Building a Customer Experience Culture in Healthcare ft. Craig Kartchner

Craig Kartchner (00:00):
Because it’s such a complex industry and everyone’s tends to focus on different things. To coalesce around one central point of customer experience, that’s the reason we exist to serve patients and customers the best way we can and maximize their experience. It takes years to get there. It’s a hard cultural shift.

Chris Hemphill (00:28):
Hello, Healthcare. We’re excited to be back on the floor at H&PS 2021. We’ve been covering themes around digital transformation, patient engagement, patient experience, marketing, and outreach and things like that. There’s actually a combination of the two that you’re starting to hear a lot about.

Chris Hemphill (00:47):
That’s why we’re excited to bring in Craig Kartchner, who is the AVP of not only marketing, but also consumer experience at Honor Health. Craig, just a little bit of background on what you’re doing there today.

Craig Kartchner (01:00):
Well, what we’re trying to do is improve customer experience, at the same time we’re working on marketing. They really go hand in hand. Most healthcare companies in my experience don’t even have a customer experience department, but they have a marketing department.

Craig Kartchner (01:13):
Who is closest to the customer the end consumer who understands the consumer best and has done the most research on consumers? Usually it’s the marketing department. We’re trying to bridge that divide between marketing and CX, and the rest of the system so that we change.

Craig Kartchner (01:28):
We’re not just adding technology to improve CX, but we’re trying to change the culture and the processes and the operations in order to maximize customer experience. That’s the theory, at least.

Chris Hemphill (01:39):
You’re hearing it from Craig right now for everybody who’s been really excited or really even scared of a lot of the new disruptors that are coming in that are more adept with developing customer experiences, listening to their customers. They’re taking that same knowledge into healthcare.

Chris Hemphill (01:57):
This combination between the marketing experience and the consumer experience is starting to take hold and become really important. It begs the question, a lot of marketers might be looking at these experiences, but not really feel like there’s any input that they have or ability to start making change there.

Chris Hemphill (02:19):
We’re starting to see that like with the convergence of the consumer experience and the market role, we’re starting to see some change with regards to that. Let’s back up a little bit and talk about this consumer experience. Craig, could you talk about what the consumer experience actually means at Honor Health? What is that?

Craig Kartchner (02:35):
I’ll start with the story. One of my favorite coworkers at Honor Health is the chief patient experience officer. She’s a trained OB. She’s incredible. I love her so much. I want to hang out with her on weekends. She’s cool, she’s smart, but we had major conflict when I first came, because I kept talking about, “CX, we need to do this. I want to do this. I want to lead out on this.”

Craig Kartchner (02:59):
She said, “Whoa, who are you? I’m the chief patient experience officer. You’re getting in my territory.” Of course, she didn’t do it in that hostile manner because she’s too cool for that. That was her concern that we were invading her territory. We really had to sit down, the two of us, and define what is patient experience versus what is customer experience.

Craig Kartchner (03:20):
They are not the same thing. Her focus and the focus of things like HCAHPS and CG-CAHPS, those studies that everyone tends to use, they focus very much on the experience of the patient in the hospital environment or in the clinic environment. Sarah Snell, the chief patient experience officer that I referenced, she does a lot of training for frontline clinicians in the hospital.

Craig Kartchner (03:43):
That’s what she focuses on. In specific behaviors they need to do to live up to in order to deliver a good patient experience. The customer experience starts long before they come through the threshold of the hospital. Even when they’re considering their trying to discover what their ailment is, what is their condition?

Craig Kartchner (04:03):
What type of care do they need? Where do they go for information? Once they find out the information, the type of care they think they need, then what? How do they find the right person to see? How do they judge quality? Is it by outcomes? Is it by just reviews and reputation? Then how do they schedule?

Craig Kartchner (04:20):
You can see it’s all the different points in their journey from the time they realize they need healthcare until they get the healthcare and beyond, that’s customer experience, far broader than just patient experience. I think just understanding the difference in definition can help a health system focus where they need to focus.

Chris Hemphill (04:40):
Now, when we say focus where we need to focus and you’ve laid out this broad definition, I’m curious, is somebody already owning this aspect of the process? Do you think that there’s a lot there in that scope that does even have an owner that’s getting ignored in a lot of situations?

Craig Kartchner (04:58):
I would say it’s the exception rather than rule that there is a clear owner. There are very few customer experience departments, in my experience. I said before, marketing seems to be the natural fit, but even marketing has its purview, its scope. Until you involve a multidisciplinary team, you have to have IT.

Craig Kartchner (05:18):
You have to have analytics, you have to have clinical leaders and ops leaders. If you don’t get those teams together and working toward the same cause, then you’re not going to succeed in improving customer experience. That is so hard in healthcare because it’s such a complex industry and everyone tends to focus on different things.

Craig Kartchner (05:38):
To coalesce around one central point of customer experience, that’s the reason we exist to serve patients and customers the best way we can and maximize their experience. It takes years to get there. It’s a hard cultural shift.

Chris Hemphill (05:52):
I can only imagine that’s a lot of gravity required to bring all those different parts together. I want to be a little bit coy. The subject of your speech at H&PS is around the consumer experience index or customer experience, consumer or customer?

Craig Kartchner (06:10):
Customer.

Chris Hemphill (06:10):
Customer experience index, I don’t know, intuitively it sounds like there might be involvement in that gravity. If we’re bringing all these bolts together, there has to be something that we can measure against. Could you talk about the origin of that or just even more broadly what it took to bring all those different parts together?

Craig Kartchner (06:29):
By the way, we’re far from complete in our journey. We’re still very much at the beginning, but when I first joined Honor Health, I think this is the same way at a lot of healthcare systems, they use HCAPS and CG-CAHPS to measure customer experience. It’s because those have been developed over years and years.

Craig Kartchner (06:43):
They’re mandated to use HCAPS if they’re a CMS beneficiary, they have to do a certain number of surveys. It’s logical to look to HCAPS and see the CAPS surveys for your customer experience. The problem is they measure this tiny little sliver of the experience just when you’re in the clinic or when you’re in the hospital, and there is no composite.

Craig Kartchner (07:05):
You have to look question by question. There is no total grand average of your score is this for HCAHPS. You have to look question by question, which makes it difficult, but it’s still useful, but it makes it difficult to be the one metric to look to and to set goals around for improving customer experience. That’s why we put together this proprietary CX index that has four components.

Craig Kartchner (07:32):
We wanted something that measured not just that tiny sliver when the patient is in the hospital, but before and after. We wanted something where we could point to one score and say, “Look, our grand composite average is bam, this. We’re setting goals to improve this by 1% per month, over the next three years.” Again, early on in the journey and we’re not where we want to be yet.

Chris Hemphill (07:57):
Thank you for shedding light on the score, what it was developed for and things like that. I wonder how is it going or how did you start to get adoption, or buy-in or interest in that number from these different groups?

Craig Kartchner (08:13):
It’s a good question. We reorganized not too long about two years ago and hired a chief transformation officer who is a trained MD. He’s a trained doc. Under him, we have all the departments I listed before that need to be involved in improving customer experience.

Craig Kartchner (08:32):
IT, the informatics chief medical and nursing informatics officers and marketing, the project management office, et cetera. There’s several other departments under him. The governance and accountability is a clear line under one leader. We didn’t have to convince 50 leaders in 19 different committee meetings.

Craig Kartchner (08:49):
It was one leader. Not that doesn’t mean no one else was involved. Of course, many others were involved. He holds the purse strings and the accountability for a lot of the departments that are working on customer experience. That helped us enormously.

Craig Kartchner (09:02):
He was able to socialize it with other executives, and because he’s a physician, he was able to socialize it even among the clinical staff and get buy-in better and more efficiently than I would’ve been able to do on my I own or any individual department would’ve been able to do on its own. That made a huge difference.

Craig Kartchner (09:20):
One of the main reasons that the CX index now is one of the board goals at the board level, our goal against the CX index is on that dashboard. The board all the way up to the senior leaders and the board are looking at the CX index quarterly as they assess our progress. It’s now that important that has become at the board level.

Chris Hemphill (09:41):
That highlights a powerful reason as to why you need to have that composite score, because if you have so many different variables, different definitions, “We got to talk about customer experience.” Let’s just talk about this aspect or pick this aspect out, and cherry pick what’s going well.

Chris Hemphill (09:56):
What you’re talking about is a scenario, where there is a forced look at how this thing changes up and down over time. You’re behold to that. There’s no ability to cherry pick your way out of that. It forces the organization to deal with the real one.

Craig Kartchner (10:11):
You’re spot-on. We still do measure all those individual things that make up the broader CX index, of course. You’re right, there’s no hiding behind it. You can’t cherry-pick the ones where you’re already doing well, or you know you’re going to make a lot of progress this quarter because you’re bringing on a new physician who excels at that or whatever. It forces you to focus on the entire experience. You’re right.

Chris Hemphill (10:34):
Let’s talk about that. Scenarios where there’s going to be ebbs and flows with the customer experience index. What happens once we see that number go down? What’s happened in the past once we’ve seen that drop?

Craig Kartchner (10:50):
I wish I could say that we show the data and there is a mad dash to change it. Everyone’s saying, “It’s dropped to half point. We need to do something right now.” It hasn’t been quite that burning platform E. I wish it were that way, but it hasn’t been, but because all the way down to our incentive plans that executives are paid against are paid in part on achieving all our board goals, including the CX index.

Craig Kartchner (11:23):
There is a lot of pressure and importance, and a lot of scrutiny. I think that’s something that people sometimes forget. Marketing departments they’re always want more credibility, more respect. They want to be at the table and they should. They should be at the table, but that comes with scrutiny.

Craig Kartchner (11:40):
Having a CX index that my department does controls, or however you want to say that means that we are scrutinized. If it drops, they look to us, “Well, is the technology not working, Craig? Why is your website appointment scheduling fulfillment down? You haven’t hit your goal.”

Craig Kartchner (11:58):
There’s a lot of pressure and scrutiny. It’s an uncomfortable sometimes, but necessary place to be. It does mean that we can get action quicker, even though it’s not exactly burning platform all the time. We definitely can get action quicker from the departments that need to act when there is a drop, because we can say, “Look, this isn’t just a nice to have thing. This is a board level goal.”

Chris Hemphill (12:22):
Excellent. It sounds like by having that process where there’s ownership, where there’s visibility on this, where I didn’t even recognize this part, but incentives tied to this from a pay perspective, it’s not necessarily the burning platform.

Chris Hemphill (12:40):
We might want to reserve that for more immediate and urgent issues anyway. There’s actions that are able to be taken. Any examples as far as we were looking to marketing to improve the experience on the website. Any stories for examples as a result of that additional scrutiny?

Craig Kartchner (13:02):
When we first started measuring, online scheduling is a big part of improving customer experience. Making it easy for people to get appointments when they want that convenes them. The right type of appointment to the right time for them. Well, a lot of the focus was on my chart. We’re an Epic client.

Craig Kartchner (13:20):
Our patient portal is my chart and there was a lot huge emphasis to push people into MyChart to do their scheduling. We have pretty good numbers in MyChart, in fact, against our other Epic clients in the country, we compared very favorably.

Craig Kartchner (13:36):
For guests who don’t either don’t have a MyChart account, or don’t want to log into their MyChart account to set an appointment as a new appointment as a guest, we were really underperforming. Our website was not built for that. We tended to focus on MyChart and not enough on just the broader digital experience.

Craig Kartchner (13:56):
Our throughput, if you tried to schedule an appointment from our website without logging into MyChart, our throughput was abysmal. We didn’t really realize it at first until we started measuring it. Then we realized, “Wow, we are not performing there.” We started looking into what portions were tech problems.

Craig Kartchner (14:13):
There were some tech problems, the way we surfaced physician data to make physicians how to find them when you do your search for a doc we had to fix some things with the data. We had to fix some things with the technology, and certainly had to fix some things with the operations, the backend, how our schedules built?

Craig Kartchner (14:30):
Can we make this slot of appointment visible to guests and to patients in MyChart, to both? There was a lot of political and operational changes we had to make as well. The fact that we’re measuring it and focusing on it, alerted us to that fact that we needed to make changes. Otherwise, we wouldn’t have known.

Craig Kartchner (14:49):
We’re now steadily making progress. We’re still so far short of where I want to be, but we’re moving in the right direction.

Chris Hemphill (14:56):
Good. We’re chasing where the puck is going it sounds like. That leads to another question. I know that there’s the focus on the scheduling and access component right now, but I’m curious if opening up the CX index, seeing the ebbs and flows, digging into why.

Chris Hemphill (15:14):
Curious about what other consumer experience aspects are just on the radar for you, things that you’re interested in?

Craig Kartchner (15:22):
A good question. It’s access in terms of scheduling the right appointment at the right time. Another huge one is choice. I find this in healthcare marketing that everything is cumulative, it’s additive, just because you now can do paid search advertising doesn’t mean you no longer do billboards that have been around for 200 years or whatever.

Craig Kartchner (15:46):
It means you add to it. It’s the same with customer experience options, access ways to improve patient access to care just because we have telehealth now doesn’t mean that in person, primary care visits go away, they don’t. It’s about getting the whole bevy of offerings in front of your customers and letting them choose.

Craig Kartchner (16:04):
Making it easy for them to find it and then choose the way that works best for them and their schedule, and their issue. There’s some clinical protocols. You can’t do all things remotely. You can’t do any type of visit via telehealth. It’s just not going to work. There’s clinical protocols and parameters. You have to abide by, but we can give a lot more choice to customers and let them pick how they want to access.

Craig Kartchner (16:27):
That’s another huge areas, adding more tools in more ways. Another huge one is communication. This one surprised me when we started digging more and more into the research that communication with the care team is as cumbersome and difficult as it is. A huge way that people you communicate with their care team is again using MyChart, the patient portal.

Craig Kartchner (16:49):
It’s a great tool for that it’s secure, and you can get all the way to your doctor or your doctor’s staff. You know who to go to is my point when you message, it’s going to the right person, which is awesome. On the doctor’s side, they are inundated with messages buried in messages. They can’t get to them fast enough.

Craig Kartchner (17:08):
They have these very busy days. Then when they go home at night, they’ve got to tackle the 179 chart messages they have from their patients. We’ve really got to find a better way for patients to communicate with their care team when they have questions. Some of it’s going to have to be automated.

Craig Kartchner (17:25):
I think there’s huge opportunity for AI that AI can satisfy and answer a lot of those questions without having to involve a human. There need to be other solutions. Communication is a big problem.

Chris Hemphill (17:38):
Great way to frame it up too. I’m glad that we’re not here to beat up on billboards. They still serve a purpose.

Craig Kartchner (17:45):
It’s a place.

Chris Hemphill (17:45):
Yes, they’re definitely a place. An example, just because there’s a new technology or a new way of doing things doesn’t mean that we should get rid of the old. One good example is the phone system. There’s online scheduling available, but I’m a millennial personally, but I’m just very inclined to tap that phone [crosstalk 00:18:12].

Chris Hemphill (18:11):
Tap zero a bunch of times and just schedule it, not to worry about. I might not have as much faith that my schedule online might actually go through. Just some different tendencies.

Craig Kartchner (18:23):
See, I wouldn’t have predicted that for your generation, for your age category.

Chris Hemphill (18:29):
On average, you could, but we’re evolving, like you mentioned AI, we’re evolving beyond averages. There’s all kinds of different concepts. Now, instead of averages, it’s personalization, which having that bevy of options leads to. Super exciting to think about.

Chris Hemphill (18:47):
Here’s another question that I had. In looking at this consumer experience index and, and looking at all these different factors that you’re measuring, are there any kind of insights that came out that were unintuitive? Just things that came out about the experience that surprise you?

Chris Hemphill (19:04):
I just surprise you with I’d rather call you on the phone. Any other surprises to come out of it?

Craig Kartchner (19:10):
Actually, a lot of surprises. One of them was that telehealth was not the answer I thought it was. I personally, maybe it’s based on my demographics. I expected people to want telehealth now. We want to use virtual visit. We started this before COVID, by the way. There wasn’t quite the drive arrive to do things virtually.

Craig Kartchner (19:32):
I expected that to be the answer. Let us do telehealth. I don’t want to have to drive to the clinic and park and sit in the waiting room with sick people and blah, blah, blah. Just give me telehealth. It was the last on the list. That’s not exactly true, halfway down the list when we’re researching what is most important to people to solve CX problems?

Craig Kartchner (19:51):
It wasn’t high. People didn’t at least at the time, were not as interested in telehealth as I thought they might be. That was shocking to me. I was really surprised at the adoption of MyChart. There’s so many people that have MyChart accounts, but don’t want to use them. They don’t remember their login. They don’t want to mess with it.

Craig Kartchner (20:13):
They want to be able to do everything they can do in MyChart without logging into MyChart. It’s this struggle because MyChart is you put such an investment in your EMR, hundreds of billions of dollars over the lifetime in your EMR and you want utilize. If there’s a tool they offer, you want to utilize it because it’s free, you’ve already paid for it.

Craig Kartchner (20:32):
It’s finding out what people are willing to log into and enjoy MyChart and it’s good experience versus the things they hate and resist, and won’t use it for. Trying to accommodate both sides. Use this, a powerful tool that you invested in, but also investing in best in class, regardless of whether it’s your EMR or not. There were some surprises there too.

Chris Hemphill (20:56):
Interesting. Can you tell me more about those surprises?

Craig Kartchner (21:01):
If you think about MyChart specifically and some of the tools that it offers, we, you found that this is pretty demographic. People don’t have a relationship with their physician like they once did. That relationship used to be sacrosanct. Your dad went to this doc and you go to the same doc, all your siblings, go to the same doc.

Craig Kartchner (21:22):
She probably lives in the neighborhood. Maybe if you can’t pay, you could barter a service instead. That’s the way the relationship used to be long time ago was that way, family friend, family neighborhood doc. Then into the maybe not neighborhood doc anymore, but at least a very solid relationship.

Craig Kartchner (21:39):
You would never think of going to a different doctor. It’s not that way anymore. Your go-to is convenience is king. You’ll go wherever you can get your script the fastest or get whatever you need solved as quickly and easily as possible. Things like asynchronous care, this was another surprise, sorry, long lead up to get to the surprise.

Craig Kartchner (21:58):
We turned on the Epic at MyChart asynchronous care. Basically, you fill out a form and it’s not for every service, but there are many services that you can fill out this form and submit it. Within 24 hours you will get a diagnosis and/or treatment plan. Based on how you filled out that form.

Craig Kartchner (22:19):
We did exactly nothing to market it, zero marketing because we just weren’t to that point yet. We were intended to market it, turned it on and got it all operationally working. We were amazed at how many people used it. They found it in MyChart, used it, loved it, left good reviews and referred others to use it as well.

Craig Kartchner (22:40):
We literally spent zero on marketing that surprised me too that people would. The uptake for telehealth wasn’t quite as fast, but asynchronous care was. People loved that. Surprised by that.

Chris Hemphill (22:55):
I love it. I love these surprises that by starting to look at this, starting to measure it. You start ending up finding out why it was not a good idea to rely on preconceived notions.

Craig Kartchner (23:09):
Telehealth, we found it further research, sorry to interrupt Chris, but we found that for telehealth video visits, there was intimidation around the platform. Not just if it’s secure, although that was a concern, but people weren’t as accustomed when we were doing this survey two years ago with the video portion of it.

Craig Kartchner (23:27):
What system are they using? Will my phone be compatible and don’t know how the video works? I look hideous today cause I’m sick and I haven’t put on my makeup. Do I want someone to see me? There were all these things that went into it. Maybe that’s part of the reason we found that’s part of the reason that people didn’t adopt telehealth as quickly as we thought they might.

Craig Kartchner (23:42):
Whereas a synchronous care, you’re at work and you can do that on the side. You don’t have to interrupt for an actual video visit, just fill out this form. There’s no question about whether your phone or your computer, your platform is going to accommodate it, because it’s just like a text document.

Craig Kartchner (24:00):
Well, maybe that’s why we were surprised by that, but maybe we shouldn’t have been surprised by that because like, “Well, it fit their modality, it fit the way they wanted to operate.”

Chris Hemphill (24:08):
Amazing. The fact that it was on their time. I can only imagine just not having to do any scheduling, but just get the information that I need. Wait a little bit and then send the information I need, wait a little bit and get the information I want. I’m thinking that somewhere near 100% of the viewers of this are going to want to get started.

Chris Hemphill (24:30):
I’m wondering what your advice is, hearing these surprises, hearing the different insights that have led to strategic shifts and better direction of your investments. As you outline early on starting is hard. The marketer or the director or the VP who’s watching this, what are some steps that they can start doing personally to start getting adoption or interest around this in their own organizations?

Craig Kartchner (25:01):
That’s a great question. I think it’s a key question. I think it’s communication and talking and it’s multidisciplinary. This probably sounds so obvious, but it really is fundamentally the most important thing to do. You need to ultimately build a multidisciplinary team to tackle CX.

Craig Kartchner (25:19):
To implement the technologies, to change the culture, to change the procedures in order to improve CX of focus on that. You’re not going to get to that structure of an actual CX department, CX team, multidisciplinary team to do that right off the bat. It’s not possible. Just start with conversations.

Craig Kartchner (25:38):
If you’re in marketing, like you said, start with conversations with your IT department. What projects are they working on and what drives them? Even specifically around CX talk to them about your patient portal, what are you working on in the patient portal?

Craig Kartchner (25:54):
Who’s driving it? What clinicians and operations leaders are telling you asking what to do and putting in requests, talk to them. What matters to the clinicians? What’s most frustrating to their patients? We did a lot of human-centered design and of really watching, talking with clinicians, and watching the way that patients interact with their clinicians.

Craig Kartchner (26:14):
What they do in the waiting room and how the front desk interacts with the patient? Talk to them. Talk to the frontline staff, they’re the ones who interact with patients all day, every day. Find out the things they hear the questions they hear, what frustrates and angers the patients they interact with, and so on.

Craig Kartchner (26:31):
That’s going to give you not just a list of pain points and things you know you need to work on, and potential solutions, ideas for solutions to solve those problems. Also, you’re already starting to coalesce the team. You’re already starting to figure out the people who matter, who are the decision makers and who understand patients, and what the clinicians are going through.

Craig Kartchner (26:51):
You’re starting to form that informal team that you can slowly formalize over time once you get that governance process more and more ingrained.

Chris Hemphill (26:59):
That’s a great way to look at it. It’s not just data. It’s not just pulling in a bunch of different reports and coalesce and saying, “Here’s a number.” It’s a network of relationships that you need to establish to even be able to address and act on whatever score the scores end up being once you’re through that process.

Craig Kartchner (27:17):
That’s the truth. Something you said triggered something in my mind that you have to focus on data relentlessly, measure results, have data integrated in the right way so that you can analyze it and measure it properly. Data isn’t everything you need.

Craig Kartchner (27:35):
I imagine naively, probably, that I’d show data to the right leaders and they’d say, “We didn’t realize that now that you showed us the data going to change everything.” Of course, that’s laughable, it didn’t happen that way. Even things like online scheduling. I would show a clinic lead, a clinic manager, or a medical group leader the data that how the slots were being used and how they’re being scheduled online.

Craig Kartchner (27:59):
Now, it’s not optimized and there’s a lot of work to do. The response was like, “Well, it’s complex. You don’t know how it is, Craig. You’re in marketing. This doc has unique needs and this doc has a different patient data, better patient base than this doc. You probably just don’t get it.” That was the reaction, I was flabbergasted.

Craig Kartchner (28:20):
They’re right in a way. That’s why it’s communications really under ending the needs and frustrations, and their stories. That’s what makes the difference. That’s why I say the communication, I believe, is more important than anything else to start out.

Craig Kartchner (28:37):
You need the data, but you got to start with the communication and then weave in the data, and always focus on the what’s in it for me, it’s the with them.

Chris Hemphill (28:47):
It sounds like we need the data and we also need the buy-in for the people that can act on the data.

Craig Kartchner (28:52):
That’s about relationships, which is about communication.

Chris Hemphill (28:56):
Well, I love where we’ve gone with this conversation. Imagine a lot of other people might love it too and we just want to get in touch with Craig. I was curious, what’s the best way folks can reach out to you?

Craig Kartchner (29:05):
I can only hope that people are interested enough to flood my inbox. That sounds super cool, but I’m not as cool as Chris Hemphill. If you do want to get in touch with me, ckartchner@honorhealth.com is my email address.

Craig Kartchner (29:20):
I’m probably @CraigKartchner on Twitter and on LinkedIn, I’m probably even more active on LinkedIn. Reach out to me. That’d be great.

Chris Hemphill (29:27):
Cool. Get in touch with Craig. We are excited to have been able to meet Craig in person and have this conversation. For those that would like to have that conversation too and are focused on the consumer experience, feel free to reach out to him.

Chris Hemphill (29:40):
What we did this for was to bring you a little taste of HMPS. We hope you’ve enjoyed the little slice that we’ve given you.

Voiceover (29:47):
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