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Similarly, statements that describe our future plans, objectives or goals are also forward-looking statements.
−Removed: In this Annual Report on Form 10-K, statements regarding the future impact of adopting new accounting standards, value and utility of, and market demand for, our service offerings, future opportunities for growth and respect to new and existing clients, our future ability to compete and the types of firms with which we will compete, future consolidation in the healthcare industry, future adequacy of our liquidity sources, future revenue sources, future capital expenditures and the sources of cash to fund such capital expenditures, the expected impact of pending claims and contingencies, the future outcome of uncertain tax positions, our future use of owned and leased real property, the source of funds for future payments of deferred purchase price obligations and other cash expenses, the future phase out of LIBOR and applicable replacement benchmark rates and the expected impact of the COVID-19 pandemic and related government mandates and recommendations, among others, are forward-looking statements.
+Added: In this Annual Report on Form 10-K, statements regarding the future impact of adopting new accounting standards, value and utility of, and market demand for, our service offerings, future opportunities for growth with respect to new and existing clients, our future ability to compete and the types of firms with which we will compete, future consolidation in the healthcare industry, future adequacy of our liquidity sources, future revenue sources, future revenue growth, future revenue estimates used to calculate recurring contract value, future capital expenditures and the timing, amount, and sources of cash to fund such capital expenditures, future stock repurchases and dividends, the expected impact of pending claims and contingencies, the future outcome of uncertain tax positions, our future use of owned and leased real property, the source of funds for future payments of deferred purchase price obligations and other cash expenses, the future phase out of LIBOR and applicable replacement benchmark rates and the expected impact of the COVID-19 pandemic and related government mandates and recommendations, among others, are forward-looking statements.
Such forward-looking statements are subject to certain risks and uncertainties which could cause actual results or outcomes to differ materially from those currently anticipated.
Factors that could affect actual results or outcomes include, without limitation, the following factors:
−Removed: The likelihood that the COVID-19 pandemic will adversely affect our sales, earnings, financial condition and liquidity;
−Removed: The possibility of non-renewal of our client service contracts and retention of key clients;
+Added: The likelihood that the COVID-19 pandemic will adversely affect our operations, sales, earnings, financial condition and liquidity;
+Added: The possibility of non-renewal of our client service contracts, reductions in services purchased or prices, and failure to retain key clients;
Our ability to compete in our markets, which are highly competitive with new market entrants, and the possibility of increased price pressure and expenses;
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The possibility for failures or deficiencies in our information technology platform;
−Removed: The possibility that we could be subject to cyber-attacks, security breaches or computer viruses;
+Added: The possibility that we or our third-party providers could be subject to cyber-attacks, security breaches or computer viruses;
The factors set forth under the caption “Risk Factors” in Part I, Item 1A of this Annual Report on Form 10-K and various disclosures in our press releases, stockholder reports, and other filings with the Securities and Exchange Commission.
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The forward-looking statements included are only made as of the date of this Annual Report on Form 10-K and we undertake no obligation to publicly update such forward-looking statements to reflect subsequent events or circumstances, except as required by the federal securities laws.
−Removed: Our purpose is to establish human understanding.
−Removed: Our solutions enable health care organizations to understand what matters most to each person they serve.
−Removed: We are a leading provider of analytics and insights that facilitate measurement and improvement of the patient and employee experience while also increasing patient engagement and customer loyalty for healthcare organizations.
+Added: Our purpose is to establish human understanding by enabling our clients to understand what matters most to each person they serve.
+Added: We are a leading provider of analytics and insights that facilitate measurement and improvement of patient engagement and customer loyalty for healthcare organizations.
Our heritage, proprietary methods, and holistic approach enable our partners to better understand the people they care for and design experiences that inspire loyalty and trust, while also facilitating regulatory compliance and the shift to population-based health management.
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Our expertise includes the efficient capture, transmittal, benchmarking, analysis and interpretation of critical data elements from millions of healthcare consumers.
−Removed: Using our digital Voice of the Customer platform, our clients gain insights into what people think and feel about their organizations in real-time, allowing them to build on their strengths and resolve service issues with greater speed and personalization.
+Added: Using our solutions, our clients gain insights into what people think and feel about their organizations in real-time, allowing them to build on their strengths and resolve service issues with greater speed and personalization.
We also provide legacy experience-based solutions and shared intelligence from industry thought leaders and the nation’s largest member network focused on healthcare governance and strategy to member boards and executives.
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We partner with clients across the continuum of healthcare services.
−Removed: Our clients include integrated health systems, post-acute providers and payer organizations.
We believe this cross-continuum positioning is a unique and an increasingly important capability as evolving payment models drive healthcare providers and payers towards a more collaborative and integrated service model.
−Removed: We have achieved a market leadership position through our more than 39 years of industry innovation and experience, as well as our long-term, recurring revenue relationships (solutions that are used or required by a client each year) with many of the healthcare industry’s largest organizations.
−Removed: Since our founding in 1981, we have focused on meeting the evolving information needs of the healthcare industry through internal product development, as well as select acquisitions.
−Removed: We are a Wisconsin corporation headquartered in Lincoln, Nebraska.
−Removed: Our portfolio of solutions represents a unique set of capabilities that individually and collectively provide value to our clients.
−Removed: The solutions are offered at an enterprise level through the Voice of the Customer platform, The Governance Institute, and legacy Experience solutions.
−Removed: We partner with clients across the continuum of healthcare services.
−Removed: Our clients include integrated health systems, post-acute providers and payer organizations.
+Added: We have a broad and diversified client base that is distributed primarily across the United States.
Our ten largest clients collectively accounted for 14%, 14%, and 16% of our total revenue in 2021, 2020 and 2019, respectively.
Approximately 2%, 2% and 3% of our revenue was derived from foreign customers in 2021, 2020, and 2019, respectively.
−Removed: Voice of the Customer Platform Solutions
−Removed: Our Voice of the Customer (“VoC”) platform represents a portfolio of solutions that collectively provide a comprehensive set of capabilities that enable healthcare providers to collect, measure and analyze data collected across the patient journey to understand the preferences, experiences and needs of the people they serve.
−Removed: The digital platform consists of three primary solution categories which can be implemented both collectively as an enterprise solution or individually to meet specific needs within the organization.
−Removed: The primary solution categories include Market Insights solutions, Transparency solutions, and certain Experience solutions.
−Removed: Our solutions within the digital VoC platform accounted for 73.3% of total revenue in 2020.
+Added: We have achieved a market leadership position through our more than 40 years of industry innovation and experience, as well as our long-term, recurring revenue relationships (solutions that are used or required by a client each year) with many of the healthcare industry’s largest organizations.
+Added: Since our founding in 1981, we have focused on meeting the evolving information needs of the healthcare industry through internal product development, as well as select acquisitions.
+Added: We are a Delaware corporation headquartered in Lincoln, Nebraska.
+Added: Human Understanding Solutions
+Added: Our portfolio of solutions collectively provide a comprehensive set of capabilities that enable healthcare providers to collect, measure and analyze data collected across the patient journey to understand the preferences, experiences and needs of the people they serve.
+Added: Our digital solutions consist of three primary solution categories which can be implemented both collectively as an enterprise solution or individually to meet specific needs within the organization.
+Added: The primary solution categories include Market Insights solutions, Transparency solutions, and Experience solutions.
Market Insights Solutions –
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Our Market Insights solutions provide clients with on-demand tools to measure brand value and build brand equity in their markets, evaluate and optimize advertising efficacy and consumer recall, and tailor research to obtain the real time voice of customer feedback to support branding and loyalty initiatives.
−Removed: Our Market Insights solutions were historically marketed under the Healthcare Market Guide and Ticker brands.
Experience Solutions –
−Removed: Our Experience solutions are provided on a subscription basis via a cross-continuum VoC platform that collects and measures data and then delivers business intelligence that our clients utilize to improve patient experience, engagement and loyalty.
+Added: Our Experience solutions are provided on a subscription basis via a cross-continuum multi-mode digital platform that collects and measures data and then delivers business intelligence that our clients utilize to improve patient experience, engagement and loyalty.
Patient experience data can also be collected on a periodic basis using CAHPS compliant mail and telephone survey methods for regulatory compliance purposes and to monitor and measure improvement in CAHPS survey scores.
−Removed: CAHPS survey data can be collected and measured as an integrated service within the VoC platform or independently as a legacy service offering.
−Removed: Our Experience solutions provide hospitals and healthcare providers the ability to receive and take action on customer and employee feedback across all care settings in real-time.
−Removed: Experience solutions include patient and resident experience, workforce engagement, health risk assessments, transitions, and improvement tools, which are provided through the Experience, Transitions and National Research Canada Corporation operating segments.
+Added: Consumer Assessment of Healthcare Providers and Systems (“CAHPS”) survey data can be collected and measured as an integrated service within our digital platform or independently as a legacy service offering.
+Added: Our Experience solutions provide healthcare systems the ability to receive and take action on customer and employee feedback across all care settings in real-time.
+Added: Experience solutions include patient experience, workforce engagement, health risk assessments, care transition, and improvement tools.
These solutions enable clients to comply with regulatory requirements and to improve their reimbursement under value-based purchasing models.
−Removed: More importantly, our Experience solutions provide quantitative and qualitative real-time feedback, improvement plans, and coaching tools to enable clients to improve the experiences of patients, residents, physicians and staff.   By illuminating the complete care journey in real time, our clients are able to ensure each individual receives the care, respect, and experience he or she deserves.
−Removed: Developing a longitudinal profile of what healthcare customers want and need allows for organizational improvement, increased clinician and staff engagement, loyal relationships and personal well-being.
−Removed: These solutions have previously been marketed under the NRC Picker, My InnerView (“MIV”), Customer-Connect LLC (“Connect”), and NRC Canada brands.
−Removed: Our Health Risk Assessment solutions (formerly Payer solutions) enable our clients to understand the health risks associated with populations of patients, analyze and address readmission risks, and efficiently reach out to patients to impact their behaviors outside of the healthcare provider settings.
−Removed: These health risk assessment solutions enable clients to effectively segment populations and manage care for those who are most at-risk, engage individuals, increase preventative care and manage wellness programs to improve patient experience and outcomes.
−Removed: Our Transitions solutions are provided to healthcare organizations on a subscription basis to drive effective communication between healthcare providers and patients in the critical 24-72 hours post discharge using a discharge call program.
+Added: More importantly, our Experience solutions provide quantitative and qualitative real-time feedback, improvement plans, and coaching insights.   By illuminating the complete care journey in real time, our clients are able to ensure each individual receives the care, respect, and experience he or she deserves.
+Added: Developing a longitudinal profile of what healthcare customers want and need allows for organizational improvement and increased customer loyalty.
+Added: Our Experience solutions also include the Transitions solution to drive effective communication between healthcare providers and patients in the critical 24-72 hours post discharge using an automated discharge call workflow supported by our digital platform.
Through preference-based communications and real-time alerts, these solutions enable organizations to identify and manage high-risk patients to reduce readmissions, increase patient satisfaction and support safe care transitions.
Tracking, trending and benchmarking tools isolate the key areas for process improvement allowing organizations to implement changes and reduce future readmissions.
−Removed: Our Transitions solutions were previously provided by Connect.
Transparency Solutions –
Our Transparency solutions allow healthcare organizations to share a picture of their organization and ensure that timely and relevant content informs better consumer decision-making.
−Removed: Our Star Ratings solution (formerly Reputation) enables clients to publish a five-star rating metric and verified patient feedback derived from actual patient survey data to complement their online physician information.
+Added: Our Star Ratings solution enables clients to publish a five-star rating metric and verified patient feedback derived from actual patient survey data to complement their online physician information.
Sharing this feedback not only results in better-informed consumer decision-making but also has the ability to drive new patient acquisition and grow online physician reputation.
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The Governance Institute
−Removed: Our Governance solutions, branded as The Governance Institute (“TGI”), serves not-for-profit hospital and health system boards of directors, executives, and physician leadership.
−Removed: TGI’s subscription-based, value-driven membership services are provided through national conferences, publications, advisory services, and an online portal designed to improve the effectiveness of hospital and healthcare systems by continually strengthening their board governance, strategic planning, medical leadership, management performance, and transparency positioning.
−Removed: TGI also conducts research studies and tracks industry trends showcasing emerging healthcare trends and best practice solutions of healthcare boards across the country.
+Added: Our Governance solutions, branded as The Governance Institute (“TGI”), serves not-for-profit health system boards of directors, executives, and physician leadership.
+Added: TGI’s subscription-based, value-driven membership services are provided through national conferences, publications, advisory services, and an online portal designed to improve the effectiveness of hospital and healthcare systems by continually strengthening their board governance, strategic planning, medical leadership, management performance and customer loyalty.
+Added: TGI also conducts research studies and tracks industry trends showcasing emerging healthcare trends and best practice solutions of healthcare system boards across the country.
TGI thought leadership helps our client board members and executives inform and guide their organization’s strategic priorities in alignment with the rapidly changing healthcare market.
−Removed: For additional information on our operating segments and our revenue and assets by geographic area, see Note 13, “Segment Information,”
+Added: For additional information on our operating segment and our revenue and assets by geographic area, see Note 13, “Segment Information,”
to our consolidated financial statements.
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Pursue strategic acquisitions and investments.
−Removed: We have historically complemented our organic growth with strategic acquisitions, having completed seven such transactions over the past eighteen years.
+Added: We have historically complemented our organic growth with strategic acquisitions, having completed eight such transactions over the past nineteen years.
These transactions have added new capabilities and access to market segments that are adjacent and complementary to our existing solutions and market segments.
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We generate the majority of our revenue from the renewal of subscription-based client service agreements, supplemented by sales of additional solutions to existing clients and the addition of new clients.
−Removed: Our sales activities are carried out by a direct sales organization staffed with professional, trained sales associates.
+Added: Our sales activities are carried out by our direct sales organization staffed with professional, trained sales associates.
We engage in marketing activities that enhance our brand visibility in the marketplace, generate demand for our solutions and engage existing clients.
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Our primary competitors among such specialty firms include Press Ganey, which we believe has significantly higher annual revenue than us, and several other organizations that we believe have less annual revenue than us.
−Removed: We, to a certain degree, currently compete with, and anticipate that in the future we may increasingly compete with, (1) market research firms and technology solutions which provide survey-based, general market research or voice of the customer feedback capabilities and (2) firms that provide services or products that complement healthcare performance assessments such as healthcare software or information systems.
+Added: We also compete with market research firms and technology solutions which provide survey-based, general market research or voice of the customer feedback capabilities and firms that provide services or products that complement healthcare performance assessments such as healthcare software or information systems.
We believe the primary competitive factors within our market include quality of service, timeliness of delivery, unique service capabilities, credibility of provider, industry experience, and price.
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experiences are integral to quality healthcare.
−Removed: This foundation has been enhanced through the digital VoC platform offering that provides the delivery of data and insights on a real time basis.
−Removed: Premier client portfolio across the care continuum.
−Removed: Our client portfolio encompasses leading healthcare organizations across the healthcare continuum, from acute care hospitals and post-acute providers to healthcare payers.
−Removed: Our client base is diverse, with our top ten clients collectively representing approximately 14% of total revenue for the year ended December 31, 2020, and no single client representing more than 4% of our revenue.
+Added: This foundation has been enhanced through our digital platform offering that provides the delivery of data and insights on a real time basis to understand what matters most to each individual.
+Added: Based on our more than 40 years of experience, we are able to deliver unique and relevant healthcare domain expertise to the clients we serve.
+Added: Established client base of leading healthcare organizations.
+Added: Our client portfolio encompasses a majority of the leading healthcare systems across the United States.
+Added: Over 275 of the top 400 healthcare systems based on net patient revenue are currently using one or more of our solutions.
+Added: Our client base provides a unique network effect to share best practices among existing clients and to attract new clients.
+Added: Our existing client base also provides a significant organic growth opportunity to upsell and cross sell additional solutions.
Highly scalable and visible revenue model .
−Removed: Our solutions are offered to healthcare providers, payers and other healthcare organizations primarily through subscription-based service agreements.
−Removed: The solutions we provide are also recurring in nature, which enables an ongoing relationship with our clients.
+Added: Our solutions are offered primarily through fixed price, subscription-based service agreements.
+Added: The solutions we provide are also recurring in nature, which enables an ongoing relationship with our clients and favorable retention.
This combination of subscription-based revenue, a base of ongoing client renewals and automated platforms creates a highly visible and scalable revenue model.
Comprehensive portfolio of solutions .
−Removed: We offer a portfolio of solutions that provide insights across the patient journey, which is unique in the healthcare industry, enabling our clients to initially establish an enterprise relationship utilizing the entire portfolio or begin with an individual solution and increase the scope of services over time, increasing overall contract value.
+Added: We offer a portfolio of solutions that provide insights across the patient journey, which is unique in the healthcare industry.
+Added: Our solutions enable the collection of data and insights from individuals prior to receiving care and then throughout their care journey from first encounter to after completion of their care.
+Added: The data and insights provided through our solutions enable our clients to better understand what matters most to each person they serve to meet expectations and increase customer loyalty.
Exclusive focus on healthcare.
We focus exclusively on healthcare and serving the unique needs of healthcare organizations across the continuum, which we believe gives us a distinct competitive advantage compared to other survey and analytics software providers.
+Added: Our value proposition incorporates the benefits to clients derived from our deep subject matter expertise that has been built from helping healthcare organizations over the past 40 years.
Our platform includes features and capabilities built specifically for healthcare providers, including a library of performance improvement content which can be tailored to the provider based on their specific customer feedback profile.
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Our senior management team has extensive industry and leadership experience.
−Removed: Hays, our Chief Executive Officer and President as of October 2, 2020, founded NRC Health in 1981.
+Added: Hays, our Chief Executive Officer and President, founded NRC Health in 1981.
Prior to launching the Company, Mr.
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and NovaCare, Inc.
−Removed: Jackson, our President through October 1, 2020, served as Chief Strategy Officer for Vocera Communications.
−Removed: Jona Raasch has served as our Chief Operating Officer for most of the last 30 years and as Chief Executive Officer of the Governance Institute for nearly 15 years. 
+Added: Jona Raasch has served as our Chief Operating Officer for most of the last 30 years and as Chief Executive Officer of the Governance Institute for more than 15 years. 
Helen Hrdy was appointed as our Chief Growth Officer in 2020. 
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We believe that our current portfolio of solutions is uniquely aligned to address these healthcare market trends and related business opportunity.
−Removed: We provide tools and solutions to capture, interpret and improve the Consumer Assessment of Healthcare Providers and Systems ("CAHPS") data required by CMS as well as real time feedback that enables clients to better understand what matters most to people at key moments in their relationship with a health organization.
+Added: We provide tools and solutions to capture, interpret and improve the CAHPS data required by CMS as well as real time feedback that enables clients to better understand what matters most to people at key moments in their relationship with a health organization.
Our solutions enable our clients to both satisfy patient survey compliance requirements and design experiences to build loyalty and improve the wellbeing of the people and communities they care for.
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We consider our relationships with our associates to be good.
+Added: We are committed to providing a workplace free of harassment or discrimination based on race, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, ancestry, veteran status, or disability.
+Added: We are an equal opportunity employer committed to inclusion and diversity.
Available Information
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Compared sentence by sentence after normalising whitespace, quotation marks, case and digits, so re-formatting and restated figures do not read as changed language. Wording changes appear as one removal and one addition. The current filing and the prior one are authoritative.