A blog covering the health/care ecosystem and people.

Over one-half of Americans would likely use virtual care for their healthcare services, and one in four people would actually prefer a virtual relationship with a primary care physician, according to the fifth annual 2020 Consumer Sentiment Survey from UnitedHealthcare. What a difference a pandemic can make in accelerating patients’ adoption of digital health tools. This survey was conducted in mid-September 2020, and so the results demonstrate U.S. health consumers’ growing digital health “muscles” in the form of demand and confidence in using virtual care. One in four people would consider online options as their first-line to evaluating personal health

2020 will be remembered for disruption and dislocation on many fronts; among the major blips in the year will be it remembered as the largest funding year for digital health recorded, according to Rock Health’s report on the 3Q2020 digital health funding. This funding record (“already” before year-end, tallied by the third quarter as Rock Health notes) was driven by “mega”-deals accelerated during the public health crisis of COVID-19. In the third quarter of 2020, some $4 billion was invested in U.S. based digital health start-ups adding up $9.4 billion in 2020….so far. This is $1.2 billion more than two

In the pandemic, I’ve been weaving together data to better understand how people as consumers are being re-shaped in daily life across their Maslow Hierarchies of Needs. One of those basic needs has been digital connectivity. People of color have faced many disparities in the wake of the pandemic: the virus itself, exacting greater rates of mortality and morbidity being the most obvious, dramatic inequity. Another has been digital inequity. Black people have had a more difficult time paying for phone and Internet connections during the COVID-19 crisis, we learned in a Morning Consult poll fielded in June 2020. In

The coronavirus pandemic has revealed the importance of connectivity, WiFi, broadband, as a social determinant of health and living. Connecting from our homes — now our health hubs, workplaces, schools, entertainment centers, and gyms — is necessary like air and water for survival across daily life flows. Digital connectivity can ameliorate social isolation and anxiety, bolster mental health, and access needed medical care via telehealth channels. As a result of the pandemic, staying connected is more important than ever for older people, Best Buy Health learned in a survey of U.S. adults. Insights from this study have informed the launch

On February 4th, 2020, in a hospital in northern California, the first known inpatient diagnosed with COVID-19 died. On March 11th, the World Health Organization called the growing prevalence of the coronavirus a “pandemic.” On May 25th, George Floyd, a 46-year-old Black man, died at the hands of police in Minneapolis. This summer, the Dixie Chicks dropped the “Dixie” from their name, and NASCAR cancelled the confederate flag from their tracks. Today, nearly 200,000 Americans have died due to the novel coronavirus. My new book, Health Citizenship: How a virus opened hearts and minds, launched this week. In it, I

Home is where the health is, we know in the wake of the COVID-19 pandemic. To be sure, many of us who have been preaching that our ZIP codes are more impactful to our health than our genetic codes have known the evidence backing the social and behavioral determinants of health for a long time. This week, Parks Associates convened the Connected Health Summit, focused on the theme of consumer engagement and innovation. I attended all three days’ worth of sessions in this well-planned and -executed virtual meeting. In this post, I’ll weave my favorite themes of consumer health engagement

In the COVID-19 era, most U.S. consumers believe they have an obligation to share personal health information to stop the spread of the coronavirus. However, only 44% would be willing to share their personal data with a national database, a MITRE study learned. Only one-third of Americans would be willing to share their temperature, 29% their location, and one-fourth information about their chronic conditions. The Harris Poll conducted the study among 2,065 U.S. adults 18 and over in mid-June 2020 to gauge peoples’ perspectives on health data and privacy. Three-quarters of people in the U.S. believe that data privacy “is a

“Digital transformation” was the mantra for all industries before we heard about the COVID-19 virus. Since the emergence of the pandemic, the coronavirus has accelerated the adoption of digital platforms, AI, and ecommerce. That is at least as true for the health care sector as it has been for other industry segments. So, will the fast-adoption of virtual care and other forms of digitization in health care last? Accenture probes this question in a report published today asking, How Can Leaders Make Recent Digital Health Gains Last? In Accenture’s words, “COVID-19 forced a surge” in virtual health care following a

The COVID-19 pandemic hastened digital transformation for both the health care industry and for individuals — as health consumers, patients, caregivers, and health citizens. Two new reports from Accenture update our understanding of the changed health consumer in the context of both “home: and the health care ecosystem. These reports are Accenture’s annual Digital Health Technology Vision 2020, and an analysis of the firm’s Wave 7 of consumer research, answering the question, How will COVID-19 change the consumer? The 2020 tech vision for health is summarized here, tying to Accenture’s previous two years of forecasts. This year, the five pillars

This week, announcements from the Consumer Technology Association (CTA) and Withings further bolster the case for the private sector bolstering public health in this pandemic…and future ones to come beyond the Age of the Coronavirus. Since the pandemic emerged, CTA has been reaching out to members and stakeholders to be a useful resource for the consumer electronics industry and its customers. Digital health resources have been an especially useful touch point for CTA’s constituents (including me, as a member who is active with the Association). On 27th July, CTA announced the Association’s launch of the Public Health Tech Initiative. In

The phrase, “burden of health care,” has two usual meanings: one, to do with the massive chronic care burden, and the other, involving costs. There’s a third area of burden in U.S. health care — the onerous patient experience in finding and accessing care, assessed in the 2020 Change Healthcare – Harris Poll Consumer Experience Index. Two in three U.S. consumers feel like “every step of the healthcare process is a chore.” That burdensome patient experience leads to one in two people in America avoiding seeking care, the poll found. That’s not just self-rationing health care due to costs, but due

“The COVID-19 pandemic…has highlighted like never before the pitfalls of paying for healthcare based on the number of patients seen and services rendered,” a Modern Healthcare article asserted in mid-June 2020. In other words, the U.S. health care financing regime of volume-based payment didn’t fare well as millions of patients postponed or cancelled procedures and visits for fear of contracting the virus in the halls, offices and clinics of hospitals and doctor’s offices. “Just imagine if you were 100% fee-for-service,” commented Dr. Fuad Sheriff, a primary care physician whose practice is based on capitated payments. “You would have been dead

The pace of digital health investments quickened in the first half of 2020, based on Rock Health’s look at health-tech financing in mid-year. Digital health companies garnered $5.4 billion in the first half of the year, record-setting according to Rock Health. Underneath this number were very big deals, shown by the size of the blue bubbles in the first graphic from the report. Note that in H1 2020, the average deal size exceeded $25 mm. Among the largest deals valued at over $100 mm were ClassPass (raising $285 mm), in the business of virtual fitness classes;  Alto Pharmacy, a digital

Some 6 in 10 people in the U.S. have been financially impacted by COVID-19. Those most negatively affected by the pandemic tend to be younger, Gen Z age group and African-American, 63% of whom felt financial pressure directly due from the virus and the national economic lockdown. By late May 2020, 34% of black Americans had lost their jobs compared with 21% in late April, compared with 18% of white consumers, reported in The COVID-19 Pandemic’s Financial Impact on U.S. Consumers, survey research from TransUnion. This post describes data from TransUnion’s Wave 9 report, which polled 2,086 U.S. adults 18

The 21st Century Cures Act emphasizes patients’ control of personal health information. ONC rules issues in March 2020 called for more patient-facing health tools and apps to bolster health consumer engagement and empowerment. But the emergence of the coronavirus in the U.S. revealed many weakness in the American health care system, one of which has been health inequities faced by millions of people — especially black Americans, who have sustained higher rates morbidity and mortality for COVID-19. There have also been digital health divides found in the COVID-19 pandemic, discussed in a timely essay in JAMA, Digital Health Equity as

Patients in the U.S. are self-rationing care in the era of COVID-19 by cutting spending on health care visits and prescription drugs. The coronavirus pandemic’s impact on health consumers’ spending varies depending on whether the household is generally a healthy family unit, healthy “enthusiasts,” dealing with a simple or more complex chronic conditions, or managing mental health issues. PwC explored how COVID-19 is influencing consumers’ health care behaviors in survey research conducted in early April by the Health Research Institute. The findings were published in a May 2020 report, detailing study findings among 2,533 U.S. adults polled in early April

“U.S. workers were stressed before COVID-19; now, stress levels are through the roof,” based on data analyzed by Ginger, the digital behavioral health innovator, asserting this major mental health headline in its latest press release. Working Americans were becoming increasingly stressed, distressed, and anxious in February 2020, when Ginger fielded this study. Key data points from their analysis of U.S. workers’ feelings about the COVID-19 pandemic included: 7 in 10 working people said this was the most stressful time of their working lives 7 in 10 workers believed fellow employees in their companies were significantly less productive due to stress

One in two Americans trust the Centers for Disease Control for the facts on the coronavirus pandemic, and 43% trust the World Health Organization. But there’s a huge trust deficit when it comes to trusting President Donald Trump on the facts about COVID-19, a poll from Morning Consult and The Hollywood Reporter found. 2,200 U.S. adults were surveyed between 12 and 15 March 2020 on the coronavirus pandemic and their perspectives on the media and political leaders’ information credibility. For news on the pandemic, only one in five Americans believed the President and 18%, the Vice President, Mike Pence, followed

With President Trump’s somber speech from the Oval Office last night, we wake up on 12th March 2020 to a ban on most travel from Europe to the U.S., recommendations for hygiene, and call to come together in America. His remarks focused largely on an immigration and travel policy versus science, triaging, testing and treatment of the virus itself. Here is a link to the President’s full remarks from the White House website, presented at about 9 pm on 11 March 2020. Over the past week, I’ve culled several studies and resources to divine a profile of the U.S. consumer

The coronavirus has shaken U.S. consumer confidence, both in terms of financial markets and personal health risks. COVID-19 is re-shaping peoples’ behavior and daily choices, from using public transit to choosing where to shop, based on Morning Consult’s National Tracking Poll #200276 conducted February 28-March 1, 2020. Morning Consult surveyed 2,200 U.S. adults, finding that 3 in 4 Americans were concerned about the coronavirus outbreak. The first chart from the survey shows various consumer activities by peoples’ likelihood of choosing to do them. Clearly, our daily life-flows outside of our homes have been impacted by our perceived risks of the coronavirus:

Outpatient revenue is crossing the curve of inpatient income. This is the new reality for U.S. hospitals and why I’ve titled this post, “outpatient is the new inpatient,” a future paradigm for U.S. hospitals This realization is informed by data in a new report from Deloitte, Where have the many hospital inpatient gone? The line chart illustrates Deloitte’s top and bottom line: “The shift toward outpatient is happening and will likely have a tremendous impact on operations, business models, staffing, and capital. Health systems should prepare for the future today and start thinking not only about how to manage their

Patients are now front-line payors in the U.S. health care system. As such, American health consumers are wrestling with sticker shock from surgical procedures, surprise medical bills weeks after leaving the hospital, and the cost of prescription drugs — whether six-figure oncology therapies or essential medicines like insulin and EpiPens. To manage personal health finances, patients-as-payors are increasingly willing to face trade-offs and change personal behaviors to lower health care costs, based on research in The Future of Health Care Study from USC’s Center for the Digital Future. The Center analyzed the perspectives of 1,000 U.S. adults in August 2019 regarding

There are 1,844 rural hospitals operating in the U.S. That number is down by 19 in the 2019 calendar year, the worst year of rural hospital closings seen in the past decade. That hockey-stick growth of closures is shown in the first chart, where 34 rural hospitals shut down in the past 2 years. Rural U.S. hospitals are in poor fiscal health. “The accelerated rate at which rural hospitals are closing continues to unsettle the rural healthcare community and demands a more nuanced investigation into rural hospital performance,” threatening the stability of the rural health safety net, according to the

With our HealthConsuming “health is everywhere” ethos, this post updates some of the most impactful recent retail health developments shaping consumers’ health/care touchpoints beyond hospitals, physicians, and health plans. For inspiration and context, I’ll kick off with Roz Chast’s latest New Yorker cartoon from the February 3rd 2020 issue — Strangers in the Night, taking place in a Duane Reade pharmacy. Roz really channels the scene in front of the pharmacy counter, from Q-tips to vitamins and tea. And it’s hummable to the tune of, well, Strangers in the Night. Check out the 24-hour pharmacist under the pick-up sign. Now,

Physicians are evolving as digital doctors, embracing the growing role of data generated in electronic health records as well as through their patients using wearable technologies and mobile health apps downloaded in ubiquitous smartphones, described in The Rise of the Data-Driven Physician, a 2020 Health Trends Report from Stanford Medicine Stanford Medicine interviewed 523 physicians and 210 medical students and residents in September and October 2019 to assess clinicians’ perspectives on digital health topics for this study. The study title citing the “data-driven physician” is based on the key survey finding that doctors are preparing to embrace data, from both traditional

The digital health presence at CES 2020 is the fastest-growing segment of consumer technologies at the Show this year, increasing by 25% over 2019. Heart-focused technologies are a big part of that growth story. In fact, in our search for devices and tools underpinned with clinical proof, evidence is growing for consumer-facing technology for heart-health, demonstrated by this year’s CES. Wrist-worn devices, digital therapeutics, patient engagement platforms, pharma and health plans converged at this year’s CES, with the professional association “blessing” of the American College of Cardiology who granted a continuing medical education credit for physicians attending a one-day “disruptive

The top two health care concerns facing Americans are out-of-pocket costs and prescriptions drug costs, according to a poll published today in Morning Consult. Apropos to my title of this post, the survey was sponsored by the Bipartisan Policy Center, whose mission is to promote, cross-party affiliations, “health, security and opportunity for all Americans.” Health care is the top issue driving voters’ choices in the 2020 elections for most Americans. The economy follows second with 44% of voters, then immigration with 33% of Americans keen on the issue. For overall healthcare reform, the plurality of Americans prefer improving the current system

In CTA’s 2020 Consumer Tech Forecast launched yesterday at Media Day 1 at CES, Steve Koenig VP of Research, said that, “digital health is an ecosystem of ecosystems.” Health, medical and wellness trends featured large in the forecast, which brought together key trends for 5G, robotics, voice tech, AR/VR/XR, and the next iteration of IoT — which Steve said will still be called “IoT,” but in this phase will morph into the “Intelligence of Things.” That speaks to Steve’s phrase, “ecosystem of ecosystems,” because that’s not just “digital” health — that’s now the true nature of health/care, and what is

Next week, the Consumer Technology Association (CTA) will convene CES, the Consumer Electronics Show, where over 180,000 tech-minded people from around the world will convene to kick the tires on new TVs, games, smart home devices, 5G connections, 3-D printing, drones, and to be sure, digital health innovations. At #CES2020, exhibitors in the health/care ecosystem will go well beyond wearable devices for tracking steps and heart rate. I’ll be meeting with wearable tech innovators along with consumer electronics companies and retailers. I’ve also scheduled get-togethers with pharma and life science folks, health plan people, and execs from consumer health companies.

As Boomers age, they’re adopting mobile and smart technology platforms that enable people to communicate with loved ones, manage retirement investment portfolios, ask Alexa to play Frank Sinatra’s greatest hits, and manage prescription refills from the local grocery store pharmacy. Last week, the Giant Eagle grocery chain was the first pharmacy retailer to offer a new medication management skill via Alexa. That program has the potential to change our Medicare members manage meds at home to ensure better adherence, supporting better health outcomes and personal feelings of efficacy and control. [As an aside, consumers really value pharmacies embedded in grocery

As technology continues to re-shape consumers’ experiences and expectations with health/care, retail, travel and work, peoples’ concerns about data privacy are also growing as observed by a 2020 consumer trends forecast from GlobalWebIndex, Connecting the dots. First, some overall context to the study. GlobalWebIndex “connects the dots” of consumers trends in 2020 including the topics shown in the first graphic including commerce and retail, gaming, travel, human touch, nostalgia, privacy and digital health — the first of these trends discussed in the report. Note that the data discussed in this post include responses from consumers residing in both the U.S.

On the demand side of U.S. health care economics, patients are now payors as health consumers with more financial skin in paying medical bills. As consumers, people have great expectations from the organizations on the supply side of health care — providers (hospitals and doctors), health insurance plans, pharma and medical device companies. But as payors, health consumers face challenges in getting care, so great expectations are met with frustration and eroding trust with the system, according to the latest Connected Healthcare Consumer report from Salesforce published today as the company announced expansion of their health cloud capabilities. This is

Patients searching online for health information and health care provider reviews is mainstream in 2019.  Digital health tracking is now adopted by 4 in 10 U.S. consumers. Rock Health’s Digital Health Consumer Adoption Report for 2019 was developed in collaboration with the Stanford Medicine Center for Digital Health. Rock Health’s research has tracked peoples’ use of telemedicine, wearable technology, digital health tracking, and online health information since 2015, and the results this round show relative flattening of adoption across these various tools. Rock Health’s top-line findings were that: Patient-generated health data creates opportunity, and potential challenges Online health information is

“Bold thinking is great. Bold doing is better,” Dr. Eric Topol introduced his talk yesterday at Medecision’s Liberation 2019 conference. I have the opportunity, for which I’m so grateful, of not only attending this meeting but playing a role as a speaker, a sometimes stage “emcee,” and a keynote speaker. And as an attendee, I learn so much from other speakers, fellow attendees, and Medecision staff all sharing perspectives during breakouts and networking breaks. In mode of attendee (and self-confessed collegial-groupie of Dr. Topol’s), I took in his remarks taking notes as fast as I could thanks to Mom teaching

Older people are re-framing their personal images and definitions of aging, from continuing to work past typical retirement age, Skyping and texting with grandchildren, and traveling to destinations well beyond the “snowbird” locales of Florida and Arizona to more active and often charitable/volunteer situations in developing economies. And so, too, are older folks re-imagining how and where their health care services could be delivered and consumed. Most people over 50 years of age are cautious but open to receiving health care virtually via telehealth platforms, according to the National Poll on Healthy Aging from my alma mater, the University of Michigan. U-M’s

Based on the influx of research studies and position papers on social determinants of health flowing into my email box and Google Alerts, I can say we’re past the inflection point where SDoH is embraced by hospitals, professional societies, health plans and even a couple of pioneering pharma companies. PwC published a well-researched global-reaching report this week appropriately titled, Action required: The urgency of addressing social determinants of health. The “wheel of determinants” illustrates potential partners for collaborating in communities to address SDoH factors. The collaborators include governments, health care providers, payors, life science and pharma, tech and telecomms, policy

“Digital transformation” is the corporate strategy flavor of the moment across industries, and the health are sector isn’t immune from the trend. As this 13th year of the annual Health 2.0 Conference kicks off this week, I’m focused on finding digital health innovations that engage people — consumers, caregivers, patients, health citizens all. This year’s conference will convene thought leaders across a range of themes, and as is the Health 2.0 modus operandi, live demo’s of new-new things. As Health 2.0 kicks off today in pre-conference sessions, there is useful context described in a new report from the American Hospital

“Every company is a tech company,” Christopher Mimms asserted in the Wall Street Journal in December 2018. Connectivity, artificial intelligence, and automation are now competencies every company must master, Mimms explains. This ethos underpins Humana’s decision to join CTA, the Consumer Technology Association which hosts CES every January in Las Vegas. If you read this blog, you know one of the fastest-growing “aisles” at the annual conference is digital health. Humana joined up with CTA’s Health and Fitness Technology Division this month. Last year, Humana hired Heather Cox in the new post of Chief Digital Health and Analytics Officer, reporting directly

There are many definitions of the word, “labor.” Oxford Dictionary provides context for the definition as follows: To work, as in especially hard physical work To make great effort (as in, “laboring from dawn to dusk”) To have difficulty in doing something despite working hard. For this third point, Oxford offers these synonyms: “strive, struggle, endeavor, try hard, do one’s best, do all one can, go all out, fight, push, be at pains, put oneself out.” And finally, one fourth contextual point: “A labor of love.” That is indeed the perfect framing this Labor Day week for my welcome to

U.S. employers are tightening their focus on mental and behavioral health, addressing workers’ chronic conditions, emphasizing women’s health, and allocating more resources to digital and telehealth investments, we learn from Optum’s Ten Years of Health and Well-Being at Work: Learning from our past and reimagining the future. Four in five medium, large and jumbo companies expect their spending on health and wellness programs will increase over the next three years. That spending will have a strong focus on behavioral health services: 9 in 10 employers are concerned with the level of access workers have to mental health services. Companies will

There are over 60 million enrollees in Medicare in 2019, and fully one-third are in Medicare Advantage plans. Medicare is adding 10,000 new beneficiaries every day in the U.S. Medicare Advantage enrollment is fast-growing, shown in the first chart where over 22 million people were in MA plans in January 2019. Better understanding this group of people will be critical to helping manage a fast-growing health care bill, and growing burden of chronic disease, for America. To that end, HealthMine conducted a survey among 800 people enrolled in Medicare Advantage plans ag 65 and over with at least one diagnosed

Marc Iskowitz, Executive Editor of MM&M, warmly welcomed me to the Haymarket Media soundproof studio in New York City yesterday. We’d been trying to schedule meeting up to do a live podcast since February, and we finally got our mutual acts together on 6th August 2019. Here’s a link to the 30-minute conversation, where Marc combed through the over 500 endnotes from HealthConsuming‘s appendix to explore the patient as the new health care payor, the Amazon prime-ing of people, and prospects for social determinants of health to bolster medicines “beyond the pill.” https://www.pscp.tv/MMMnews/1eaJbvgovBYJX Thanks for listening — and if you

Of the $401 billion that will flow through retailers for consumer technology products, many of the fastest-emerging categories will play a role as platforms for health and medical care at home and in wearable tech. This is my tea-leaf read from reviewing the projections in the report, U.S. Consumer Technology Sales and Forecasts, July 2019, from the Consumer Technology Association (CTA). [CTA is annual convener of CES, the world’s largest consumer electronics meet-up.] Along with artificial intelligence (AI) and fast 5G networking, the forecast also quantifies growth prospects for smart speakers, home robots, wireless earbuds, smartwatches. and in-vehicle technology —

The health care section of Mary Meeker’s 334-page annual report, Internet Trends 2019, comprises 24 of those pages (270 through 293). These two dozen exhibits detail growing adoption of digital tech in health care, the growth of genomics and EHR adoption, examples of these tools from “A” (Apple) to “Z” (Zocdoc), and on the last page of that chapter, medical spending in the U.S., the highest in raw and per capita numbers versus the rest of the world. But the most important implications for American health care aren’t found in those pages: they’re in other parts of the report addressing

              In the U.S., rural residents’ access to broadband at home continues to lag behind urban and suburban dwellers, the Pew Research Group noted in a May 2019 research note on Americans’ use of technology. The Pew survey explored Americans’ adoption of technology and found that rural dwellers are also less likely to have multiple devices than non-rural consumers. Across the four types of tech studied, it’s smartphones that top the list of penetration in rural areas (at 71%), closely followed by computers (desktop or laptop, with 69% adoption), broadband (at 63%) and tablets

Over the ten years between 2007 and 2017, U.S. consumer spending for education, food and health care substantially grew, crowding out spending for other categories like transportation and housing. Furthermore, income disparity between wealthy Americans and people earning lower-incomes dramatically widened: between 2007-2017, income for high-income earners grew 1,305 percent more than lower-incomes. These two statistics set the kitchen table for spending in and beyond 2019, particularly for younger people living in America, considered in  Deloitte’s report, The consumer is changing, but perhaps not how you think. The authors are part of Deloitte Consulting’s Retail team. The retail spending data

People want to make health with their health care providers, and they want more than care from them: most patients are looking for support with healthy eating, exercise, emotional support, sleep, stress management, social relationships, and financial health. And in case physicians, nurses and pharmacists aren’t sufficiently business with that punch-list for health, two in three U.S. patients would also like to receive help in finding a higher purpose. This is the health consumer’s mass call-out for holistic health, Welltok discovered in a survey conducted among over 1,600 U.S. adults in March 2019. The results are detailed in the assertively 

The supply side of digital health tools and tech is growing at a hockey-stick pace. There are mobile apps and remote health monitors, digital therapeutics and wearable tech from head-to-toe. Today in America, electronic health records (EHRs) are implemented in most physician offices and virtually all hospitals. Chapter 5 of my book, HealthConsuming: From Health Consumer to Health Citizen, details the promise of digital health: wearable, shareable and virtual. Today, we can also call on Alexa to remind us to take medications, play nostalgic music when we are lonely, check our physical activity status with Fitbit, and query WebMD about

What will telemedicine look like in 2030?  imagined Kaveh Safavi, Accenture’s Senior Managing Director and Health of Global Healthcare Practice. Kaveh was brainstorming the future of telehealth a decade from “now,” with three innovators attending #ATA19: Deepthi Bathina of Humana, Matthew Holt of Catalyst Health (and Co-Founder of Health 2.0), and Kim Swafford of Providence St. Joseph. This week convened the ATA annual conference where healthcare industry stakeholders met up to deal with the current telehealth environment and imagine what the future prospects would/could be. As Kaveh invoked the futuristic theme, I couldn’t help thinking about Elroy Jetson, pictured here