My wife gives tips in YouTube videos on Breast Cancer Answers, an awesome website launched this year.

It’s World Cancer Day — and the fourth anniversary of the diagnosis of my wife’s breast cancer recurrence. As readers of this blog know, Tami has tapped the power of the Internet to empower herself and others as they live with advanced-stage cancer and life’s other challenges. Her book, From Incurable to Incredible: Cancer Survivors Who Beat the Odds, continues to gain momentum and her blog, www.miraclesurvivors.com, draws readers from across the globe. 

Today, I want to give a shout-out to a new website called Breast Cancer Answers. Tami was invited to share tips on the site — in part due to her ranking as one of Cision’s Top 10 Most Influential Breast Cancer Bloggers. Todd Hartley of WireBuzz recorded the YouTube video of Tami using Skype. He was great at prepping her for the interviews, taped on a day when Tami was encountering a major scare with her cancer. (That’s another story.)

I am in awe of the way this site pulls together so many elements to empower patients. It includes expert advice from the likes of Dr. Jay K. Harness, a past president of the American Society of Breast Surgeons and Breast Surgery International. E-patients such as my wife offer tips based on their real-life experiences. There are lots of interactive elements. Social media are sprinkled throughout the site, such as links to the LinkedIn profiles of Dr. Harness, Todd Hartley and project manager Amanda Wible, and other relevant resources.

Here’s the writeup about Hartley in the About Us section: ”After Todd’s step-mom developed breast cancer, he called his friend Dr. Jay Harness and together they developed the first social media show. Their goal, provide a free service where women around the world, regardless of economic status, could ask a breast cancer question and the get the answer. Todd Hartley, the president of WireBuzz is a digital marketing innovator, creator of the first video medical encyclopedia on the Internet, who once led Internet marketing projects for seven of the largest national talk shows. We are happy to report that Todd’s amazing step-mom is now in recovery and back to living life on her terms.”

And here’s a summary about the site: “Discover, what every newly diagnosed breast cancer patient should do to improve their chances for survival of breast cancer, how breast cancer diagnosis has advanced, where the cutting edge for the treatment for breast cancer is today and what breast cancer medical terms really mean. Breast Cancer Answers covers a wide variety of information. For example, if you have symptoms for breast cancer, like a lump in breast, pain in breast, or you simply want to know what breast cancer is, please send us your question. It’s our mission to help patients understand breast cancer carcinoma, the most effective breast cancer treatment strategies, the latest breast cancer technological advances and help improve the lives of women living with breast cancer. If you would like to increase breast cancer awareness, please click on the Save Lives link.”

I encourage you to check out Breast Cancer Answers — an example for all of us in healthcare PR, a best practice from which we can learn… and, even more importantly, a website that can help many!

Dr. Natasha Burgert is a full-time pediatrician, blogger, and social media community manager.

For those who may wonder if there is room for doctors in the social media space, you need look no further than Dr. Natasha Burgert of Pediatric Associates in Kansas City.

Dr. Burgert, a private practice pediatrician (full-time patient care), shows by example how social media can deliver tangible results for doctors. She shared her experiences in an excellent webinar this week called “Convince Your Docs to Dive into Social Media.” The webinar came as part of my employer’s membership in the Social Media Health Network.

As Dr. Burgert pointed out, she is not a social media expert, lawyer, public relations or marketing pro, or IT person. She is simply someone who “has a passion for educating families in unique ways, in order to promote and encourage positive heath choices for her Kansas City community.”

She cited convincing stats reported by Susannah Fox of the Pew Internet and American Life Project, such as 80 percent of patients use the Internet and 44 percent talk about health care providers online. One in three — people like my wife — talk about themselves in “participatory medicine.” They are increasingly connecting via mobile devices.

“What does this mean?,” she asked. “Being online matters to our patients… Why is this great news? We can go where our patients are.”

For her, that includes a blog, Twitter, LinkedIn and even Google+!

Dr. Burgert had an “ah-ha” moment during the H1N1 flu outbreak a few years back. Instead of repeatedly answering the same questions coming by patients via phone, why not do something online that they could access at their convenience? Why not save time and reassure patients by answering their questions in a space they already visit? Why not serve as their information source, instead of having them go to Dr. Oz or WebMD?

She overcame the usual fears: What if I do something wrong? What if I’m not good at this? What am I getting myself into? In fact, she listed six considerations that often derail doctors thinking about social media — (1) The How-To: Technically. How do we use these tools?, (2) Legal. Are we just opening ourselves up to get sued? (3) What about HIPAA? How can we keep private things private? (4) Vulnerability. How will this change our doctor/patient relationship? (5) Time. How much time is this going to take? (6) Return on Investment. Is this going to be worth it?

She overcame all — and pointed out that the ROI has been impressive. She gets a patient a week, thanks to her social media efforts. When you factor the national average cost of care per year, that translates into $114,00 per year.

Over time, she has developed authentic relationships with patients. “Social media is bigger than the dollar,” she said. “The value of the online space is deeper.” She found that being online was “SAVING ME TIME!” Patients came to appointment equipped with knowledge. When she’d start to go into an explanation, a patient would cut in and say: “I already read that on your blog.”

Dr. Burgert found that she was making a difference in her community… and even had attracted a worldwide audience. “What I do online positively impacts the health care of children,” she said. “The goal is universal. Change the outcome of health. Healthcare communicators: Be valuable to your patients to see impact. Create a place where doctors want to participate.”

She shared a content formula that works — 70 percent curating/sharing valuable information from evidence-based sources, 20 percent creating your own content, and 10 percent fun (after all it’s “social” media).

“Social media is a tool to share a message,” she said. “YOU will be the trusted source, no matter the author.”

Plus, your evidence-based “good stuff” will move to the top of Google searches and push down the not-so-good medical advice.

Speaking of Google, Dr. Burgert pointed out that docs who do social media have a much more impressive “digital image.” If you Google the name of a doctor who blogs, tweets or otherwise uses social media, you’ll get links to a lot of information related to the doc. If not, you get very little.

Dr. Burgert finished with steps PR and Marketing pros in health care can follow to get physicians in their organizations to move into the social media world. That’s another topic, and I’ve hit my blogging time limit for the week. Hope you found this helpful. I’m excited about the work of Dr. Burgert and others. They are tapping the power of social media to help lots of people.

I consider myself one of the New Age, tree-hugging hippies mentioned in the above book, but I’m also grounded in my upbringing as the son of an electrical lineman and school teacher in small-town Ohio. I believe in the spiritual principles of giving and receiving as I incorporate social media into my personal and professional lives, but I’m also big on the strategic process — research, planning, implementation and evaluation. There’s got to be a method behind the madness!

That’s why I really liked No Bullshit Social Media: The All-Business, No-Hype Guide to Social Media Marketing by Jason Falls and Erik Deckers. Unlike the books written several years back selling people on the value of social media marketing as a concept, this writing gives specific methods and tools for getting the job done. It provides case studies — solid examples you can wrap your mind around.

Falls and Deckers dive deeply into the seven things social media marketing does for your business:

* Enhance branding and awareness
* Protect brand reputation
* Enhance public relations
* Build community
* Enhance customer service
* Facilitate research and development
* Drive leads and sales

This paragraph on the jacket gives a great summary: “Stop hiding from social media — or treating it as if it’s a playground. Start using it strategically. Identify specific, actionable goals. Apply business discipline and proven best practices. Stop fearing risks. Start mitigating them. Measure performance. Get results. You can. This book shows you how.”

OK, now time for my tree-hugger, hippie side. I found this book through a set of circumstances I couldn’t have planned.

A friend gave me a Barnes & Noble gift card for Christmas, so the family went to a bookstore for the first time in a while. (We’re Amazon people now, especially since I got a Fire.) I intended to get a book about innovation or perhaps travel — in advance of a trip planned to Oregon and Washington next summer — but this one caught my eye, as well as another on a similar topic.

I brought both to the cafe area and began to recall that Falls attended my first Cincinnati Social Media breakfast and had blogged about social media at the government social services agency where I used to work. I thought about how I like following Deckers on Twitter. I recalled that both live near Cincinnati — Falls in Louisville and Deckers in Indianapolis… So I bought their book.

Perfect timing. Right when I’m trying to figure out how to improve measurement and evaluation of social media marketing.

Guess I can hug a tree and saw away at strategic communication at the same time!

A wise person once taught me the power of three little words — I don’t know. For some reason, early in my career, I felt embarrassed to admit a lack of knowledge in certain areas. I’d nod my head, as if to indicate I had it down. Or smile, as if to show agreement for a point that had shot straight over my head. Thankfully, those days are long gone.

Lately, for example, I’ve felt a bit perplexed at times while researching paid social media monitoring/reporting/engaging tools. For several years, I’ve relied on free tools such as Google Alerts, Twitter search, Facebook Insights and YouTube Insight to monitor, measure and report social media success. For even longer, I’ve used WebTrends — a paid product — to measure and evaluate web site strategy and tactics.

But I keep reading in books such as The NOW Revolution: 7 Shifts to Make Your Business Faster, Smarter and More Social and No Bullshit Social Media: The All-Business, No-Hype Guide to Social Media Marketing and others about these cool things you can do with paid tools such as Radian6 and Sysomos — measuring “share of voice,” identifying “key influencers,” calculating and reporting Return on Investment (ROI), doing competitive analysis… Lots of stuff that could create lots of value for your organization and give you great information to assist with your decision-making.

I also hear from my cohorts in health care social media how they employ these tools to more effectively use social media to improve public relations, marketing, customer service… So I started checking with vendors, who were very willing to give demos and explain how their products work. That’s where some of my “I don’t knows” started.

Q: How would you like to use this? A: I don’t know. I want to see what it’s capable of doing. At times, I feel a bit stupid, really. But that’s OK.

Here are some thoughts from Facebook friends:

* Jason Lee Overbey You can do most of those things for free on your own. It truly depends on what you current campaign is trying to do. If you have a big project or brand/message release, I say you need it. But everyone has an opinion on this.

* Jackie Danicki I think it depends on the scope of your project and how important results tracking is to you.

* Allison Brinkman I agree w/ Jackie, though having used Sysomos I can tell you there are benefits however there was more of a learning curve associated with it than other PR related sites I’ve used. Thankfully, they have great customer service!

* Susan Gosselin Mike the free tools are really incomplete. They miss a lot and it’s a pain to aggregate the results. An organization your size should at least have the lite version of Radian 6

* Aldon Hynes We don’t use them… We’ve talked about it, but so far, the cost just doesn’t seem justified. Maybe if we were bigger we might consider them a little more seriously.

* Howard Luks What are you looking to do. Very costly … would suggest you talk to the folks at @brightwhistle or perhaps demandforce.

Some of the social media peeps in our system are using, or are about to purchase, paid tools. Perhaps I’ll tap into their efforts. Maybe I’ll help them, and others, move into more advanced areas. Time will tell.

Meantime, I asked Jason Falls, co-author of the No BS book mentioned above, in a recent TweetChat which he recommends. He gave this list: @radian6 @sysomos@ubervu and @visible. SMMS? @Expion @Spredfast@argylesocial. I’m evaluating the first two very closely.

So the quest goes on. I’d appreciate your insights in the comments section.

It was a thrill for me to meet E-Patient Dave DeBronkart at the Health Care Social Media Summit at the Mayo Clinic

2011 will go down as an amazing year in my book — one in which I made the transition into health care social media (and media relations, web content, internal communications… in the health care world). I started a job as media manager at Catholic Health Partners, the largest health system in Ohio and one of the largest non-profit systems in the country, on Jan. 10. 

I have no regrets about leaving a satisfying career in government public relations after almost 17 years to enter health care at a time of tremendous transformation. It reminds me of when I started in government social services — and the country was in the midst of welfare reform. I feel extremely fortunate to be involved in such important events.

Here are some highlights from 2011, a year that I believe has set the stage for an even more incredible 2012:

* Attending the Health Care Social Media Summit at the Mayo Clinic in Rochester, Minn., in October. I’m still in awe of the experience of connecting with health care social media leaders from across the country (as well as several other nations). I choke up when I tell people about meeting people such as E-Patient Dave DeBronkart, who are using social media to save lives. I made connections with dozens of PR and marketing pros from hospitals and health systems who are passionate about making a difference for the patients and families we serve. I also connected with doctors and nurses who have embraced social media as a way to improve the health of their communities. We continue to connect via Twitter chats, Facebook. LinkedIn…

* Leading the Catholic Health Partners Social Media Champions!, a group of social media practitioners from across the system. We confer regularly via online forums and phone, sharing best practices and lessons learned. We met in August for a Social Media Summit, featuring Krista Neher, author of the Social Media Field Guide and CEO of Boot Camp Digital. It was awesome hearing from Krista, who took a lot of time preparing for this health care audience. I sincerely appreciate the fine work she did.

* Participating in media training offered by Empower MediaMarketing. It was probably one of the most challenging experiences of my PR career, guiding a selection process that led to us choosing Empower over a number of firms that provide excellent media training. But Empower didn’t disappoint. Highly regarded PR pros Kevin Dugan, Ashley Walters and Claire Guappone packed a lot into a tight time frame. They also were flexible and catered to our needs.

* Working with an amazing team of seasoned professionals at Catholic Health Partners. (In all reality, this is No. 1 by far.) Greg Smith, my manager, has decades of health care experience and is a great all-around person. Debbie Copeland-Bloom is the consummate PR professional, also with an extensive health care background. Kathi McQuade knows video production like nobody else I’ve encountered. Carrie Allison is a talented PR pro with lots of years in health care. I am so blessed to be a part of this team. They are a joy to be around. I learn something from them every day.

* Supporting my wife’s blog and book. In case you didn’t know, Tami Boehmer is author of From Incurable to Incredible: Cancer Survivors Who Beat the Odds and the highly acclaimed www.miraclesurvivors.com blog. Despite battling Stage IV breast cancer, she pushes on and inspires and informs many. Here is her year in review.

* Reading lots of good books and getting some new gadgets. This seems trivial, compared to the above. But I read some really good books this year. You can read my reports elsewhere on this blog or see my reading list on my LinkedIn profile. Through the power of social media such as this blog and Twitter, I connected with most of them individually. As for the gadgets, I got a tablet (Kindle Fire) and a new Android phone. My daughter delights in my geekness!

* Attending lots of great events offered by Cincinnati PRSA, Cincinnati Social Media, New Media Cincinnati and the Cincinnati American Marketing Association. They all put on very good programs and gave us a place to connect with others who are passionate about our profession. I encourage you to check out their websites or LinkedIn pages.

* Returning to Twitter full-force after a detour into Google+ and health care blogland. There are lots and lots of health care folks (PR, marketing, clinicians, techies…) in areas such as #mccsm and #hcsm. I have learned so much from them — and hopefully have shared links and tidbits that have helped them. (Find me on Twitter at @MikeBoehmer57).

There are just some thoughts that come to mind as I sit here on a PTO day, reflecting after a walk around the neighborhood. I’m really excited about the year ahead. I think we can all make a positive difference in the lives of others through the power of social media. Great potential lies ahead!

Speaker Heather Whaling with Ashley Walters and Andrew Shipp of Cincinnati PRSA

It was appropriate that we heard Heather Whaling of Columbus-based Geben Communication talk about how her team cooked up a successful launch for Zaarly, a new online marketplace. Cincinnati Cooks, an entity of the Freestore Foodbank,  operates in the area next to the conference room where Whaling (@prtini) spoke to a combined Cincinnati PRSA/Cincinnati Social Media gathering.

The talk was particularly relevant for me  because I had been stewing up some new/old media during the week to attract quality candidates for job openings at Catholic Health Partners’ new Corporate Physician Business Center (CPBC) in Blue Ash, Ohio. A combination of social and traditional media strategies and tactics allowed my employer to attract hundreds of applicants for customer service, claim followup and billing jobs — within five days. (More on that in a later post.)

Here are some of the things Whaling said in her Zaarly case study that got me tweeting away on my new Droid:

* Start with solid messaging and story telling. Tap your online and offline networks to build momentum.

* Capitalize on trends while pitching stories to the media and bloggers. Use tools such as PitchEngine, closed Facebook groups, Twitter and blogs. Connect with high-profile supporters.

* Embargo press announcements. Not all media allow embargoes, but many do. Do guest posts on blogs. Provide infographics. Plant seeds with reporters — tell them you’ve got a story coming.

* Go beyond trade press and seek coverage in general business media to build credibility. Seek local coverage to build interest.

* Compile and monitor a list of reporters on Twitter. They often seek story ideas on Twitter.

* Facebook ads and promoted tweets can be effective.

* Go grassroots with community events. Start-up crawls, sort of like pub crawls, helped Zaarly.

* Handle crisis communication. Seek awards. Line up speaking engagements. Do e-mail marketing. They all helped.

* For the most part, see bloggers as part of the media. However, they’re responsible to their communities. Tradition journalists report to editors, (while targeting readers and viewers).

* Customize pitches to bloggers. Take into consideration factors such as the fact that mommy bloggers often work after the kids have been put to bed. Offer to do a guest blog when you know a blogger is going on vacation.

* Monitor social media with tools such as HootSuite or Radian6. Look for trends, pitch opportunities.

I can testify that many of these strategies and tactics were on my work menu this week, too. Hope my notes did Whaling’s talk justice. I was hungry for what she had to say and happily gobbled it up.

Just finished Steve Jobs official  biography by Walter Isaacson. I’m really glad I invested the time into learning more about this amazing individual — someone who has made a huge impact on computing, music, movies…  Fascinating stuff.

It was interesting to read how Jobs approached public relations. He threw out the playbook in certain areas — and followed closely in others.

For example, after hearing different opinions from PR veterans on how to handle widely reported problems with a new version of the iPhone, he decided against those who wanted him to apologize. He instead listened to a PR pro who counseled him to be factual — share data about industry cell phone standards, showing all phones have similar issues — and not sound a contrite tone. They felt an apologetic Jobs wouldn’t sound genuine. So he offered no apology, but did offer refunds for those who wanted to turn in their phones. The return rate ended up below industry standards, and the phone went on to be a top seller.

On the other hand, he followed a more traditional path — getting front-page coverage in top publications by brokering exclusive interviews with trusted journalists — when doing product launches. He knew how the media worked, and built on mutually beneficial relationships to achieve his objectives.

The bottom line for me, was the confirmation that PR is both art and science. There’s no cookie cutter approach. You’ve got to consider the individuals involved, the culture of the organization, the product/service, the market… Many factors.

Would be curious of what you thought about the book, from a PR or marketing angle.

Within hours of getting my Kindle Fire (on the first day of availability!), I had downloaded an excellent new book by David Meerman Scott called Newsjacking: How to Inject Your Ideas Into a Breaking News Story and Generate Tons of Media Coverage. I read it in two days.

Scott offered me a peak into the playbook of PR pros who have capitalized on real-time communication to score big media coverage. It got my mind going about the tremendous opportunity for us to shine the media spotlight on our clients, their products and services.

“In a 27/7/365, second-by-second news environment, savvy operators realize there are new ways to generate media attention,” Scott writes. “…Newsjacking favors quick, observant, and skilled communicators.”

He shared example after example of PR pros who jumped into the news cycle early and came  up with angles that got their clients widespread coverage. For example, a high-end sunglasses company got coverage valued at $41 million by giving glasses to Chilean miners as they emerged from 69 days being trapped in a mine. In the political world, Rick Perry newsjacked the Iowa Straw Poll by announcing his candidacy the day of the poll. Bloggers wrote about controversial topics as stories were breaking and put a link to their posts in the comments sections of online articles — and found their comments inserted into followup coverage…

Scott spelled out this technique:

“(1) When something breaks in the news, journalists the world over scramble to put out a news flash within minutes. For local stories and industry-specific news, the same process happens but on a much smaller scale.

“(2) Next, journalists have to update the story, fleshing it out with details and context, so they scour the web for anything that might give them a second paragraph. They turn to Google and Twitter to see who might have something interesting to add. Often they are near-desperate and willing to snap at whatever relevant bait you can provide.

“(3) Your job is to instantly spot an angle and get it online — via your blog, Twitter, or media alert — as fast as you can. You need to be clever and quick. You need to operate in real time.”

Scott gives tips for monitoring and promptly responding to coverage. He shares how others have done this with great results.

Fire up your electronic reader and check it out!

Last month, Jay Baer — co-author of The NOW Revolution — 7 Shifts to Make Your Business Faster, Smarter and More Social — shared some great insights at a jam-packed coffee house. Cincinnati Social Media sponsored the event, which attracted a number of PR, marketing, IT and social media enthusiasts. 

Fortunately, I had read his book before the talk — and liked it. (And so had the person next to me on my flight back from the Health Care Social Media Summit in October, at the direction of her boss, who owns an East Coast PR shop!) Jay underscored all of the key points in the book in an engaging talk given from the top of the steps overlooking the group. Here’s his PowerPoint, which he wasn’t able to use due to technical issues.

Here are some highlights:

* We are living in a real-time world, where every customer is a reporter. If you have a negative experience now, you let the world know on Fourquare, Yelp, Facebook, Twitter, Google+, blogs… Complaint letters are quaint practices of the past.

* Companies have got to become faster, smarter and more social. You don’t have much time to verify and contemplate. You’ve got to be quick on your feet.

*  Organizations need to empower their employees to make the right decisions. That’s about culture, not about training.

* Businesses must hire for passion, train for skills.

* If your company sucks, Twitter is not your problem. Social media does not create negativity. It puts a magnifying glass on it.

* Social media is measurable. The last quarter of the book is about metrics. There is no linear relationship between Facebook Likes and business success. 84% of Facebook followers are current customers. As a general rule, you want to measure behaviors.

* How do we as companies get more social? Thank You and I’m Sorry. If you do that, you’ll be in really good shape. 70 % of customer complaints on social media go unanswered. Name the people who tweet on behalf of companies.

* Sales, marketing, customer relations and operations know what is going on. It never gets to PR and Marketing. Use Yammer and e-mail to harvest.

* In social media, you earn the right to promote by being helpful first. The more you sell, the less you sell, in social media.

* Capitalize on real-time opportunities. This requires more people in your organization in social media. Decentralization. It’s OK that every employee is potentially in marketing. The people will make you successful, not your official Facebook page.

* Every company is going to have to be social. Customers will demand that you interact with them in new ways. They’ve got to be faster, smarter and more social to win.

* We will see much more data segmentation. What do our best customers say about us? Etc. Drill down.

I highly recommend that you read the book for more details. Exciting stuff, as we move ahead in this new world of real-time communication.

Tucked near the end of many great marketing and PR sessions at the Health Care Social Media Summit at the Mayo Clinic last month was this discussion: How to Avoid Legal Issues in Social Media with David Harlow of The Harlow Group and Dan Goldman  and Randy Schwartz from Mayo Clinic.

OK, it might not have sounded as interesting as some of the other sessions. But the trio presented a  thorough and easy-to-understand 60 minutes of helpful info.

They first assured us that you can use social media effectively and stay on the right side of the law. In fact, one  in five institutions are using social media.

New rules are nudging the health care industry to get more social. Accountable Care Organizations (ACOs), a key component of the Patient Protection and Affordable Care Act,  center on patient engagement. Healthcare organizations must be where people live.  They must move existing norms into the online environment. (AMA Policy, Nov. 15, 2010, does this.)  However, the open-book ethic of social media runs up against privacy concerns of healthcare, so the speakers said to adopt a risk management mindset to understand risk and avoid liability. They noted that a patient can release her or his own health info online under HIPAA, but you can’t release someone else’s without permission.

Here are some notes culled from my Twitter stream:

Harlow: You can limit liability by clearly defining roles and responsibilities in social media policies and procedures. Good to scrub your Facebook page and take down inappropriate content every day. However much you may want to talk about individual cases, be super careful even if think have de-identified. Important for healthcare providers to curate to provide good content for patients.

Schwartz: Leadership buy-in important. Share successes and failures. Address IT and Security concerns. Share your guidelines — staff meetings, manager/supervisor meetings, department meetings, newsletters, brown bags… Discuss recurring issues, other guidelines. Make adjustments. Example: Not want providers friending patients. At Mayo, updated policy last week. First was two years ago. Involve HR, Legal, Social Media, Public Affairs

Goldman: There are some risks here, but you can manage those risks. There is risk in all you do. Challenges of social media: reach, blurring of professional/personal lives. Another challenge of social media — a new generation of lifecasters. Expectation of sharing all life details, work. Ethical challenges — Do you really want to be friending your patients? Supervisor? Employees? Control challenges — You may have to tolerate some things you don’t like, especially challenging with HIPAA. Prohibit employees from speaking anonymously or pseudonymously about where they work (FTC endorsement/testimonial), NLRB — Employees have a right to post about working conditions or wages to, or on behalf of, co-workers. Identify who can speak on behalf of your company. Have social media policy training part of new employee orientation, Social media policy best practices — No one-size-fits all. Is a reflection of corporate culture as law.

Hope you found this helpful. I did. Feel free to share any thoughts, or additions.