent Mile in The Windy City, I took a several-thousand step walk along this shopping mecca and found health and wellness in the form of wearable technology, fitness, smart homes and the Internet of Things spanning the eastern end of Michigan Avenue to the western Gold Coast lakefront. Here’s a photo of the Garmin store, whose windows feature wearable tracking device promotions and devices. It was surprising to see Garmin investing in this expensive piece of real estate, with its logo

What happened when Rosie the Robot started ordering Jane Jetson around? Not a happy scenario for the Jetsons family. The same scenarios can be played out in the future of the Internet of Things (IoT) without attending to people-centered design principles, and for the home — women-centered design and ethos. The design process can play out future scenarios and anticipate unexpected consequences that can, ultimately, inform delightful user experience. Women are the Chief Household Officer, making the majority of home-based financial decisions. In fact, increasingly, women are taking on the job of Chief Financial Officer at home, too. To learn more,

Sales of computers and tablets and LCD TVs won’t be hot on peoples’ holiday shopping lists in 2015. But smartwatches, health and fitness tech, and 4K Ultra HD TVs will be in peoples’ gift wish-lists and under homes’ holiday trees. The Consumer Electronics Association (CEA) published its 2015 U.S. Consumer Electronics Sales and Forecasts report, and it shows a shifting retail picture where traditional consumer electronics categories — notably computers and mainstream TVs — are declining in demand. But new-new categories are expected to buoy 2015 retail sales. The new categories of consumer electronics will generate about $10 bn (wholesale

We’re entering the era of personalized healthcare promising convenient and meaningful health experiences, according to Accenture’s 2015 Healthcare IT Vision articulated in their report, Top 5 eHealth Trends. This post is third in three published here on Health Populi this week, exploring the growing role of the Internet of Things in health/care. On 8th July, we dug into McKinsey Global Institute’s research on IoT’s influence over nine industries, including human health; and on the 9th, we reviewed Goldman Sachs’ report on digital health’s potential impact on the U.S. healthcare system. Accenture’s five eHealth trends include: The Internet of Me; the Outcome Economy, with

‘Tis the summer of big, smart reports covering the Internet of Things (IoT) impact on health and fitness. Just this month, three of these missives have come to my inbox, and they all contribute sound thinking about the topic. Today, tomorrow and Friday, I’ll cover each of these here in Health Populi. We begin with McKinsey Global Institute’s The Internet of Things: Mapping the Value Beyond the Hype. [In full disclosure, I was an outside adviser to the MGI team members who focused on the human/health and fitness aspects of this report, and thank MGI for the opportunity to provide

Two forces are converging to shape a new era of “living services,” Accenture posits: the digitization of “everything” and consumers’ “liquid” expectations — which are demands for personalized, engaging and adaptable experiences. Accenture’s report on this phenomenon, The Era of Living Services, spans the broad range of consumers’ daily lives where these services will impact: homes, families, transportation, shopping, leisure time, jobs, finances, education, cities, and above all for Health Populi readers, “our bodies.” Living services are physically close to us, as Accenture sees them, “wrapping themselves around the everyday things we do.” They are digital services that are aware

People in the U.S. spend over five-and-a-half hours a day with digital media in 2015, with time on mobile devices exceeding use of laptop and desktop computers. The growth of mobile means people are using and seeking more just-in-time services in daily living, and this has big implications for health/care, based on the annual mega-report on Internet Trends from Mary Meeker, KPCB’s internet analyst. “People” in health/care are patients, consumers and caregivers; people in health/care are also health plan administrators, employer benefits managers, doctors, nurses, allied health professionals, financial managers in hospitals, pharmacists, and the entire range of humans who

Health care consumers face a fragmented and complicated payment landscape after receiving services from hospitals and doctors, and paying for insurance coverage. People want to “view their bills, make a few clicks, pay…and be done,” according to Jamie Kresberg, product manager at Citi Retail Services, a unit of Citibank. He’s quoted in Money Matters: Billing and payment for a New Health Economy from PwC’s Health Research Institute. The healthcare service segment most consumers are satisfied with when it comes to billing and payment is pharmacies, who score well on convenience, affordability, reliability, and seamless transactions – with only transparency being

Living my mantra of Health is Everywhere, where we live, work, play, pray, and shop, I am always on the lookout for signs of health in my daily life. Today I’m in Washington, DC,  speaking on a webinar led by the National Council on Patient Information and Education (NCPIE), discussing the findings in a survey of U.S. adults on self-care health care – my shorthand for healthcareDIY. And the hashtag for the webinar also speaks volumes: #OwnYourHealth. Here’s the link to the survey resources. On my walk from Farragut North Metro station to a nearby office where the meeting will take place,

Alex Gourley, President of The Walgreen Company, addressed the capacity crowd at HIMSS15 in Chicago on 13th April 2015, saying his company’s goal is to “make good health easier.” Remember that HIMSS is the “Health Information and Management Systems Society” — in short, the mammoth health IT conference that this year has attracted over 41,000 health computerfolk from around the world. So what’s a nice pharmacy like you, Walgreens, doing in a Place like McCormick amidst 1,200+ health/tech vendors?  If you believe that health is a product of lifstyle behaviors at least as much as health “care” services (what our

Financial wellness is integral to overall health. And the proliferation of high-deductible health plans for people covered by both public insurance exchanges as well as employer-sponsored commercial (private sector) plans, personal financial angst is a growing fact-of-life, -health, and -healthcare. Ask any hospital Chief Financial Officer or physician practice manager, and s/he will tell you that “revenue cycle management” and patient financial medical literacy are top challenges to the business. For pharma and biotech companies launching new-new specialty drugs (read: “high-cost”), communicating the value of those products to users — clinician prescribers and patients — is Job #1 (or #2,

While shopping is a life sport, and even therapeutic for some, there’s one product that’s not universally attracting shoppers: health insurance. McKinsey’s Center for U.S. Health System Reform studied people who were qualified to go health insurance shopping for plans in 2015, covered by the Affordable Care Act. McKinsey’s consumer research identified six segments of health insurance plan shoppers — and non-shoppers — including 4 cohorts of insured and 2 of uninsured people. The insureds include: Newly-insured people, who didn’t enroll in health plans in 2014 but did so in 2015 Renewers, who purchased health insurance in both 2014 and

As people take on self-service across all aspects of daily living, self-care in health is growing beyond the use of vitamins/minerals/supplements, over-the-counter meds, and trying out the blood-pressure cuff in the pharmacy waiting for a prescription to be filled. Today, health consumers the world over have begun to engage in self-care using digital technologies. And this isn’t just a phenomenon among people in the Millennial generation. Most seniors who regularly use technology (e.g., using computers and mobile phones) are also active in digitally tracking their weight, for example, learned in a survey by Accenture. Older people who use technology in daily

The 87th annual 2015 Oscars show (#Oscars15) feted more than the movie industry: the event celebrated health in both explicit and subtle ways. Julianne Moore took the golden statuette for Best Actress, playing the title role in Still Alice, the story a woman diagnosed with early-onset Alzheimer’s Disease. In accepting her award, Moore spoke of the need to recognize and “see” people with Alzheimer’s – so many people feel isolated and marginalized, Moore explained. Movies help us feel seen and not alone – and people with Alzheimer’s need to be seen so we can find a cure, she asserted. See Moore’s lovely

In our ADHD-addled, over-messaged and noisy world, it’s hard to break through the media clutter and binge-watching to get a health message out. Here’s the way it’s done: an engaging, humorous, impactful and crisp campaign focusing on making smoking so un-sexy and un-cool, you swipe the prospective date off of your Tinder app. Watch and learn, from The Truth. You can follow the campaign on Twitter using the hashtag #LeftSwipeDat. Kudos to the truth® anti-smoking campaign and the creative team who got this blend of message and medium so right. truth® is part of the Legacy project which is funded by the

The FTC has weighed in on privacy and security and the Internet of Things (IoT) in a report published on 27th January 2015. When it comes to IoT and devices that connect to the internet, the FTC will focus on Enforcing privacy laws Educating consumers and business on privacy and security for connected devices Participate in multi-stakeholder groups such as the NTIA’s team considering guidelines for facial recognition, and Advocate with other agencies, at the state level, and with courts. The report summarizes input received in a FTC workshop conducted in November 2013 with IoT industry experts, and offers recommendations

Evidence of the rise of retail health grows, with the data point that on-demand health care is in-demand by 2 in 3 U.S. adults. American Well released the Telehealth Index: 2015 Consumer Survey, revealing an American health public keen on video visits with doctors as a viable alternative to visiting the emergency room. Virtual visits are especially attractive to people who have children living at home. [For context, this survey defines “telehealth” as a remote consultation between doctor and patient]. Convenience drives most peoples’ interest in telehealth: saving time and money, not leaving home if feeling unwell, and “avoiding germs

2015 is already becoming a year where bedfellows of different stripes are joining together to build a health care ecosystem well beyond hospitals, doctors and health plans. Announcements launched last week at the 2015 Consumer Electronics Show in Las Vegas, and coming out this week at the J.P. Morgan Conference in San Francisco, the first two weeks of 2015 reveal that new entrants and legacy health stakeholders are crossing corporate and cultural chasms to (try and) solve challenges that prevent us from getting to that Holy Grail of The Triple Aim: improving health care outcomes, driving down per capita costs,

Are you Feelin’ Groovy about wearables? Well slow down, you move too fast… …at least, according to Accenture’s latest survey into consumers’ perspectives on new technologies, published this week in conjunction with the 2015 Consumer Electronics Show in Las Vegas, the largest annual convention in the U.S. featuring technology for people. At #CES2015, we’re seeing a rich trove of blinged-out, multi-sensor, shiny new wearable things at the 2015 Consumer Electronics Show. Swarovski crystals are paired with Misfit Wearables, called the Swarovski Shine, shown here as a shiny new thing, indeed. Withings launched its Activite fitness tracking watch in new colors.

The Field of Dreams works in nostalgic plotlines about baseball, but as I’ve pointed out since the advent of consumer-facing health technologies, there’s no Field of Dreams effect in health care when it comes to consumer health engagement. U.S. health consumers aren’t using the patient portals that health care providers have built as part of their efforts to bolster health engagement via EHRs and health IT, Xerox found in the company’s 5th annual survey on electronic health records. I spoke with Tamara St. Claire to discuss the implications of the consumer poll, which was conducted among 2,017 U.S. adults in

“Disruption” is a well-used word these days in business and, in the past few years, in the health care business. That’s because there’s a general consensus that the U.S. health care system is broken. “System” is a word that I shouldn’t use as my friend J.D. Kleinke smartly argued that it’s that lack of system-ness that makes using the phrase “health care system” an Oxymoron. The fragmented health care environment creates innumerable pain points when accessing, receiving, and paying for services. And it’s women who feel so much of that pain. In that context, I’m gratified and humbled to be one

Consumers’ growing health care cost burden is competing with other household spending: basic costs for Americans are eroding what’s left of the traditionally-defined Middle Class. At the front end of health costs is the health insurance premium, the largest single line item for a family. It looks like a big number because it is: Milliman gauged the cost for an employer to cover a family of four in a PPO in the U.S. at around $23K, with the employee bearing an increasing percent of the premium, copays, coinsurance, and a larger deductible this year than last, on average. There are