A blog covering the health/care ecosystem and people.

Digital health innovations were fast-proliferating at CES 2017. The bad news is there are so many of them, it’s dizzying and fragmented. The good news is that there are emerging health data ecosystems that will streamline consumers’ user experience so that people can derive knowledge, actionable advice and value out of using these tools. Walking miles of aisles in the Sands Convention Center in the first week of January 2017 can be a dizzying prospect, with hype and best-faces-forward in every single exhibitor at the show. In the health segment at CES, there’s a long list of digital tools to

Several market forces are converging that boost patients’ ability to engage in their health and self-care, including peoples’ growing adoption of smartphones, demand for self-service and DIY lifestyles, and Americans’ growing responsibility as health consumers. Health consumers are using a growing array of self-health tools, enabled through digital technologies. However, these tools aren’t yet engaging some of the very people who need them the most: high-need, high-cost patients. Research into this situation is discussed in the December 2016 Health Affairs article, Many Mobile Heaath Apps Target High-Need, High-Cost Populations, But Gaps Remain, published in the December 2016 issue of Health Affairs. For

Most U.S. hospitals have not put consumerism into action, a new report from KaufmanHall and Caden’s Consulting asserts from the second paragraph. Patient experience is the highest priority, but has the biggest capability gap for hospitals, the report calls out. KaufmanHall surveyed 1,000 hospital and health system executives in 100 organizations to gauge their perspectives on health consumers and the hospital’s business. KaufmanHall points out several barriers for hospitals working to be consumer-centered: Internal/institutional resistance to change Lack of urgency Competing priorities Skepticism Lack of clarity (vis-a-vis strategic plan) Lack of data and analytics. The key areas identified for consumer centricity

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,

Personal fitness equipment is getting connected in the growing Internet of Things ecosystem (IoT), and fitness enthusiasts are getting more digitally connected well beyond their wristband tracking device. , a healthy living portal, looked into fitness consumers’ digital habits and found a health-engaged cohort that’s online in the Web 1.0 world — sharing workout tips in social media communities but not so much product information. Product information is still learned Old School-wise, via product websites, traditional magazines, from peers and word-of-mouth (offline), and trying new gear out at the gym in real time. This survey was conducted among HellaWella’s readers,

J.D. Power, the company best known for evaluating consumers’ experiences with automobiles, published its 2016 Fitness Band Device Satisfaction Report this week. The bar chart summarizes overall satisfaction with activity tracking wristbands, led by Samsung with the highest index score, followed by Garmin. Below the average index were LG, Fitbit, and Jawbone. Samsung’s top grade translates into J.D. Power’s methodology as “among the best” fitness bands, based on a 1,000 point scale. Samsung’s high ranking was earned based on particularly strong scores for customer satisfaction in comfort, reliability, and ease of use. Garmin’s customer service was also highly rated, along

About two-thirds of health consumers would be open to virtual health care options for non-urgent situations, according to the 2016 Connected Patient Report from Salesforce Research. Salesforce conducted the survey with the Harris Poll online among 2,025 U.S. adults in June 2016. 1,736 of these health consumers had health insurance and a primary care physician. Among the many findings in the report, Salesforce found that: In terms of communications and relationship… The vast majority of consumers with primary care physicians are very satisfied with them (91% of people with PCPs) However, one-third of people with a PCP believe their physicians would

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,

How can digital technologies enable self-healthcare in novel ways? This was the theme of a meeting sponsored by Pfizer Consumer Healthcare and hosted by Google, with the title, “Advancing Consumer Health through New Technology and Next Generation OTC Healthcare” held on 12th April 2016 at Google offices in Manhattan’s Chelsea neighborhood. Pharmaceutical brand drugs switching to over-the-counter packaged goods, the Cellscope Otoscope used by parents checking their young children’s earaches, connected shoes and earbuds for athletic enhancement, and omni-channel retail shopping….these are a few of the signals we see emerging to enable consumers’ to drive healthy behaviors, wellness and self-healthcare. Speakers

One in 3 consumers is using mobile apps for health, doubling from 16% in 2014 to 33% in 2016, according to a survey from Accenture released during HIMSS 2016 conference. The proportion of people donning a wearable device for health more than doubled, from 9% to 21% between 2014-15. Part of this response is due to more physicians asking their patients — consumers — to adopt a wearable to track a health or fitness metric. One in 5 consumers said their doctor “prescribed” the use of a wearable, and 76% of these people followed the doctor’s recommendation. Most consumers and

Telehealth will be in the spotlight at HIMSS 2016, the biggest annual conference on health information technology (HIT) that kicks off on 29th February 2016 in Las Vegas – one of the few convention cities that can handle the anticipated crowd of over 50,000 attendees. Some major pre-HIMSS announcements relate to telehealth: American Well, one of the most mature telehealth vendors, is launching a software development kit (SDK) which will enable  The new videoconferencing option can simultaneously connect patients with multiple physicians and specialists, and the SDK is designed to enable users to incorporate telemedicine consults into patient portals and

9 in 10 people in the U.S. believe working with their health clinician as a partner will help them better manage their overall health, according to a survey conducted for The Society for Participatory Medicine. Consumers’ majority call-out for shared decision-making with health care professionals also extends to their self-tracking health data — for example, via activity trackers, digital glucometers for blood sugar, technologies for blood pressure, and food logging apps. 84% of people said that sharing their personal self-tracking health data with clinicians between visits would also help people manage health. That clinician’s involvement is very important to health

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

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

By shifting primary care visits by 5 minutes, moving some administrative tasks and self-care duties to patients, the U.S. could conserve billions of dollars which could extend primary care to underserved people and regions, hire more PCPs, and drive quality and patient satisfaction. Accenture’s report, Virtual Health: The Untapped Opportunity to Get the Most out of Healthcare, highlights the $10 bn opportunity which translates into conserving thousands of primary care providers. PCPs are in short supply, so virtual care represents a way to conserve precious primary care resources and re-deploy them to their highest-and-best-use. The analysis looks at three scenarios

Direct-to-consumer retail health options are fast-growing in the U.S. health ecosystem. CVS Health brought three telemedicine vendors to its pharmacy brick-and-mortar stores. CVS also acquired Target’s pharmacies, expanding its retail health footprint. Rite Aid has added HealthSpot kiosks to its pharmacies, while Walgreens expanded its relationship with MDLive. And, Cox Cable acquired Trapollo to bring remote health monitoring into subscribers’ homes, along with the cable company’s venture with Cleveland Clinic, Vivre Health. Coupled with the growing supply side of telemedicine vendors, the latest National Business Group on Health survey found that most large employers plan to expand the telemedicine services they

Taking literally the maxim that health is where we live, work, play and pray, Cox Communications acquired Trapollo, a remote health monitoring company, extending the core business of cable TV into the world of health services to the home. “We believe that the home will be an increasingly important node within the healthcare delivery architecture,” Asheesh Saksena, executive vice president and chief strategy officer, Cox Communications, said in the company’s press release. In the past year, Cox Communications entered in a joint venture with the Cleveland Clinic, to form Vivre Health for developing digital health care services. Cox also invested in

From elite soccer and football fields to youth athletes in public school gyms, wearable technology has come to sports bringing two big benefits of gathering data at the point of exercise: to gauge performance and coach back to the athlete in real time, and to prevent injury. I discussed the advent of the Internet of Things in sports on the Scoop and Score podcast with Andrew Kahn, sports journalist and writer, and Stephen Kahn, sports enthusiast and business analyst. [In full disclosure these two Kahn’s are also my brilliant nephews.] We recorded the podcast on July 14, 2015, the day

‘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

Retail health v1.0 encompassed the pharmacy, then embraced urgent care and retail health clinics co-located in brick-and-mortar pharmacy chain stores. In v2.0, retail health encompasses all health/care, really, because people, patients and consumers are essentially self-insured up to the point when their health plan kicks in some cash. The high-deductible health plan era is ushering in the retail health era, broadly writ. Hospitals & Health Networks magazine (HHN) ran a story titled Think Like a Retailer to Engage Patients, covering founder of WEGO Health Jack Barrette‘s and my panel presentation at the 2015 HIMSS conference in Chicago last week. Writer

As sensors begin to proliferate our “Things,” from refrigerators to cars, toasters to t-shirt, our health could benefit mightily. Approaching this weekend’s South-by-Southwest Interactive meet-up in Austin, several authors have crowdsourced views on using technology for good in ImpactX, a special section in the Huffington Post sponsored by Cisco. I was asked to develop a view on using technology for good — for health and health care. Here’s my offering: How the Internet of Things Can Bolster Health. The promise of sensor-laden stuff in our lives can work for personal and public health in myriad ways — from perceiving impending epidemics

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 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

Health is where we live, work, play and pray — my and others’ mantra if we want to truly bend (down) the cost curve and improve medical outcomes. If we’re serious about achieving the Triple Aim — improving public health, lowering spending, and enhancing the patient/health consumer experience (which can drive activation and ongoing engagement) — then you see health everywhere at the 2015 Consumer Electronics Show in Las Vegas this week. With this post, I’ll share with you the major themes I’m seeing at #CES2015 related to health, wellness, and DIYing medical care at home. The meta: from health care to self-care.

Men are from Mars and Women, Venus, when it comes to managing health and using digital tools and apps, based on a poll conducted by A&D Medical, who will be one of several hundred healthcare companies exhibiting at the 2015 Consumer Electronics Show this week in Las Vegas. Digital health, connected homes and cars, and the Internet of Things (IoT) will prominently feature at the 2015 Consumer Electronics Show in Las Vegas this week. I’ll be attending this mega-conference, meeting up with digital health companies and platform providers that will enable the Internet of Healthy “Me” — consumers’ ability to self-track,

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

Dr. Joseph Kvedar has led the Center for Connected Health for as long as I’ve used the word “telehealth” in my work – over 20 years. After two decades, the Center and other pioneers in connected health have evidence proving the benefits, ROI (“hard” in terms of dollars, and “soft” in terms of patient and physician satisfaction), and technology efficacy for connecting health. The 11th Annual Connected Health Symposium is taking place as I write this post at the Seaport Hotel in Boston, bringing health providers, payers, plans and researchers together to share best practices, learnings and evidence supporting the

With the goal of driving a digital health platform for well-informed, effective self-care, the nation’s largest retail pharmacy chain and prominent consumer-facing health information portal are allying to move from serving up pills and information to health “care.” Walgreens and WebMD launched their joint effort on 2nd October 2014, a few weeks after CVS/pharmacy re-branded as CVS Health. Welcome to the reinvention of the retail pharmacy. I spoke for a few minutes with David Schlanger, CEO, WebMD, and Alex Gourlay, President, Customer Experience and Daily Living, Walgreens, the day of the launch, to get early insights into the vision for

Wearables met health and medicine at the 8th annual Health 2.0 Conference in Santa Clara, CA, last week. I had the real pleasure of shepherding a wearables panel of five innovators during the conference, in a well-attended session followed by an energetic Q&A. The organizations who demonstrated their tools and brainstormed the wearables market included, in alphabetical order, Atlas Wearables, Heartmath, MySugr, SunSprite and Withings. I hasten to add that among the five presenters, two were women: that 2 in 5 = 40% gender representation is, happily to my way of thinking about women’s roles in health-making, a very good

Remote health monitoring is in the Trough of Disillusionment. Wearables are at the Peak of Inflated Expectations, with Big Data leapfrogging wearables from the 2013 forecast — both descending toward the Disillusionment Trough. Mobile (remote) health monitoring, however, has fallen into that Trough of Disillusionment as RHM has been undergoing reality checks in the health care system especially for monitoring and patient self-management of heart disease (most notably heart failure) and diabetes. Welcome to the 2014 edition of the Gartner Hype Cycle, one of my most-trusted data sources for doing health industry forecasts in my advisory work. Compared with last year’s

Smarter homes can conserve energy, do dirty jobs, and remind you to take your medicine. In doing all these things, smart homes can also collect data about what you do inside every single room of that home. The fast convergence of Wi-Fi and sensors are laying the foundation for the Internet of Things, where objects embedded with sensors do things they’re specially designed to do, and collect information while doing them. This begs the questions: what do you want to know about yourself and your family? How much do you want to know? And, with whom do you want to

Three of the world’s biggest technology companies – Apple, Google and Samsung — have made big announcements in the world of connected health in the past few weeks. A fourth is positioned to enter the fray. These major announcements illustrate the convergence of consumer technology, health, and wearables, with the potential for Big Data and population health impacts. Among the three tech giants, Samsung announced its consumer health/tech story first, on May 28, 2014, at its Digital Health Initiative meeting. Samsung unveiled the Samsung Architecture Multimodal Interactions platform, SAMI, along with the Simband prototype wristband that would enable users to

Employer wellness programs are growing in the U.S., bundled with consumer-directed plans and health savings accounts. A wellness company’s work with employee groups is demonstrating that workers who adopt mobile health technologies — especially “wearables” coupled with smartphone apps — helps change behavior and drive health outcomes. Results of one such program are summarized in Wearables at Work, a technical brief from Vitality, a joint venture of Humana and Discovery Ltd., published April 23, 2014. Vitality has been working in workplace wellness since 2005, first using pedometers to track workers’ workouts. In 2008, Vitality adopted the Polar heart rate monitor for

In 2014, we are digital omnivores. Most people “consume” information and entertainment on more than one screen: 7 hours’ worth over a 5-hour period. You read that right: most people who watch TV, use a laptop or PC, smartphone or tablet are multitasking use of these devices in parallel. And above all, people are using smartphones as their primary screen. The AdReaction: Marketing in a multiscreen world report from Millward Brown paints a picture of global consumers who are cobbling together multiscreen experiences. The smartphone has become the “do it all” device if you don’t carry a laptop or tablet around, especially favored

With health costs increase increasing at 4.4% in 2014, a slightly higher rate of growth than the 4.1% seen in 2013. While this is lower than the double-digit increases U.S. employers faced in 2001-2004, it’s still twice the rate of general consumer price inflation. That’s what the first graph shows, based on the The 19th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care.  Employers generally want to continue to provide health insurance…for the time being. 92% of companies expect to make changes in health plan provisions in 2014, with 1 in 2 anticipating “significant

Thinking about personal health information technology – the wearable devices, remote health monitors, digital weight scales, and Bluetooth-enabled medical equipment scaled for the home – there are two glasses. One is half-full and the other, half-empty. The half-full glass is the proliferation of consumer-facing devices like Fitbit, Jawbone and Nike, which comprise the lion’s market share in the health wearables segment; the mass adoption of mobile phones and tablets; consumers’ multi-screen media behavior (as tracked by Nielsen); and consumers’ growing share of medical spending, now about 40% of annual spending (or something north of $8,000 for a family of four

The convergence of technology developments – such as the internet, mobile phone adoption, cloud computing, sensors, electronic health records – with societal evolution including consumerism, demand for transparency, and “flatter” organizations – enable the phenomenon of Connected Health. Connected Health by definition includes mobile health (mHealth), telehealth and telemedicine, as presented in the February 2014 issue of Health Affairs which is dedicated to this theme. Why Connected Health’s time is Now relates to those factors cited above, and the underlying challenge of managing health care costs. While all nations in the developed world are facing difficult health economies, the U.S. spends so

When the head of the Consumer Electronics Association gives a shout-out to the growth of health products in his annual mega-show, attention must be paid. The #2014CES featured over 300 companies devoted to “digital health” as the CEA defines the term. But if you believe that health is where we live, work, play, and pray, then you can see health is almost everywhere at the CES, from connected home tech and smart refrigerators to autos that sense ‘sick’ air and headphones that amplify phone messages for people with hearing aids, along with pet activity tracking devices like the Petbit. If

Of 100 broad-based trends to expect in 2014, most relate in some way to health. I’ve reviewed every one of the 100 forecast points in JWT’s 100 Things to Watch in 2014 report, and it seems Health is Everywhere. Let me point out many, which I’ve allocated to health-ified buckets (note that JWT organizes the list of 100 by alphabet, from “A” to “Z,” so they are not in any prioritized or strategic order). The most direct-health impacting bucket of trends are those in health tech. These include E-cigarette regulation (#35), Glassware (#42), Haptic technology (#46), Needle-free vaccines (#64), Oculus Rift (#65), OTT TV (#66), Telediagnostics

While about 53% of people globally are willing to share various types of personal data overall, the kind of data willing-to-be-shared varies by type of information — and what country we’re from. When asked how likely they would be to anonymously share information if it could lead to improvements or innovations in that technology, Americans are less likely to be willing to share any type of personal data — except for gender. When it comes to sharing several specific types of health information, fewer Americans are likely to want to share it as Intel found in their survey published in the company’s Healthcare

Coast-to-coast, stress is the modus vivendi for most Americans: 55% of people feel stressed in every day life, according to a study from Televox. A Stressful Nation: Americans Search for a Healthy Balance paints a picture of a nation of physically inactive people working too hard and playing too little. And far more women feel the stress than men do. 64% of people say they’re stressed during a typical workday. 52% of people see stress negatively impacting their lives. And nearly one-half of people believe they could better manage their stress. As a result, physicians say that Americans are experiencing negative

There are thousands of downloadable apps that people can use that touch on health. But among the 40,000+ mobile health apps available in iTunes, which most effectively drive health and efficient care? To answer that question, the IMS Institute for Healthcare Informatics analyzed 43,689 health, fitness and medical apps in the Apple iTunes store as of June 2013. These split into what IMS categorized as 23,682 “genuine” health care apps, and 20,007 falling into miscellaneous categories such as product-specific apps, fashion and beauty, fertility, veterinary, and apps with “gimmicks” (IMS’s word) with no obvious health benefit. Among the 23,682 so-called

Return on innovation in medical technology is on the decline. Med tech needed a GPS for its role in the health ecosystem, and lost its way as it focused on a few wrong priorities. In a $349 billion market, there has been much to lose…and will be to gain. The new world for medical technology and how the industry can turn around is the subject of P2C’s report, Medtech companies prepare for an innovation makeover, published in October 2013 by the PwC Health Research Institute (HRI). The problem has been an addiction to incremental improvements on existing products: think about the analog in

The FDA has spoken: there are 2 statutory definitions for a mobile health tool as a “medical device” that the Agency says it has regulatory oversight: To be used as an accessory to a regulated medical device, or To transform a mobile platform into a regulated medical device. On page 8 of the Guidance for Industry and Food and Drug Administration Staff, you can read the FDA’s expanded definition of a mobile health app as being: “…intended for use in performing a medical device function (i.e. for diagnosis of disease or other conditions, or the cure, mitigation, treatment, or prevention

In game-scoring unit terms, 52 is the number of hours an average American spends seeking health information online each year. The 1 (hour) is roughly equivalent to the approximate total time a patient spends with a physician (an average of 3 visits, with an average time per vision of 20 minutes). Thus, 52:1. This means that the average U.S. health consumer spends much more time DIYing her health using digital information resources than speaking face-to-face with their physician in the doctor’s office. Still, the physician continues to be a go-to source for health information, according to Makovsky, a health communications