December 30, 2008

Electronic Health Records: The Next Step in Health Care Management

Although electronic health records have been used for the past few years, it garnered attention during the 2008 U.S. presidential race with the discussion focused on the area of health care reform. The New York Times published an article, "City to Pay Doctors to Contribute to Database," on December 29, 2008 about how doctors in New York City is working with 1,000 primary-care physicians in using a $60 million city health department project aimed to create an electronic record-keeping system. (Photo courtesy of Brian Palmer for The New York Times.)

"Experts say it is the most ambitious government effort nationwide to harness electronic data for public-health goals like monitoring disease frequency, cancer screening and substance abuse....The system, custom-designed for New York by a Massachusetts company, eClinicalWorks, would cost a typical doctor’s office $45,000 to implement, but city subsidies reduce that to $24,000 for practices with at least 10 percent of their patients on Medicaid or uninsured; those in neighborhoods with the highest poverty rate pay $10,000. The health department is also putting together groups of doctors to share services like calling or sending text messages to patients to remind them of follow-up visits."

On December 1, 2008, Milliman, Inc., a Seattle-based global consulting and actuarial firm, sponsored the Healthcare Town Hall. This event consisted of ten panelists representing government agencies from all levels (federal, state, and local), nonprofit organizations, and the private sector. The evening's agenda focused on four areas:
  1. What are electronic health records (EHRs) and what can they do?
  2. How do we encourage EHR adoption?
  3. Who owns the information that is gathered?
  4. What can/should we do with this information?

You can watch the program in its entirety below courtesy of TVW, but here are a few points of interest from the event:

  • Scott Armstrong, President and CEO of Seattle-based Group Health Cooperative, said that Group Health has been using electronic health records for four years with very effective results. Patients feel empowered having easy access to their medical records, which make them more educated when making a medical decision. Group Health has invested in secured accessibility to patient records. However, according to Mr. Armstrong, Group Health has been unable to quantify profitability since there are too many outside factors.
  • Mike Kreidler, Washington State Insurance Commissioner, said that 40 percent of funds in the health care system is wasted. The panel collectively agreed that electronic health records will make the system more efficient and reduce costs and financial waste.
  • Ron Sims, King County (WA) Executive, noted that many medical professionals cannot afford to implement an electronic health record system.
  • John Hammarlund, regional administrator for the Seattle and Chicago offices of the Centers for Medicare and Medicaid Services explained that he has not seen any good business cases using electronic health record technology, "No studies in correlation between electronic health records and quality of health care."
  • The discussion shifted to standardizing electronic health records where Mr. Hammarlund said that an industry standard should be created, but this responsibility should not rest solely on the federal government nor should it be left up to the private sector, but a collaborative effort between the two. Moreover, according to Mr. Hammarlund, we should be paying for greater value for health care rather than volume.
  • Joe Scherger, MD, a consulting medical director for informatics at San Francisco-based Lumetra, a health care consulting organization, believes electronic health records will be incorporated in our daily lives similar to e-banking and online shopping.
  • Regarding ownership of the information, Ron Sims said the consumer (patient) should solely control the release of medical records and warned of the consequences should genetic information be stored in electronic health records.
  • Rich Moyer, the MedInsight® product manager in Milliman's Seattle office further questioned who legally owns the information. If a medical provider is using Microsoft HealthVault (there are dozens of health information management systems including Google Health), does the patient, medical provider or information management system own the data? George Scriban, Microsoft HealthVault's senior global strategist quickly responded that his company does not own the data, but they simply manage the database.
  • Dr. Scherger made an excellent point by saying Internet access is a public health issue. It is one thing to have an EHR, but a digital divide still exists in many communities throughout the United States, particularly in minority communities. However, he explained that disadvantaged communities in Orange County, California have a very high child vaccination rate as a result of electronic health records and an expansive volunteer network.

Issues or concerns about electronic health records include:

  1. Who owns the electronic health records? The patient, health care provider, insurance company, data storage company?
  2. What information should be stored in electronic health records? Genetic/DNA information? If so, will this allow insurance companies the ability to prescreen applicants and deny coverage or benefits based on genetic code?
  3. How do you guarantee the accuracy of information posted?
  4. Who should create an industry standard for electronic health record systems? Governments, nonprofit groups, private sector or a collaborative effort among the three?
  5. How do we encourage electronic health record adoption? As The New York Times article indicates, a electronic health record database may be cost prohibitive for medical providers without government subsidies.
  6. Need to integrate preventive medical information and pertinent resources into electronic health records.

There is no question that electronic health records will quickly become the norm in managing healthcare. EHRs will allow the patient to become better educated when making medical decisions and I hope EHRs will give patients not only the ability to manage medical treatments, but EHRs will be used as a source for preventive medicine. One significant concern I have is without proper regulations and oversight, medical information that should remain confidential between the medical professional and patient could be misused particularly if DNA information is included in electronic health records.

Electronic health records will certainly provide a great benefit to people living in industrialized nations, but can you imagine the positive impact EHRs would have on billions of people living in the developing world?

December 29, 2008

Jordan to Build Health Centre in Darfur

During the past few days, there have been several negative news articles coming from Africa including "Witnesses report massacre at church in Congo," "African Union suspends Guinea following coup," and "Zimbabwe cholera death toll soars past 1,500." However, I was pleasantly surprised to read about Jordan's King Abdullah II plan to setup a health center in Sudan's Darfur region. Here is the complete article from AFP (Photo courtesy of King Abdullah II's official website,

AMMAN (AFP) - Jordan's King Abdullah II on Thursday ordered the setting up of a health centre in Kas in Sudan's war-torn region of Darfur to serve more than 25,000 people there, an official said.

"A military airplane left today (Thursday) for Darfur, carrying equipment to build the medical centre, which will be fully operational in January 2009," Mohammed Aitan, secretary of Jordan's Hashemite Charity Organisation, said in a statement.

Aitan said the facility is expected to cost 400,000 dollars.

"A second military plane carrying more equipment will go to Darfur later," he said without elaborating.

Conflict has been raging in the Darfur region in western Sudan since 2003, when ethnic minority rebels took up arms against the Arab-dominated regime.

UN officials estimate that up to 300,000 people have died and 2.7 million have been forced to flee their homes.

Although I would have preferred aircraft from Royal Jordanian Airlines to carry the equipment rather than military transport, Jordan's effort is a significant step in providing the necessary humanitarian assistance necessary to facilitate the process of ending the war in western Sudan and building a sustainable future for everyone.

To maximize its effectiveness, I hope this health center is part of an orchestrated effort to provide humanitarian relief to the region's most vulnerable people and I encourage other countries to contribute in similar ways. A small amount of foreign assistance to support programs that have clearly-defined measured results will go far in providing the tools for people to help themselves.

December 23, 2008

Providing Private Health Insurance in Africa

During my extensive travels throughout Africa, one of the greatest problems I see for many Africans is having access to health care. There are several organizations working make health care accessible, but one organization is worth mentioning: the Amsterdam-based Health Insurance Fund ( The Fund, established in 2005, is creating an innovative method to accessing quality health care including HIV/AIDS treatment through an innovative approach: building accountable and reliable demand-driven, output-based private health insurance schemes for low-income groups. (Photo courtesy of the Health Insurance Fund)

According to the Fund's website, "The Health Insurance Fund has been established to set up private health insurance programs for low-income communities in different countries in sub-Saharan Africa. PharmAccess has been contracted by the Fund to develop, manage and control the insurance programs. PharmAccess contracts local implementing partners to provide the insurance to the selected communities. Independent operational research organizations measure the impact of the insurance program. The Health Insurance Fund is responsible and accountable for the overall program in the context described above."

I had the pleasure of meeting Mr. Onno Schellekens, Managing Director of the PharmAccess Foundation and Mr. Chris van der Vorm, Health Insurance Fund's Executive Director during their visit to Seattle in September 2008. I learned that the Health Insurance Fund will carry out programs in at least four African countries, which will be implemented by local (African) Health Maintenance Organizations or insurance companies. PharmAccess, in collaboration with the local partner, selects local healthcare providers (clinics, hospitals, laboratories, pharmacies) on the basis of a pre-defined criteria and these providers may be either publicly or privately operated.

In October 2006, the Dutch Ministry of Foreign Affairs awarded the Fund a €100 million grant for the development and implementation of insurance schemes in four countries over a period of six years. The first scheme was launched in Nigeria in January 2007 targeting 115,000 women in Lagos and farmers in Kwara State. A second program is currently being developed in Tanzania.

The Fund's website explains the implementation strategy, "To ensure that the target population will participate in the schemes, an enrollment strategy is applied. Communities are mobilized through community leaders, information meetings or radio messages, among other things. Special 'marketing teams' will undertake 'on-the-spot' registration and enrollment in the field. Upon payment of their part of the premium, insurance scheme beneficiaries immediately receive their insurance ID card. Enrollment is done on a yearly basis. To limit adverse selection, family enrollment is encouraged." (Photo courtesy of the Health Insurance Fund)

The Fund's objectives include:

  • To build local financial-administrative and medical capacity in the health sector;
  • To lower the threshold for investments in health infrastructure: to increase investments and leverage public money by attracting private funds;
  • To demonstrate that demand-based health schemes applying an output-based approach are transparent and efficient and reinforce quality standards; and
  • To evaluate different healthcare delivery models based on a demand-driven and results- oriented approach.

On October 23, 2008, the first Health Insurance Fund Conference was held in Amsterdam titled "Africa Healthcare Systems in Africa: Time for a New Paradigm – Mobilizing the Private Sector to Develop a Sustainable Healthcare Economy in Africa." While I was unable to attend the conference, I have read about its success. The Health Insurance Fund is developing an excellent model of effectively engaging the government, civil society, and private sector by implementing an innovative strategy to increase the accessibility of quality health care including HIV/AIDS treatment to potentially millions of individuals throughout Africa.

December 17, 2008

DUX Spray Gun: A Model of the Green Tech Evolution

On a recent trans-Pacific flight, I had a conversation with a woman about the current global economic crisis. She asked, "What sectors, if any, will benefit the most during the economic crisis?" I responded that while some sectors will feel the impact more than others (i.e, financial and retail), I think renewable energy and green (clean) technology will come out stronger than ever.

In the United States, President-elect Barack Obama has repeatedly explained that his economic plan calls for a significant increase of investment in the "New Economy," which include the renewable energy and green technology sectors. Other countries like Germany, Brazil, United Kingdom and even China are looking at making large investments in renewable energy and clean tech.

One benefit of traveling on long flights is having uninterrupted time to review documents. In doing so, I found documents from a consulting project I worked on advising DUX Area, Inc., a Tukwila, Wash.-based green technology company, on identifying strategic international markets conducive to increasing market capitalization and strengthening market position. In explaining the company's mantra, DUX's CEO Kevin Kelley says DUX spray guns bring the global coatings application market a technology that exceeds transfer efficiency expectations while providing coating specialists the finish and productivity output they demand.

The DUX spray gun is a prime example of the green technology evolution--taking an existing product and redesigning it into a product that is good for the environment and business profits alike. DUX's competitors who produce High Volume Low Pressure (HVLP) and other spray gun technologies use 1,800-2,500 pound-force per square inch gauge (psig) to apply the paint or coating application, whereas DUX's spray guns use only 10-11 psig. DUX's patented Advanced Laminar Airflow Technology reduces booth fog and blowback from the target, the two leading causes of coatings waste. These reductions create a healthier work environment because less material is wasted, fewer volatile organic compounds (VOCs) and other hazardous pollutants are released into the atmosphere. In addition to reduced coating usage and decreased cleanup costs, other return on investment results include faster production speed and energy savings.

DUX designed three spray guns: Pressure Feed, Gravity Feed, and Automatic (pictured here). I had the opportunity to test the Gravity Feed spray gun (pictured above) and was amazed with its lightweight and balanced design, which facilitated the ease of spraying paint across a large surface. DUX guns can be used a variety of industries including transportation, industrial equipment, wood, plastics, aerospace, military, marine, and architectural.

World governments are hedging their investments on green technology to increase jobs while fighting climate change. We need to invest in the talented people similar to those you will find at DUX who produce products or provide services that will play an integral part in the new "green" economy.

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.

December 11, 2008

Ghana: A Model for Democratic Elections

Voters in Ghana went to the polls on December 7, 2008 to elect a successor to President John Kufuor who is stepping down after serving the maximum two terms. According to the CNN article, "Nana Addo Danquah Akufo-Addo of the incumbent New Patriotic Party and John Evans Atta Mills of the National Democratic Congress are the leading candidates, but neither was able to garner more than 50 percent of the vote. The Ghanaian constitution requires a second round of balloting if no candidate wins a clear majority." At a time when African nations are looking for a leader in social and economic development including free democratic elections, Ghanaians are showing that they can serve as a role model in choosing government officials without corruption and violence that plagued Zimbabwe and Kenya's elections earlier this year.

Ghana is making an effort to become a leader, not just in West Africa, but for the entire African continent. I had the chance to meet Nana Akufo-Addo, Ghana's former Minister of Foreign Affairs, on June 4, 2008 in Washington, D.C. where he spoke at an event, "Democratic Governance and Economic Growth in Ghana," sponsored by the U.S. Institute of Peace and the Center for Strategic & International Studies (CSIS) Africa Program. Mr. Akufo-Addo talked about his vision for Ghana's future. Accra, Ghana's capital, should be the financial center for West Africa similar to how Dubai is becoming the financial capital for the Middle East. In addition, Mr. Akufo-Addo explained the recent discovery of offshore oil will help provide needed capital to the country, exploration and extraction should be done without damaging the environment or causing civil unrest like we are witnessing in nearby Nigeria. The discovery of oil, Mr. Akufo-Addo said, should benefit the Ghanaian people not foreign corporations.

There are fair reasons to criticize the Ghanaian government. The former British colony is the world's second biggest cocoa grower and Africa's second largest gold producer. Many Ghanaians, however, say they not have received the benefits from the increased wealth. In addition, cocaine trafficking last increased in West Africa over the past few years. Despite these issues and regardless which candidate prevails as Ghana's next president, Ghanaians should be proud to demonstrate the ability to exercise their democratic right to vote in a civil manner. As explained in the CNN article, "'All of us agreed that these were high quality, very transparent, orderly, peaceful, patient fine elections,' said observer John Stremlau with the Carter Center...'My colleagues with more experience than I have think these were probably the best elections they have observed.'"

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.

December 8, 2008

Unlimited Potential: Making Technology Affordable, Relevant and Accessible

On October 18, 2008, I attended the 10th Annual African Day Business Forum and Celebration Dinner & Auction sponsored by the Seattle-based African Chamber of Commerce of the Pacific Northwest (ACCPNW). There were several good speakers, but I found James Utzschneider's presentation particularly interesting and relevant regarding the problems presented by the digital divide (i.e., the gap between people with effective access to digital and information technology and those without) to hundreds of millions of people in the developing world and how Microsoft is providing the tools necessary to overcome these problems through fostering innovation and education. (Picture is taken during one of my trips to St. Theresa Girls Secondary School Bwanda, a private school located in Masaka, Uganda for girls 14-20 years of age. My friend, Sister Noelina Namusoke, a graduate of Seattle University who was born and raised in Uganda, is the school's headmistress.)

Mr. Utzschneider is the general manager of marketing and communications for the Unlimited Potential Group at Microsoft Corp. According to the company's website, "Microsoft, through its Unlimited Potential vision, is committed to making technology more affordable, relevant and accessible for the 5 billion people around the world who do not yet enjoy its benefits. The company aims to do so by helping to transform education and foster a culture of innovation, and through these means enable better jobs and opportunities. By working with governments, intergovernmental organizations, nongovernmental organizations and industry partners, Microsoft hopes to reach its first major milestone — to reach the next 1 billion people who are not yet realizing the benefits of technology — by 2015."

Speaking about the digital divide and how the Unlimited Potential vision is providing the tools necessary for people to cultivate innovative skills and enhance educational strategies aimed to eradicate poverty, Mr. Utzschneider said that it is necessary to combine to efforts of governments, nongovernmental organizations (NGOs), and the private sector to promote the benefits of technology to the world's underserved population. Unlimited Potential is an ideal vehicle to overcoming these challenges through three core areas: Transforming Education, Fostering Local Innovation, and Enabling Jobs and Opportunities.

Mr. Utzschneider explained that an example of these core areas is through Microsoft's Partners in Learning initiative, which is "designed to increase technology access for schools, foster innovative approaches to teaching, and provide education leaders with tools to better engage students and improve learning outcomes." He further said that the Local Language Program was allowing people worldwide to benefit from technology while preserving local languages and cultural identities by making software available in as many languages as possible.

Speaking at the second annual Information and Communication Technologies Best Practices Forum in Ouagadougou, Burkina Faso last April, Microsoft's CEO Steve Ballmer said, "Technology alone will not turn these goals into achievements...Technology is just a tool to empower people to make progress. It is an enabler." (see "Ballmer: African Business Needs to Be More Transparent"). With the right implementation strategy, Microsoft's Unlimited Potential vision can empower the world's most underserved population with the tools to break the generational cycles of poverty.

For your reference, I am providing two additional resources about Microsoft's Unlimited Potential vision:
  1. Unlimited Potential World Updates
  2. Inside UP - James Utzschneider's blog to help tell the story of how his group works with partners and governments around the world to develop and deploy technology that helps improve people's lives in a sustainable way.

December 4, 2008

Economic Impact of AIDS

Many of you responded to my blog entry, "World AIDS Day 2008," discussing HIV/AIDS and ways to prevent the spread of this deadly disease. One of the purposes of this blog is to discuss the challenges people face in developing nations and how economic and private sector development can serve as a solution to resolving many of the world's human crises. A preliminary step is diagnosing and examining the problem before formulating sustainable solutions. Although we realize the human costs of AIDS, particularly in the developing world, we may not understand the economic impact of AIDS.

Breakdown of the Family Structure

In many countries, women are the primary caregivers in their households. What happens to the family structure when the father infected with AIDS? Who will provide the source of income? Conversely, who takes care of the children when the mother becomes ill or dies? Although many families in Africa, Asia, and Latin American tend to be extended with several potential caregivers, providing economic security or household stability is threatened when multiple members of the family are coping with HIV/AIDS.

According to the 2008 Report on the Global AIDS Epidemic produced by the Joint United Nations Programme on HIV/AIDS (UNAIDS), "In addition to being more physiologically and socially vulnerable to infection, women also disproportionately suffer the epidemic’s negative effects. As the primary caregivers in Africa and other regions, women have seen their household and community burdens grow as a result of HIV, often compromising their health, their ability to generate income, and other markers of well-being. Women account for two thirds of all caregivers for people living with HIV in Africa. Women who are widowed as a result of HIV are at high risk of becoming destitute as a result of legal regimes that fail to recognize or protect women’s right to inherit property."

AIDS Creates a Welfare System

Many developing countries are trying to use donor funds from agencies like the United Nations United Nations Development Program (UNDP), The World Bank and the Bill & Melinda Gates Foundation to provide individuals with the education and technical training necessary for economic development and financial independence. As a result of the collapse of the family structure resulting from AIDS, however, limited financial and human resources are transferred from economic development programs to provide for the needs for millions of orphans impacted by AIDS.

Furthermore, according to UNAIDS, "In sub-Saharan Africa, nearly 12 million children under age 18 have lost one or both parents to HIV. In Botswana and Zambia, an estimated 20% of children under 17 are orphans, with most orphaned as a result of HIV. Zimbabwe reports that 24% of its children (ages 0–17) have lost one or both parents to HIV." Although many agencies should be commended for their efforts in raising orphans impacted by AIDS, these agencies often do not have adequate resources to provide a proper education or technical training required to achieve economic independence and break the cycle of poverty.

Growing Economic Divide in Developing Nations

Until just a few months ago, a few developing countries with significant populations infected with HIV had experienced strong economic growth. The UNAIDS report states, "With one of the highest HIV burdens in the world, Botswana nevertheless experienced average economic growth of 4.8% between 1990 and 2005. Likewise, economic growth in heavily affected Uganda in 1990–2005 actually increased over rates reported for 1975–1990, even as HIV was responsible for more than 100 000 deaths per year. South Africa, home to the largest population of people living with HIV, has enjoyed robust economic growth since 1999. Certain heavily affected countries—including Kenya, Zambia, and Zimbabwe—experienced negative economic growth in 1990–2005, but it is difficult to link this weak negative performance to HIV."

Having traveled to many countries where AIDS is part of the daily lives of its citizens, I have seen the positive impact resulting from strong economic growth. Creating an economic divide is a major threat HIV poses in several developing markets. While some people in developing nations will prosper financially, HIV will also increase the poverty rate. The UNAIDS report further explains, "Even within economies that are steadily growing, HIV can create a 'poverty trap' that ensnares the most vulnerable. Given the heavier burdens borne by poor households, HIV also widens inequality within societies, which may increase vulnerability to HIV in the future...Ironically, the sickness and death of skilled workers may also increase inequality by reducing overall labour demand and leading to a fall in the wages of unskilled workers....It is estimated that HIV imposes an additional US$2 billion in costs each year on affected households in Asia" There is a growing concern on how HIV will impact the economies of India and China.

The Impact of AIDS on Donor Countries

President-elect Barack Obama said that his budget proposal will call for an increase in foreign aid for humanitarian purposes and as a United States citizen and taxpayer, I support this proposal. For those of us who reside in nations that provide foreign aid to the developing world, our tax revenue will be spread thin between supporting economic development projects and providing funding to agencies that care for individuals impacted by AIDS.

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.

December 1, 2008

World AIDS Day 2008

1 December 2008 is the 20th anniversary of World AIDS Day. People worldwide will commemorate this day to bring attention to the ongoing battle that has plagued individual communities and entire nations. Although there have been great strides to defeating AIDS, millions of people of all demographics are still dying from this preventable disease.

Although AIDS has become a household term, I am surprised to learn how little people know about this disease. Through U.S. Department of Health and Human Services website,, "Acquired Immune Deficiency Syndrome (AIDS) is caused by HIV (Human Immunodeficiency Virus). By killing or damaging cells of the body's immune system, HIV progressively destroys the body's ability to fight infections and certain cancers. Over one million Americans are living with HIV/AIDS today. Worldwide, the figure is over 33 million."

Here in the United States, the United Nations is often criticized for its inability to prevent wars and genocides like those we are witnessing in Darfur and the Democratic Republic of Congo. However, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has the necessary infrastructure to promote HIV/AIDS education to vulnerable populations, which are often found in developing or emerging markets. According to UNAIDS, "HIV prevention services were only reaching 20% of people in need in 2005, while coverage for key populations at higher risk of exposure to HIV were considerably lower."

UNAIDS further claims, "Effective HIV prevention programming focuses on the critical relationships between the epidemiology of HIV infection, the risk behaviors that expose to HIV transmission, and also addresses the collective social and institutional factors, such as sexual norms, gender inequality, and HIV related stigma, that will otherwise continue to fuel HIV epidemic." We must continue to fight this disease through effective education strategies and industrialized countries should lead by example by providing the necessary funding to support UNAIDS' efforts and implement effective national strategies in their respective country.

To commemorate World AIDS Day, please educate yourself and talk with your friends and family members about the facts of HIV/AIDS including proven prevention techniques. According to, "The transmission of HIV occurs through three well documented means: 1) having sex (anal, vaginal, or oral) with someone infected with HIV; 2) sharing needles and syringes with someone infected with HIV; and 3) being exposed (fetus or infant) to HIV before or during birth or through breast feeding....HIV is not transmitted through day-to-day activities such as shaking hands, hugging, or a casual kiss. You cannot become infected from a toilet seat, drinking fountain, doorknob, dishes, drinking glasses, food, or pets. You also cannot get HIV from mosquitoes."

UNAIDS identifies three simple prevention techniques:

  1. Use latex condoms, which when used consistently and correctly, are highly effective in preventing sexual transmission of HIV and use male or female condoms correctly each time you have sex;
  2. Avoid injecting drugs, or if you choose to inject drugs, always use new and disposable needles and syringes; and
  3. Ensure that any blood or blood products that you might need are tested for HIV and that blood safety standards are implemented.
Please consider getting tested and treated for sexually transmitted diseases (STDs) including HIV. Through effective education and proven prevention tactics, we can eradicate this disease that is continuing to kill millions worldwide.

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.