Skip to main content
Sep 21 2011

Digital Patient Bill of Rights: check!

By cancer, e-patients, healthcare industry, participatory medicine

A group of about 20 passionate e-patients, including e-Patient Dave his own self and yours truly, gathered around a biiiiig table on Monday in Philadelphia to talk about what an e-patient Bill of Rights might look like. I have to give a shout-out to my buddies at WEGO Health, particularly Jack Barrette, Bob Brooks, and Natalia Forsyth

e-patients imageOne conclusion: don’t call it the e-patient Bill of Rights. Since we’re talking digital healthcare, let’s call it the Digital Patients Bill of Rights. That conclusion was reached hours into the discussion, which ranged over topics from chronic conditions like diabetes, HIV/AIDS, multiple sclerosis, rheumatoid arthritis, lupus, multiple sclerosis, and fibromyalgia to acute illness like cancer.

We had about four hours to hammer out a first-principles statement, and Mark Bard of the Digital Health Coalition deserves the Cat-Herding Nobel Prize for keeping a group of vocal, passionate, diverse e-patients on task.

To lift directly from the Klick Pharma blog (Klick was one of the sponsors of the event, along with Pixels & Pills, Health Central, Care Coach, Kru Research, Radian 6, Red Nucleus, Think Brownstone, Verilogue, and a who’s who of health media sponsors):

“After an intense four hours, we were able to reach consensus on the following key messages as a foundation to a Digital Patient Bill of Rights:

  • Shared access to my data
  • Attitude of collaboration and overall respect
  • The patient is the largest stakeholder
  • Transparency and authenticity across all areas
  • Voice of the patient is a legitimate (clinical) source
  • The right to efficient communication with providers who utilize the technology that we need”

It’s a start. A damn good one. The Klick Pharma blog post also has a full list of all the e-patients who participated in the conversation. It was quite a day.

Some of my thoughts about the conversation, and the event:
  • Those dealing with chronic conditions have an even deeper need to be activist e-patients. They also have a greater level of knowledge, and can be true leaders in this on-going discussion.
  • Each healthcare consumer – formerly known as “patient” – must take action and responsibility on his/her own behalf. And not shut up until they get what they need to achieve the best health possible.
  • Having town-hall meetings across the country, inviting community members – healthy, chronic, whatever – to attend, to share, and to learn how to both be consumers of healthcare and advocates for the family members who depend on them, would be a great way to keep the ball rolling and drive wide awareness/support for empowered, engaged e-health.
  • Those of us who’ve taken a trip through the medical care car wash have a duty to share our stories, to lead, to educate, to shake up the status quo, to effect change. We get the elected representatives, and the healthcare, we deserve.

Have any thoughts on what you’d like on your Digital Patient Bill of Rights? Tell me.

It’s your health, your healthcare, your life, your choice. Exercise it.

Sep 19 2011

Being in business means you’ll ALWAYS have to say you’re sorry.

By PR

sorry in the sandI don’t care what being in love means regarding saying you’re sorry. Personally, I think Erich Segal’s book sucks, but I digress.

If you’re in business – running one, managing one, working for one – you’re in the apology business. In fact, being human puts you in the apology business 24/7/365. And business always needs a good dose of human, particularly in the age of the 24-hour news cycle and the Facebook Fan Page wall post.

Not being human, and being willing to admit you made a mistake? #fail.

In a great post on INC.com, Tim Donnelly gives very solid tips on how to approach the brand apology when your business screws the pooch. His #1 tip: just say it. “I’m sorry.” Simple … so why is it so hard for a brand to do that?

I think the root cause of brand cluelessness is that businesses forget that they are, after all, human. They may own skyscrapers in cities around the world, but guess what? Those buildings are full of … people. Doing business with … people.

When your spouse, or your buddy, or your kid do something to hurt you or your feelings, they apologize. You do the same thing when you screw up. (If you don’t, let me know. I know some terrific divorce attorneys.) Same rules apply if you’re J.C. Penney, the example that Donnelly uses in his piece.

Be human, don’t be a brand-droid.

You don’t have to literally fall on your sword, or drape yourself in sackcloth and ashes (I still have random PTSD episodes from 12 years of Catholic education) to apologize. You don’t have to take responsibility for every goof since the beginning of your brand’s recorded history, either. Just say you’re sorry, and then you can move on.

If your factory releases a cloud of toxic gas that kills a few thousand people, you’ll have to do a little more than say “sorry” – just ask Union Carbide. Oh, right, you can’t ask them, because they never actually said they were sorry about poisoning Bhopal. Which explains why they WENT OUT OF BUSINESS.

See how powerful an apology could be? And how not issuing one might literally kill your business?

Use words that convey regret without taking responsibility for every hurt the offended party has ever suffered. Just saying “I’m sorry” can completely defuse a brand revolt. Couple that apology with a clear outline of how you plan to remedy the hurt: priceless. Really. Try it.

We all make mistakes. We’re human, that’s part of the journey. A business that recognizes its own humanity, and that of its customers, by making a sincere apology when they screw up will ultimately drive more loyalty for their brand than a business that’s 24/7 shiny-happy-people. ‘Cause shiny-happy will eventually fog up, or blow up. Trust me on that one.

Be human.

That’s my story, and I’m stickin’ to it …

Sep 12 2011

“Screw it, let’s do it.”

By healthcare industry

The headline on this post is the title of Richard Branson‘s business memoir. The full title: Screw It, Let’s Do It: Lessons in Life and Business. The link will take you to the book on Amazon, so you can just do it and buy the book.

I had the opportunity to literally see Branson in action on Friday, 9/9/11 at Richmond Unite’s #DSRPT11 conference right here in River City (Richmond VA), which also featured some other visionary thinkers who exhorted the crowd in attendance to get out of their business comfort zones and create some disruption.

Richard Branson has disrupted many industries: music, aviation, travel, mobile, broadband, just to name a few. He talked about his failures (Anybody here remember Virgin Cola? Yeah, me neither.), and was anxious to convey the message that his “screw it, let’s do it” rallying cry became even more important to him because of those failures. There is only do, or not do. There is no try. Thanks, Yoda.

The other big thinkers on the stage all shared the same ethos – look beyond what you perceive as your borders, whether those borders are physical, mental, geographical, or just imaginary. If you have an idea, chase it down and make it real. If you fail, get up and chase the next idea. Immobility is your only enemy.

One of the speakers, Harry Singer, said two things during his presentation that really stuck with me, and with other folks I talked to at #DSRPT11:

  • Don’t ask why, figure out how 
  • Don’t tell them what it is, tell them what it does

The first is something we should teach children from birth, and keep on teaching them and each other throughout our lives. The second is a titanium nugget if you’re in sales or marketing: what your product or service does for your customers is much more important than what it is. Communicate the doing rather than the being.

Kelly O’Keefe, a branding guru who’s also on the faculty of Virginia Commonwealth University’s Brandcenter – which is one of the top design schools in the world – spoke about the opportunities present in our current economic downturn to focus on social entrepreneurship. He talked a lot about Detroit – his home town – and the true crisis that city has been in since the Japanese started eating the lunch of Detroit’s Big 3 car makers. That crisis has deepened into a catastrophe as the global economy has imploded. Kelly said it was the outliers – the nerds, the artists, the revolutionaries – who were making a true difference in Detroit, and helping that city rise from its own ashes.

I too had the opportunity to take the stage.  I was to have eight minutes, and was invited to create a slide deck for it, which I did. My slice-o-time was to be during lunch. As will happen, the morning speakers ran long, and since Richard Branson was to take the stage at about 3:30pm, the time was to be made up during lunch come hell or high dudgeon. Each of us would have only TWO minutes, no slides. Two of the eight presenters dropped out because their presentations were so visual. The remaining four that weren’t me did what they did, some ran over.

I was always slated to be the last speaker. My topic was that patients need to seize control of healthcare, which is the only sane path to real and meaningful healthcare reform, no matter what your politics are. I knew I had to do two things: Keep it tight – I took the stage at 1:26pm, the afternoon session was starting ON TIME at 1:30pm – and, since there was a post-lunch food nap induction driven further snooze-ward by the fact that the attendees had been in their seats since 9:00am, WAKE ‘EM UP.

My attitude? Screw it, let’s do it.

Here’s a from-the-seats clip of the last :56 of my total 1:48 (I timed myself like every pro speaker must). The full version will get posted as soon as I get it from the video group who did the gavel-to-gavel coverage. Let me know what you think – I really DO want to know.

That’s my story, and I’m stickin’ to it …

Sep 05 2011

How to de-power your PR in a crisis

By PR

power outage sign imageOn August 27, a very angry Hurricane Irene came calling all up and down the east coast, including Virginia – which is where I live. I have plenty of hurricane experience, including a sojourn 500 miles offshore in a schooner during a Category 1 hurricane. I don’t recommend that experience unless you really want to know what your laundry feels like on max-agitate in your washing machine.

Landmasses with human habitation that are visited by hurricanes always have plenty of wind and flooding damage, and our experience with Irene was pretty typical. Lots of trees were knocked down, which took a lot of power lines with ’em, meaning that lots of local utility customers were in the steamy dark once Irene blew town.

#1 cause of a PR crisis: lots of unhappy people.

No one – at least, no one with a mature level of life experience – could have expected Dominion Virginia Power to restore everyone to lighted bliss immediately. Those of us who were here during Hurricane Isabel (hurricanes with “I” names must hate the Commonwealth of Virginia) knew we were in for a sweaty, dark few days, at least.

Crews from utilities in surrounding states came in to help Dominion crews get us all lit up again. They are still working their butts off, and they are most certainly not the target of this post’s ire.

Because Dominion has truly screwed the PR/crisis-comms pooch on Irene’s aftermath.

All the interactive outage maps in the world – and Dominion has some great ones – mean squat to customers who have to huddle in a local Panera or library to view them. Announcing where crews are working via local media is of some help.

What Dominion failed to do, however, was put a face on the problem. One of their top leadership team needed to become the face and voice of Dominion as they worked to restore their customers to the grid. As I write this – Sunday, Sept. 3 – 20% of Richmond-area customers are still without power.

That means that 1 out of 5 Dominion customers in this region are still in a Bronte novel, at least at night, wandering from room to room clutching candles. The contents of their refrigerators and freezers are long gone, and if they have an all-electric kitchen, they ain’t cooking dinner, either.

No one from Dominion’s senior leadership has been very visible during this event. The company’s Facebook page has been the wall where the unhappy sweaty scrum have been posting their displeasure, which has only compounded the problem, since the person or persons who manage the page seem to be as clueless as the rest of us. One response they posted in reply to a customer’s inquiry about the fact that the middle of a street was still dark, while the houses at each end had been restored:

I am sorry, we aren’t quoting specific restoration times. I don’t have the level of operations information you are looking for.

Why on earth is the person who is representing a utility on a major social network NOT given access to operations information at a meaningful level? This tells me that Dominion views social media as a one-more-thing activity, rather than a key communication tool.

#fail

For next time, here are my recommendations. Dominion may or may not ever see these, but I already feel better for posting them.

  1. Make a top leader the face and voice of the company during the crisis.
  2. Have that face-and-voice respond to media inquiries at least daily, if not more frequently. What that leader says must be mirrored in/on every online outlet for customer-facing company information … which includes Facebook, Twitter, YouTube, et al.
  3. If you don’t know, say “I don’t know.” Shiny-happy-people, pie-in-the-sky, promise-the-world will only lead to the gnashing of teeth and rending of garments. Possibly yours.
  4. Tell the truth. This goes hand in hand with #3.
Simple. Works for a utility, a consumer-products company, a hospital, a factory. Have a leader lead, tell the truth.
That’s my story, and I’m stickin’ to it …
Aug 29 2011

#1 thing NOT to do on LinkedIn

By PR

linkedin-logoThe #1-with-a-bullet rule of social media, no matter what platform, is: be authentic. This does not mean that you should be an authentic idiot, however.

I had a troubling conversation on LinkedIn a few days ago, with someone who sent me a connection request. I’m a pretty open networker – my only rules are

  • Have a profile picture of your face, not a logo
  • Be a human, with a name, not a brand or a handle
  • Be able to answer the “how did I wind up on your LinkedIn radar?” question effectively

All three of those guarantee acceptance. Any one of them missing, “ignore”.

So when a woman in my geographic zone sent me an invitation to connect, and had cleared the first 2 of the above rules, I pinged her with a “how” – and that’s where things got interesting. She told me that she was looking for a job, and a recruiter told her that she wouldn’t even get a look if she didn’t have at least 150 LinkedIn connections.

In other words, the recruiter was basically telling her that she needed to gather up connections quickly. Which is, in my estimation, really rotten advice. I’m not against the idea of a dedicated campaign to make meaningful professional connection on LinkedIn, or any other social media network. I do, however, question a recruiter instructing a potential client to essentially spam her address book. That’s likely to get you the LinkedIn bitch-slap, which can be as painful as being kicked off LinkedIn, and at a minimum highly circumscribed on the invitation-to-connect front.

Authentic connection takes time. I’ve been on LinkedIn since 2004, and my connection count of 1,000+ is a testament to my approach of authenticity. I don’t meet all my connections face-to-face – wish I could, since some of them are in Asia and Africa, meaning that meetings would satisfy my travel jones as well as my deepen-the-connection mantra. But I manage to keep tabs on the people I’m linked to, and have picked up both great business intel and actual booked business using my “authenticity” rules.

If you’re a recruiter, or work in HR in any way, be aware of the rules you require those you work with to live by. Focus less on number of connections, and more on how meaningful a candidate’s connections are.

Ragan.com, a must-read site for anyone interested in business storytelling, had a terrific post last week by Jure Klepic, 12 LinkedIn gaffes to avoid at all costs. It’s both funny and informative. Give it a read.
That’s my story, and I’m stickin’  to it …
Aug 22 2011

How far would you go for medical treatment?

By healthcare industry

medical tourism imageNo, not how far you’d go in the Denzel Washington/John Q/hold-a-hospital-hostage sense. In the get-on-a-plane-toward-care sense.

Medical tourism has seen an exponential rise with patients in the US as health care costs and the number of uninsured patients have risen over the last 15 years. In a TIME magazine piece in 2006, Curtis Schroeder, CEO of Bumrungrad Hospital in Bangkok – somehow, I don’t think he’s Thai – said that in 2005 their census of US patients rose 30% (to 55,000).

That trend has continued, even with the advent of “health care reform” – health insurance reform, really – since health care costs have continued their hockey-stick rise, with no end in sight, for two decades.

50 years ago, patients from across the globe saw health care in the US as the holy grail. Now, US patients are traveling to Costa Rica, Thailand, Mexico, New Zealand, even Cuba to get access to high-quality, low-cost care.

US companies have started to explore medical tourism, and some are offering  incentives to their employees – incentives including getting to pocket some of the savings gained from traveling abroad for treatment. Not enough, however, to make medical tourism a healthy industry here in the US of A.

An August 2011 article in Workforce Management includes a story about a nurse in Louisiana (irony is our favorite thing here at Mighty Casey Media) who traveled to Costa Rica a few years ago for dental work, including oral surgery. She paid $2,700 out of pocket for what would have cost her $10,000 at home, with her employer covering $1,500 of her care expenses. Her net cost for the procedures was $1,200, plus her travel expenses – which travel was negotiated and arranged by a broker, Companion Global Health Care Inc.

I’m sure that, even after travel expenses, her savings were still solidly in the thousands of dollars.

So why aren’t more US companies encouraging their employees to take advantage of medical tourism? According to the CEO of Companion Global, David Boucher – who certainly has a dog in this fight, and who is quoted in the Workforce Management article linked above – the rising costs of health care make the health-tourism choice a no-brainer. He says that their customers are seeing a 2- or 3-to-1 return on investment for medical tourism, and patients – their customers employees – are very satisfied with the quality of their care.

However, according to Joe Marlowe, senior VP of health and productivity at the risk-management and HR consulting firm Aon Hewitt who’s also quoted in the WM story, employers are risk-averse, particularly at the idea of making themselves liable for medical care far from home that turns out badly for the patient.

What do you think? Would you travel 8,000 miles for a knee replacement, or 3,000 for chemotherapy, to save a significant amount of money and still receive high-quality care? Or would you want to be closer to your support system – family, friends – while receiving care?

I would most certainly travel to Bangkok or San Jose for a knee replacement. Not sure about oncology, since that follow-up can be so long-term.

You? I really would like to know.

That’s my story, and I’m stickin’ to it …

Aug 15 2011

From viral to vicious can be a short trip

By Uncategorized

I consider London to be one of my home-towns – I grew up in a government-service family, we moved frequently, and one of the places we called home was London in the ’60s and ’70s.

London burns

I watched, with deep sorrow, as large parts of Greater London, and then Birmingham, fell under the torches and bricks of rampaging looters, ostensibly in protest of the death of Mark Duggan in Tottenham during what was either a traffic stop or a drug-squad operation. Whichever version is true, the aftermath was crystal clear: chaos.

Fueled by SMS technology, unrest armed with bricks and gasoline spread like wildfire across the London suburbs: Tottenham, Ealing, Barnet, Camden, and a host of other communities became war zones. Scotland Yard was caught flat-footed, with the recent leadership shake-up driven by the Murdoch mess getting blamed for their slow response.

The viral nature of 21st century communication is a powerful tool – for good, or for ill. Like the viruses it takes its name and nature from, “viral” has no morals. It just knows one thing: SHARE ME.

The danger compounds itself by what’s usually seen, in the heat of the moment, as the only way to prevent chaos, to control the message: shut down free access.

That’s what governments in the Middle East are doing to shut down their citizens’ demands for free democracy, and what the British government was asking companies like Research in Motion (the Blackberry folks) to help them do: shut down the viral vector. SMS technology, social sharing.

It’s a dangerous game, that shutting-down. Because once you’ve started, where and when do you stop? When the High St. stops burning? When the last street is cleaned? After some kind of vetting-council “approves” you for re-connection to Facebook?

The lesson here is the same one I advise businesses to take with their communication strategy: LISTEN FIRST. If governments – be they in Lagos or London – have an active listening program in place, they’ll know that they have a problem before it literally bursts into flame.

That’s true for corporate governance, civic governance, every part of human endeavor. Mark Duggan’s death may have been the match that lit the flame, but the fuel was laying all over the ground long before that match was struck.

When it comes to your community, are you LISTENING? To your fellow citizens, to your customers, to  your constituents?

Failure to use your ears will mean you’ll have to learn how to use a fire extinguisher. Which is really challenging when your house is already on fire.

That’s my story, and I’m stickin’ to it …

Aug 08 2011

A funny thing happened on the way to the dairy counter

By media commentary

When I was still doing stand-up, one of my compadres had a regular bit where her punchline was “women: we make milk. We make eggs. We’re a dairy!”

I’m a big fan of the dairy. No, not the human variety, the kind you find in grocery & gourmet stores. So imagine my surprise when I saw the latest ad campaign from the US Milk Board. The Milk Peeps have been riding on “got milk?” for almost 20 years.

It seems that they saw a niche messaging opportunity, and ran with it. Did they run over a cliff? You be the judge.

got_pms_ad

I’m a big fan of the funny, as you know. However, when you deploy the funny in service of a brand message, you’ve got to make sure that everyone in your intended audience is on board. Women howled in protest from sea to shining sea when the campaign was launched about 4 weeks ago.

As someone who knows PMS only too well – totally an insider, trust me – I would have advised the Milk Peeps to make a woman the face of the campaign. She could warn her boyfriend/husband/boss/random strangers that their lives might be at stake unless dairy products were brought forth right-damn-now.

And it wouldn’t hurt to add some commentary on the potential risks of drinking milk that has rBGH (a/k/a bovine somatotropin, or bovine growth hormone) in it: like the pus from mastitis – udder infection – that cows who get pumped full of the stuff wind up suffering from. Who needs that, right?

The campaign has certainly kicked off some buzz. I don’t think it’s exactly the buzz that the Milk Peeps were looking for, but buzz is, after all, buzz. Just ask Rupert “help-I’m-strapped-to-a-buzz-saw” Murdoch.

That’s my story, and I’m stickin’ to it …

 

Aug 01 2011

Want to add humor to your message? Hire a comedy writer. Really.

By Uncategorized

It’s fascinating to watch something take hold in the zeitgeist (look it up). Particularly when it’s something that has been solidly planted in one’s own personal zeitgeist for … ever.

The hot topic in business social media right now is humor. As in “bring the funny to get attention and customers” – which is true, but is also a dangerous recommendation.

Riddle me this: if laughter is the best medicine, why aren’t more doctors telling great jokes? Other than Ken Jeong, and he’s not actually seeing patients any more.

Recommending that marketing teams use humor is like tossing your 16  year old the car keys and saying, “you’re old enough, go drive!” It might be true, but it’s very dangerous, and it’s likely to end in tears and big legal bills.  Just ask Aflac – their recent experience with business humor via their loose cannon of a spokes-duck pitchman, Gilbert Gottfried, did exactly that.

Here’s what you have to do to put humor to work for your corporate messaging strategy: hire a comedy writer. One who understands both comedy AND business. Who can work with you to identify what makes your target customer(s) laugh, who can help you build some organic and authentic comedy that will make your message penetrate and motivate your audience.

Full disclosure: I’m a writer. I’ve done stand-up for years. I haven’t pushed the comedy thing much in the business arena over the last couple of years because whenever I did, it was to the sound of … well, not silence exactly. It was more like speaking Urdu to a room full of Inuit: blank stares.

The key here is that combination of humor and business sense. You have to understand strategic brand messaging in order to stand it on its ear.

Using humor in social media requires a clear view of your audience, an understanding of what that audience reacts to, and some special-sauce experimentation – one of which sauce’s key ingredients is the willingness to look/act funny – to create funny-with-intent content.

Willing to take a small risk that could pay off large? Hire a comedy writer, let that writer work with your marketing team, your sales team, your ad agency, your PR firm. Shake well, stir frequently, keep the heat level and even. Then, when the sauce is blended just-so, pour it on. And don’t forget to measure the results – we are, after all, talking about your business. And you cannot improve anything that you do not measure.

That’s my story, and I’m stickin’  to it …

Jul 27 2011

Data, Data, Who’s Got My Data?

By e-patients, EHR, health records, healthcare industry, medical records

 I’ll totally get one. Srsly.

I confess that I’d happily get a barcode tattooed on my neck if it meant I’d never have to fill out another ****ing health history form in a doctor’s office.

I’m totally serious.

Paper records are so … 19th century. With the advent of the current iteration of “health care reform” (which is really “health INSURANCE reform,” but that’s a blog post for another day), much has been made of the importance of Electronic Medical Record (EMR) systems in building a national Health Information Exchange (HIE).

Medicine = Acronym World. The Pentagon are pikers when it comes to fogging the battlefield with impenetrable letter-fication.

21st century health care certainly must involve a lot of easily-shared data, with health history and diagnostic information traveling literally at light speed between doctor’s offices, hospitals, and clinics. Not only does it speed care, it can ensure safety: the right record, with the right patient, makes the right care clear.

The thorny-issue part is this: whose data is it, anyway? Doctors certainly need to have full access to all the data on patients they’ve treated. Hospitals have to keep records on the people they’ve treated on their wards, in their clinics, and in their ORs. Payers (insurers, Medicare, Medicaid, et al) need data access to pay claims, track demographics, and create statistical and financial forecasts. And patients must have access to their own data, at minimum to vet it for errors, at best to own a full copy of their health history since birth to share with providers and care-givers.

I spent 8 months trying to correct an error on the report for the breast MRI I had in 2008 as preparation for my cancer surgery. The report said “family history of breast cancer.” NO. I was Patient Zero, there was NO family history of breast cancer. I fought for eight months, and I’m still only about 90% convinced the error is completely expunged. Patients need access, and we also need easy recourse to error-correction.

Back to EMRs and data exchange: access to patient data must be completely available to all concerned parties. That means doctors, healthcare facilities (hospitals, clinics, et al), and PATIENTS. However, the discussion about healthcare technology almost never includes patients. We’re considered, at best, bystanders; at worst, annoying insects.

E-Patient Dave DeBronkart – Mr. Gimme My Damn Data himself – was the 1st person I heard use the term “e-patient”. The E stands for empowered, engaged, enabled, equipped, equal – not electronic, although that’s certainly a supporting foundation for the e-patient movement. E-patients are usually placed in the “annoying insect” category by healthcare providers who don’t want to share – which can include payers, who can turn a simple record request into a Bleak-House level of bureaucracy. The most epic story in recent history, IMO at least, is Regina Holliday’s now-famous 73 Cents post (and the painting it talks about) – charging patients for access to their own data (at 73 cents a page) borders on the immoral, if not the criminal.

In the long slog through working groups, committees, implementations, and reports-to-the-board that is EMR and HIE development, don’t let the healthcare system leave us – the patients – out of the conversation.

It might be their data, too – but at root, and always, it starts with us. It’s theirs, yours … ours.

Data, Data, Who’s Got My Data?
Close Menu