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Moving Hospital EHR to the Cloud

I’ve long been interested to see how hospitals were going to handle the shift to “the cloud.” Obviously, most hospitals have made a big infrastructure investment in huge data centers and so I’ve always known that the shift to the cloud would be slow. However, it also seemed like it was inevitable.

I was interested to hear Jason Mendenhall talk in our Healthcare Data Center Google Plus hangout about healthcare entities moving their technology infratructure into their data center. Plus, I pair that with the smaller rural hospital CIO I met who balked at the idea of having a data center or really even having any sys admin people on staff.

Plus, I’m reminded of this quote I heard Dr. Andy Litt tell me about when hospitals will start using Dell to host their Epic EHR:

The opportunity to host an Epic or other EHR is in first install, not for existing ones that have invested in a data center already. -Andy Litt, MD, Dell

I can’t imagine that many institutions really want to move their Epic EHR hosted locally into the cloud. That just doesn’t happen. At least it doesn’t right now. Will we see this change?

I think the answer to that is that we will see it change. There’s a really good argument to make that hospitals shouldn’t be building data centers and that there’s tremendous value to using an outside provider. Plus, many of these “data center” companies are becoming more than just a set of rails, power, and cooling. They are now working with a variety of cloud providers that can provide you more than just a place to put your own servers.

I’ll be interested to see how this plays out, but I think we’ll see fewer and fewer hospital data centers. The outside options and connectivity to those outside data centers is so good that there’s going to be no need to do it on your own.

March 24, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Epic to Epic Conversion

Gabriel Perna has a great article on Healthcare Informatics discussing an EHR conversion that I hadn’t considered. What happens when a hospital system acquires another hospital system and they both use the Epic EHR? Here’s the challenge as described in the article:

“As we got into it, we realized Epic had done [a conversion from] IC Chart [InteGreat from Med3000] before, they had done Cerner-to-Epic conversions, they had done McKesson-to-Epic conversions. They had done those before, and they do them well. They hadn’t done Epic-to-Epic before. That was the area where they were least experienced in. It was a lot more work to do,” says [Bob] DeGrand, who assumed the position of CIO [of Froedtert Health] in January of 2009, a few months after the West Bend affiliation became official.

As we continue on our path of hospital system consolidation, this is going to become more and more of an issue. As those familiar with Epic know, every Epic installation is unique. I was recently told by someone that even within the all Epic Kaiser there are multiple Epic installations and they have a challenge communicating with each other. Now think about what that means if you’re trying to merged two different Epic installations.

The article also points out that one of the biggest challenges in a merge like this is overlapping patients and ensuring that you merge them properly. Patient identity is a big challenge in any hospital system, but even more important when you’re looking to merge two large hospital systems that have relatively close proximity with similar patient populations.

I’d be interested to hear from other people who might have gone through an Epic to Epic conversion. What challenges did you face? Would you have rather had a Cerner to Epic conversion?

December 30, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

What Can Go Wrong With An Epic Implementation

With Epic owning the lion’s share of new EMR implementations — it has as many in progress or planned as all other major vendors combined — it’s good to stop and look at just what can go wrong with an Epic implementation.

After all, while Epic installations are a fact of life, all of the news they generate isn’t good. In fact, a growing number of stories of botched Epic installs and institutional fallout are beginning to mount.

In an effort to do learn more about Epic’s strengths and weaknesses, researchers at The Advisory Board Company interviewed some of Epic’s most experienced U.S. hospital customers, as well as some of the busiest Epic implementation consultants, writes senior research director Doug Thompson.

As Thompson points out, the problems Advisory Board identified could impact any big EMR install, but with Epic in the lead, it doesn’t hurt to focus on its products specifically.  (By the way, according to the Advisory Board, there were 194 Epic installs in process or contracted for 2012 and 2013; the closest competitor, MEDITECH, had 59 and Cerner came in at 55.)

So what’s behind the stumbling? Thompson names several limitations to Epic’s own approach to implementation, including the following:

* Its young implementation staffers may be enthusiastic, but some lack operational experience in hospitals or medical practices, which means they rely heavily on Epic’s standard methods and tools –and that may not be adequate for some situations.

* Though Epic’s recommended implementation staffing numbers are higher than that of most other EMR vendors, their estimate nonetheless falls short often by 20 percent to 30 percent of the need.

*Epic’s “foundation” (model) installation plan limits customization or extensive configuration until after the EMR has gone live, which can lead to less physician buy-in and end-user cooperation.

To address these concerns, Thompson offers fourteen techniques to help hospitals get the value they want.  Some of my favorites include:

Begin with the end in mind: Make sure your facility has specific, measurable benefits they hope to achieve with your Epic implementation, and prepare to measure and manage progress in that direction.

Governance: Make sure you assign appropriate roles and responsibilities in managing your Epic rollout and ongoing use. While IT will serve as the linchpin of the project, of course, it’s critical to make sure the appropriate operations leaders have a clear sense of how Epic can and should affect their areas of responsibility.

Get outside input on project staffing: While Epic is upfront about the need for extensive staffing in its implementation, as noted its estimates still come in rather low. It’s a good idea to get in objective outside estimate as to how big the project staff really needs to be.

For more information, I highly recommend you read the full Advisory Board brief. But in short, as  the report concludes, it seems that relying too much on Epic’s approach, staff and tools can lead to problems. Surprised?

December 9, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies.

Has Epic Grown Too Big, Too Fast?

We’ve written a lot of posts over the years about some of the challenges that Epic has faced as it’s grown its EHR business. In fact, Anne Zieger’s post yesterday about a Hospital Credit Rating Lowered due to their Epic Project is one example. However, I was really struck by this reader submitted article on HIStalk.

The article is written by a “Long-Time Epic Customer”. You don’t get the sense that this customer is bitter or has any real dog in the fight. In fact, if anything this customer seems to have a love for Epic and they want Epic to win the EHR battle. However, they’re concerned by the changes that they’ve seen in Epic as its grown. His a paragraph from the article:

We installed Epic years ago, but have seen a vast difference between our prior experience and a recent rollout of newer products. The method where time was taken to help us build our own system has been replaced by a rushed, prefab Model system installed by staff where even the advisers and escalation points at Epic have little knowledge of their applications. Epic has always had newer people, but it was much more common to have advisers during the install who did have experience to watch for pitfalls.

The writer then goes on to describe how Epic seems to be investing in the wrong things. “We’re getting answers, solutions, fixes, and reports slower than ever.”

I think the reason many of things really struck a chord with me is that they’re matching up with many of the things I’ve seen and heard. Based on some real anecdotal things I’ve heard I won’t be surprised if Judy decides to get out of the day to day work at Epic sometime soon. We’ll see how it plays out, but an Epic without Judy at the helm will be quite different.

November 8, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Lessons Learned from Sutter’s EHR Implementation Challenges

One of our more popular recent posts was published on EMR and HIPAA and was titled, “Adding Insult To Injury, Sutter’s Epic EMR Crashes For A Day.” When the post was shared on LinkedIn, it prompted a really insightful discussion on EMR training and Sutter’s approach to EHR implementation. A few of the comments were so good that I wanted to share them for more people to read and learn.

The first comment is from Scott Kennedy, an Epic Stork Trainer:

I was an Epic training consultant on the E. Bay Sutter EHR implementation and I can tell you first hand that Sutter Admin, and the Nurses are at odds. This unfortunate relationship made it difficult to train the staff. Epic itself is not to blame. Those who are using the Epic EHR are not as trained as they should be.

Sutter used an “in house” training team rather than bringing on a full consulting team with much more experience in training and educating end users. The “in house’ trainers included some nurses, RTs, and the like as well as a host of newly graduated college students who had less to no experience with conducting a formal training presentation on a multidisciplinary EHR.

Hiring and training “in house” is a great addition to bringing on an experienced, skilled, professional team of Epic credentialed trainers, like myself who do this as a profession all over the country.

We were also directed by Sutter EHR implementation Administration to “facilitate” rather than “train.” “Facilitate included passing out exercise booklets to the clinical end users and having them work on their own, rather than conducing concise, lectured, guided practice prior to each exercise. Hands on exercises are an essential part of the training, but should not be the complete focus of training.

The learner is left on their own to figure out the system, which is counter productive. That approach only builds anxiety, confusion and eventual resentment for the system and the administration who have chosen the EHR they are fumbling through.

I empathize with the clinical end users. There training experience could have been much more instrumental in getting them off on the right foot with their new EHR, had the training approach been more adult learning theory based rather than self-learning based.

I only wish I could come back to Sutter and retrain the nurses and other clinicians from the proven, consistent, progressive, successful adult learning approach, which enables and empowers the end user to grasp, comprehend and assimilate the EHR system into their daily shift work flow. That is not to say that there are not implementation bumps and optimization needs that have to be addressed, but they are far less impactful when the clinician is properly trained.

I am so sorry Sutter nurses and staff that I trained, but I was firmly told to “facilitate” your learning rather than “train” you. I tried to implement adult learning methodology, but was told by your EHR administration to “stop talking and let them do it on their own.”

Epic EHR is not to blame here. Epic is a sound, EHR system that is serving the needs of millions of patients and their care providers around the world, without incidents such as those being experienced at Sutter.

There is a right way to implement and train and a wrong way. Sorry Sutter EHR implementation administration, but “I told you so!”

I asked Scott Kennedy if he’d thought of leaving the project since it was being done the wrong way and he offered the following response:

@ John, yes I did come very close to leaving the project. As a matter of fact after I was verbally “scolded” for lecturing to much I phoned my recruiter and asked to be placed on another project, but then, after careful thought, I decided to stay on the project and attempt to train and support as much as I could. But it seems that my individual efforts were not enough to counter the original training “facilitation” focus.

To add insult to injury those of us trainers who were there for the Sutter E. Bay implementation were told not to return for the W. Bay implementation. The EHR administration wanted an entirely new outside consulting team.

I got a fellow colleague on the project, hoping that the E. Bay administration would have learned from and the current W. Bay implementation would be better. The training colleague I got on the W. Bay project shared with me that it was worse than the E. Bay implementation. They kept the experienced Epic trainers as support and utilized them as little as possible for actual front end training. So sad, really.

The EHR administration at Sutter tried to cut every financial corner possible and lost sight of the long run implications of improper front end training. Now they are paying the price.

Michael A. P., an EMR consultant offered this insight as well:

I’ve also had the misfortune of working with Sutter for a (thankfully) brief period. In their long history of attempting to implement Epic, they could be counted on to make the wrong decision in almost every situation. Their internal politics trump the advice they receive from vendors and highly experienced consultants. The result is an implementation that serves neither the patient or the users best interests.

Then, Ryan Thousand, an IT Architect at Athens Regional Medical Center, offered a broader view of what’s happening in health IT and EHR:

I hate to say it but most large healthcare organizations are getting like this as well…. There are WAY too many layers in these organizations and sometimes to get work done can mean 4 weeks of executive meetings and in the end no decision or 100% opposite of the recommended direction given. That being said, with the rapid change in healthcare and the mergers and acquisitions occurring right now, I fear the worries for Healthcare in general over the next couple of years. We cannot continue to try to meet mandates the government is making while still ensuring 100% utmost patient care; and in the end that is really all I care about.. the patient in the bed who is BENEFITING from my implementation. Change is always tough but done the right way with the right people (as you all stated above was not done correctly) we will continue to see great things happen on the HIT side. But unless Epic/Cerner all the big players in the markets as well as the local clinician and providers work together and decide the best outcomes for our patients, we will all one day suffer, as we will all one day be patients.

In all the years I’ve been writing about EMR and EHR, the biggest problem with most EMR implementations is lack of EHR training or poor EHR training. It’s really amazing the impact quality EHR training can have on an implementation. However, many organizations use that as a way to save money. If they could only see the long term costs of that choice.

September 25, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Stanford Uses Epic Feature To Conduct Web Visits

Stanford Hospital & Clinics has rolled out a new primary care service, powered by a feature available within its Epic EMR, offering medical visits via web video.

The new service allows patients to schedule video visits via the hospital website, using a scheduling application available on the site, InformationWeek reports. At the scheduled time, patient and doctor meet together in a web-based video conference.

The service, which Stanford dubs “eCare,” takes advantage of Epic’s software for video consultations. The video consult is integrated into the patient’s Epic medical record automatically. eCare also integrates third–party identity verification services in an effort to make sure the patient is who they say they are.

According to Stanford CIO Pravene Nath, M.D., who spoke with InformationWeek, video visits are medically appropriate for a range of noncritical visits and follow-ups. For example, one of the service’s first patients had an eye condition; the doctor was able to help simply by looking into the camera at the patient’s eyes. Another example of condition appropriate for web conferencing is treatment of a skin rash, Nath said.

“These are cases where a quick visual is all that is needed, followed by a quick interaction of the patient talking with the doctor,” Nath told InformationWeek.

Stanford is offering eCare first to employees of self insured firms who contract with the hospital. That way, neither the employer nor Stanford has to worry about whether a managed-care company will reimburse the doctors for the video visits. But Stanford’s intent is to make video consults available to everyone, InformationWeek says.

Stanford’s care program is just one of several virtual healthcare services the hospital’s developing, IW reports. The organization is also looking into secure messaging between doctors and patients and a service which involves submitting a still photo of them conducting a live videoconference, the magazine says.

If Stanford can make the integrated EMR and web visits work, it may be breaking new ground. A few months ago, I wrote a piece noting that many telemedicine providers are very reluctant to integrate with EMRs, given that the need for interoperability with so many systems could choke their development efforts.

While enabling telemedicine isn’t going to offer Epic any huge advantage it doesn’t have already, it does offer some intriguing possibilities. If thought leaders like Stanford make a success of web visits, using Epic technology, it might force other competitors into the telemedicine arena as well. It will be interesting to see how influential Stanford’s experiment turns out to be.

September 20, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies.

Judy Faulkner Interoperability Chart

Farzad Mostashari shared the following tweet which includes a picture of the growth in standards-based exchange per Judy Faulkner.

Here’s a blown up version of the chart (click on the image for an even larger version):
Epic Data Sharing Chart

As Farzad notes in the tweet, the patient records exchanged per month is now up to 1.25 million. It’s also worth noting that the red bar in the chart is exchange of records from Epic to Epic. The Green bar in the charts is from Epic to Non-Epic. I hope that green bar continues to grow since as the chart displays, that’s a definite shift in strategy for Epic. Let’s hope this shift continues until the data in healthcare is available where it’s needed when it’s needed.

September 18, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

It’s not US (EHR Vendor), it’s YOU (Hospital)

After reading Anne Zieger’s post about an Epic investment that promoted a CIOs departure, I engaged with @LukeDeanNif on Twitter where we discussed the challenge a CIO faces with any large EHR purchase.

Luke keenly observed that a CIO departure could happen with any EMR, not just Epic. Although, I think there’s a bigger challenge when it comes to Epic. Sure, we like to say that “No one ever gets fired for choosing Epic” (a takeoff from the IBM quote). However, that’s not always the case either. In fact, Epic has the perception of successful installs at big name institutions. If your hospitals runs into issues with your EMR implementation, many will question your organization and not Epic for why it’s failed.

You can already hear Epic people saying “We’ve successfully implemented this in XXXX organizations. This must be a problem with your organization.” That’s right, it couldn’t possibly be the EHR vendors fault. At least that’s the story that will be told. Given this, I guess you could say that in some ways it’s more risky for a hospital CIO to choose Epic over other hospital EHR vendors.

One thing Luke and I agreed on is that it’s really easy for an EHR vendor to point the finger at the hospital organization instead of taking responsibility for any issues that may occur. I’m not saying that hospitals are never to blame. In fact, hospitals can often take plenty of the blame for network issues, commitment issues, physician issues, or just plan organizational resistance to change. In fact, I’d say that almost every EHR implementation has a few of these things. The problem I have is that EHR vendors far too often point the finger at the hospital when there’s a problem and they forget about the 3 fingers pointing back at themselves.

July 18, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Hospital EHR Subsidies

In response to Anne’s post on Senator’s questioning the meaningful use EHR incentive money, Gary Colvin emailed me the following comment:

I would argue for the case where the only reason some providers are in the M.U. game is due to their Hospital subsidies. Instead of paying approx $1,200/ month to lease out their Epic E.M.R., they are enjoying its benefits for under $300 per month. What happens when the subsidy goes away for good? I think you would be hard pressed to see a four doc family practice paying $4,800 / month to enjoy that system — so, when the subsidy goes away (maybe it will be extended to 2016?) it will surely have an impact on who stays in the game.

I did question Gary on his algebra of the cost of Epic per doctor and he said that he got numbers from his hospital which is a public hospital where the pricing has to be transparent. It actually makes me wonder what other EHR pricing data could be uncovered from various publicly available sources. I wonder if data geek Fred Trotter has ever worked on this.

Regardless, I think the EHR subsidies is an important topic. I’ve known many doctors that are afraid of the hospital EHR subsidy because of the lock in it creates with the hospital. However, in many areas the lock in is already there so it doesn’t matter.

I wonder if hospitals are worried what it will mean for them once the EHR subsidies are no longer available.

May 17, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Judy Calls Epic “Most Open System I Know”

After Zina Moukheiber from Forbes was declined an interview with Judy Faulkner, CEO of Epic, last year Judy decided to talk to Zina about Epic in this article “An Interview With The Most Powerful Woman In Health Care.” Zina does a nice job on the interview and raises some of the questions many people have about Epic. It’s worth a read if you like to follow the hospital EHR world.

Many people are likely going to latch on to Zina calling Judy Faulkner the “most powerful woman in health care.” I don’t think that’s really up for discussion. Judy is the most powerful woman in healthcare and so I’m really glad that Judy is starting to join the discussion about Epic and healthcare. She has an important voice in the discussion and we need her participation. Although, I’m sure she’ll hate being called a billionaire in the article. The reality is we don’t know how much Judy’s really worth until we know how much Epic is worth and I’m not sure Epic plans to go public anytime soon.

Semantics aside, the most important part of the interview was the discussion of Epic being a closed system to which Judy frankly replied, “We are the most open system I know because we’re built as a database management system, and database management systems need to allow their users to mold it to what they need.” I think she really believes that Epic is an open system and quite frankly there aren’t that many in healthcare she can look to that are more open. Sure, a number of EHR vendors have worked to be more open, but even they aren’t as open as many other non health IT software systems. Maybe Judy hasn’t looked at the APIs outside of healthcare.

The real disconnect I had when reading Judy’s thoughts on being open is her lack of understanding of how a truly open API works. In a well implemented API, you can allow any and all programmers to be able to build applications on top of your software without those programmers needing to read your code and study your internal software. I’m not saying you don’t want and need to have an application and verification process for those people who want to tap into your API. This can be part of the process, but a well implemented and documented API can be open to everyone interested in building on top of your software. The value Epic would receive from so many companies iterating and extending the core Epic functionality would be amazing.

The other facet of Epic openness discussed in the article was around interoperability. Judy offered these comments on Epic’s ability to share patient records:

As of March 2013, our customers exchanged 760,000 patient records per month; about one-third were with non-Epic systems. Based on the historical trajectory, we expect that we’re closer to exchanging approximately one million records per month. We are currently exchanging data with Allscripts, Cerner, Department of Defense, Veteran Affairs Administration, Social Security Administration, eHealth Exchange (formerly Nationwide Health Information Network), Greenway, MEDITECH, NextGen and others. We expect to be exchanging data soon with eClinicalWorks, General Electric, Surescripts, and others.

This sounds good on face, but lets consider how many records Epic is sharing. Let’s use the round number of 1 million patient records shared per month. The article says that Epic has about half of the US population on Epic, or about 150 million patients. That means that about 0.67% of Epic’s patient records are being shared.

I’m happy to applaud Epic for sharing 1 million records a month with so many different vendors. My only complaint is that they could do so much more. For example, if you can share records between Epic and Cerner now, does that work for all Epic hospitals or do you have to do the new integration with every hospital that says they want to share records with Cerner? If it was a turn key way to integrate with Cerner, I’m quite sure that instead of 1% of Epic’s patient records being shared we’d see tens of millions of patient records flowing where they needed to go.

Many might remember my surprise breakfast with Judy Faulkner at the CHIME Forum. From my personal experience, Judy is not the black widow that I’ve heard many portray her to be. In fact, I found her incredibly thoughtful, caring, and really interested in quality patient care. That’s why I hope Judy will see that she’s sitting on an opportunity to do so much more than she’s doing now. Although, it will take a shift in her understanding of what it means to be an open EHR. Right now it seems her mostly unfounded fears won’t let her see the possibilities.

May 16, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.