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Last week, the Supreme Court upheld the Affordable Care Act's individual mandate ruling it constitutional as a tax or penalty. The mandate would require everyone to have health insurance beginning in 2014 forever changing the way the country views healthcare. With this announcement, we can now move forward with the modernization of healthcare delivery through technology innovation.I think it is important to look at some areas where the ruling will help accelerate technology innovation in the healthcare industry. Here are three areas where the recent ACA ruling will help accelerate technology innovation:
HIMSS recently published an infographic shown below on their official blog highlighting the growing demand for qualified health IT professionals. With a 66% increase in IT staff shown in the infographic highlights the growing need for qualified health IT professionals to support all related HITECH initiatives. Earlier this year, HIMSS released a leadership survey stating that IT staff shortage was the key barrier to meeting IT priorities.
Packard Children's is partnering with Cisco Systems to meet the needs of families in our community and beyond. The video shown below is an overview of their innovative telehealth network promises to bring our world-class care to the patients, rather than the other way around. Given the recent Supreme Court Ruling on the individual mandate, Telehealth is one of the key areas that will spur innovation as a result of the ruling.
Contributed by Michael Sandwith, Director of Business Development at ICA
The Accountable Care Organization (ACO) aims to change the way hospitals deliver care by changing the financial incentives. There are different payment structures than can be used to encourage hospitals to lower costs, improve quality, or both. Since the goal of an ACO should be to lower costs and improve quality, using an accountability payment structure – one in which costs and quality are linked–will be the most effective. [1]
For most hospitals and health systems, appropriately synchronizing changes in payment incentives, aligning of physicians, and the clinical model will prove a tall task. The pacing and sequencing of investment and change must be very carefully managed to ensure the financial sustainability of innovation. Accepting more payment change without sufficient clinical innovation leads to underperformance against new clinical and financial measures of success. The opposite is equally true: changing a care model without a revenue model to capture the value created promises to improve someone's bottom line, but not the hospital's. [2]
What is a hospital or health system to do? Begin evaluating internally, focusing on ways to optimize care efficiency and cost control within the acute care walls of the hospital, and then extending the care continuum within the post acute care market place. The advantage to this approach is as follows. First, improvements within traditional acute care operations address the performance risk all hospitals face. Second, improvements that directly benefit hospital finances can expand capabilities to manage utilization risk in the post-acute care realm down the line.
A recent survey by Buck Consultants, 2011 Health Care Organizations Health Care Reform Readiness[3], outlines how hospitals and hospital systems were addressing the various initiatives of healthcare reform. For example, when asked, how are you adjusting your business to adapt to this new era of healthcare reform? Fifty percent responded that they were structuring quality measurements with their physicians, whereas only 17 percent were creating an ACO.[4] The survey points out that hospitals and hospital systems are focusing on performance risks and financial incentives with their approach to controlling hospital infections (76%) and reducing patient readmissions (67%).
Quality improvement is the basis for ACOs. The intent of ACOs is to promote accountability for the care that patients receive, and quality measurement is a key element of accountability. Without such measurement, it will be very difficult to assess the quality of care that patients receive and determine whether that care improves over time.
It would seem that we have a lot of work to do in the area of quality measurement considering that only between six and eight percent of the respondents felt that the quality of healthcare will improve substantially over the next five years by implementing healthcare reform initiatives. Whereas 33 to 37 percent felt it will improve somewhat, 20 to 36 percent felt that it will stay the same, 13 to 28 percent felt that it will deteriorate somewhat, and six to 13 percent felt it would deteriorate substantially.
If You Can Measure It Then You Can Manage It
ACOs are one of the key features in the Patient Protection and Affordable Care Act (PPACA) but they require a tremendous amount of administrative and operational oversight, in addition to managing risk, coordinating care, and improving overall health status. Just being able to comply with the Medicare version of accountable care requires seven additional participation and experience measures. This will include measuring care coordination, special patient safety, and outcomes along with ACOs wanting to control utilization, streamline care, reduce practice variation, control readmissions, and eliminate unnecessary procedures. To guide patients and position your ACO initially within the market place, you will have to develop a measurement infrastructure to support the collection and dissemination of both quality data and patient perception survey results. CMS has already identified 33 quality indicators for ACO accreditation and is expected to release an ACO member experience of care survey in late September 2012.
Issues for the Hospital or System
Given current market conditions, the question about whether to develop an ACO is still a strategic decision. A hospital or system that succeeds and participates as an ACO will definitely see reductions in acute inpatient utilization and other services. It is doubtful that any shared savings participation will be sufficient enough to make up for the potential losses, so it will be imperative for the ACO to build market share. If a hospital or system does not create an ACO and their competing organizations do, the non-ACO organization will more than likely lose market share, maybe not in the short-term but definitely in the long-term. Commercial insurers, Medicare and Medicaid will continue to reduce fee-for-service reimbursement and reward healthcare providers for managing the total risk of a population, therefore forming an ACO should be a strategic first step. The determining factors will depend on individual community market place competition, physician collaboration, and strategic relationships with all payers (commercial, Medicare, and Medicaid) and let's not forget about the developing health insurance exchanges.
A hospital or health system that succeeds with an ACO will probably not make a lot of money from the ACO directly, but it may succeed in transforming its organization into a patient-focused, integrated provider of high-quality care with a strongly-aligned medical staff that can provide high-value, low-cost care not only to the governmental but also to the commercial payers.
The ACO must be more than a new way to pay healthcare providers. Instead, it must encourage healthcare providers to change the way they deliver care by improving quality and care coordination through a patient-centered approach.
If ACOs are to fulfill their potential goal in lowering costs and improving quality, it is crucial to structure their payment models and quality measurement requirements appropriately. The focus must not be solely on lowering costs. Payment models will need to be structured in a way that will encourage meaningful change by the healthcare providers. Linking any payment or financial incentive to quality measurements and performance requirements will ensure that providers are lowering healthcare costs through delivering improved care, not by limiting access to medically necessary care. Publicly reporting the quality measurements and cost information will provide a new level of accountability to patients, the public, and payers.
Whether the ACO model succeeds in changing the way healthcare providers deliver care will depend on two key elements: financial incentives and performance requirements. If the financial incentives are not strong enough, providers will not be encouraged to change the way they deliver care. If the performance requirements are not set high enough, then quality will not improve and could even decline.
[1] Engelberg Center for Health Care Reform, The Brooking Institution, and ACO Learning Network Tool Kit (Washington: Engelberg Center for Health Care Reform,January 2011).
[2] "Making Good on ACOs' Promise-The Final Rule for the Medicare Shared Savings Program", Donald M. Berwick, MD, N Eng J Med 2011, 365: 1753-1756 | November 10, 2011
[3] "Health Care Organizations Health Care Reform Readiness Survey", Buck Consultants, A Xerox Company, 2011
[4] "Health Care Organizations Health Care Reform Readiness Survey", Buck Consultants, A Xerox Company, 2011
Accenture released a survey and infograpic last week stating that 90 percent of patients want to self-manage their healthcare leveraging technology, such as accessing medical information, refilling prescriptions and booking appointments online, but nearly half (46 percent) are unaware if their health records are available electronically. The survey is based on an online survey of 1,110 U.S. patients to determine the preferred channels of electronic health information and services. The online survey was fielded March 30 through April 4, 2012. One of the leading results of this survey is the desire to manage consumer health through mobile devices, which should come as no surprise with the increasing growth in the mHealth space. The infographic shown below summarizes the key highlights of the survey:
The detailed survey findings is available for view and/or download here
Mehmet Oz, MD, host of TV's Dr. Oz Show and a heart surgeon at New York Presbyterian Hospital, shares his views on current business and technology challenges facing small physician practices. One of the key gaps Dr. Oz highlights is the lack of a repository of trusted health information and the importance of collecting information prior to the patient's visit to enhance the patient care.
This global report from PwC assesses the market opportunities and challenges for mobile health (mHealth) from the perspective of health care providers, patients and payers. The report finds a growing pervasiveness of technology enabling the emergence of a new, more patient-centric health care value chain that can leverage mHealth. The distinction between traditional health care and mHealth is dissolving as consumers demand a seamless health care experience that can be provided via mobile applications, devices, access, tools and services. These changes have implications for conventional business models.
Key finding of the report include:
Expectations vs. reality
Colliding interests, competing visions
Emerging market trailblazers
Solutions vs. technology
Click on links below for report downloads
According a recent Johnson & Coker report, 80% of doctors use smartphones. In addition to making calls and using apps, docs are using their smartphones to take advantage of one of today's most convenient forms of communication: the text message.
Unlike so much about healthcare – treatment plans, wait times, the reimbursement cycle – texting is quick. And for doctors, as for everyone with thumbs, texting offers a simple way to communicate that doesn't require making a call, writing down a message, or listening to anything at all.
For physicians, though, texting's advantages can also be its flaws. Quick and simple as it is, texting has become the easiest way for docs to violate privacy laws and make themselves vulnerable to data breaches. Since it poses such serious threats, is the convenience of texting even worth it for physicians?
It Makes Notification Easy…
When no protected health information (PHI) is involved, texting is harmless. And for the sake of garnering a busy doctor's attention, texting's immediacy is hard to beat.
It wasn't all that long ago that many physicians had to be wired to pagers so that they could be contacted. In place of them, many hospitals and other health systems have built texting into their workflows.
A notification text along the lines of "Cardiac emergency, call 555-2820" doesn't violate HIPAA. Additionally, a text like that communicates far more than a pager's buzz and cryptic message system possibly could, and doesn't require a physician to make a return call and count on some one to answer it just to learn the basics of a situation.
Plus, in spite of some very valid concerns about confidentiality, the argument can be made that a text message, since it can't be overheard, is in some ways more private than a spoken phone call.
But the Pitfalls are Major
Yet the content of a spoken phone call doesn't exist electronically once the call ends, which means it's not subject to the legal rules governing "electronic exchanges," as texts are. And even though a text message can't be overheard, it is subject to being viewed by an onlooker with prying eyes.
Because docs are using texting to do much more than notify one another to make a call or come to an office, the threat of unauthorized eyes peeping those messages is a big one. One study says that 94 percent of physicians use smartphones to communicate, manage personal and business workflows, and access medical information – PHI that can be easily overseen in violation of the HIPAA Security Rule.
Plus the convenient, small size of smartphone technology makes he devices easily stolen or misplaced. If a phone full of PHI gets into the wrong hands, a doctor who hasn't been taking the proper measures to secure his text messages could find himself in some very hot water.
Avoid Text Troubles by Using Caution
Despite its drawbacks, it's nearly inevitable that physicians will use text messaging for their dealings as doctors because its become such an ingrained method of communication in their personal lives – just as it has for most everyone else these days.
To conduct the safest texting practices possible, physicians should avoid including PHI in their text messages whenever possible. Additionally, they should ensure that their phones are guardedwith adequate security measures.
All doctors should take basic protective precautions, including setting up password protection and deploying an app that gives them the ability to remotely lock and wipe a device in the event that it's lost or stolen.
Some others, especially those physicians who are more prone to including PHI in their messages, should even consider using a secure encryption service. Companies like TigerText and Doximityprovide organizations with encrypted texting capabilities, though there is a snag: both the texter and the textee must be subscribed to the service or otherwise have the capability to unencrypt in order to send or receive a secure message.
Other ways to text smartly and securely: review the content and spelling of your messages before sending (especially if you're communicating something medically serious), keep a close eye on the whereabouts of your device at all times, and frequently delete your message history.
A final best practice? When you can, avoid texting altogether and conduct a face-to-face conversation or a discreet, quiet phone call in a private space. Whether you discuss PHI or not, your voice something you won't need to password-protect – or delete.
About Madelyn Young:
Madelyn Young is a Content Writer for CareCloud who specializes in covering practice management, medical billing, HIPAA 5010, ICD-10 and revenue cycle management. You can read her work on Power Your Practice and the CareCloud Blog. Contact Madelyn with story suggestions, contributor articles or any other feedback at email@example.com.
Looking for an innovative way to hire healthcare IT trainers and provide an unique opportunity for inexperience professionals to break into the healthcare IT industry? In comes "Big Break", an American Idol styled audition process where candidates compete to become a healthcare IT trainer that will instruct healthcare professionals on the use of a sponsored healthcare provider's EMR system. HIT Consultant recently spoke with brainchild of Big Break, Tiffany Crenshaw, President & CEO of Intellect Resources to learn more.
HIT Consultant:Give me a brief background overview of yourself and Intellect Resources
Tiffany Crenshaw: A little known fact about Intellect Resources is we spun out of Healthlink, which was, in the day, a really well-known boutique consulting firm that sold to IBM. But I came in to join them when there were about 30, actually less than 20 employees. And I came in to be their first recruiter and lead their recruiting efforts to help them grow the company. And was with Phil Augustine, the CEO of time, for several years, helped him build this company to about a 100 consultant firm. Then he looked at me one day and said, "You get bored really easily and we're growing really well, so what are we going to do?" And I put the business plan for Intellect Resources on his desk. And quite honestly, I said, "Gosh, Phil, there are a lot of consultants out there, excuse me, a lot of candidates out there who can't travel like you need them to do, but they'd be great candidates to work for somebody else." We, I try to recruit a lot of managers away and they don't want to get on the road either. And they don't need consultants, they need full time employees.
These two companies can operate very well together. And he said, "Great, let's do it!" And that's how Intellect Resources spawned. We operated out of the Healthlink office. We use a lot of the same infrastructure. And when Healthlink was acquired by IBM, I was able to take the Intellect Resources. And ran Intellect Resources independently on my own, meaning I was the sales and the recruiter, it was just me for a number of years and then we started growing. Through the years, we've added on, not only the recruiting side, but also consulting go-live and then the I.R. Big Break, which I know we're going to talk about that. Those are all the services we've added on through the years. And we have about 20 core non-billable employees, and we have about 300 consultants out in the field right now. So that's the little story about how Intellect Resources started as the tiny little company that spawned out of Healthlinks.
HIT Consultant: Wow, I really didn't even know that. So, tell me a little bit more about Big Break. First, what compelled you to start Big Break?
Tiffany Crenshaw: Well, Big Break is my baby. I get all jazzed when we talk about this. It's just such an exciting, just an exciting event in general. It's exciting for the clients, it's exciting for my team, and it's really exciting for the Big Breakers to come out to it. So what Big Break is, it is an opportunity for a hospital, to basically, and please don't take offense to the word, but basically to breed new healthcare IT talent. And it's a great opportunity for those that are trying to get into this industry, to get their big break and their foot in the door.So, there's two sides to this story. One is the client side. We had a client in New York that was getting ready, getting closer to their go-live event with Epic. And they realized that their original plan for the 90 trainers they were going to need, the original plan wasn't going to work. And we'd been a recruiting and consulting partner for them, at that time, for like 5 years. And they called and they said "We need 90 trainers. We need them in 3 months. We have very limited budget. We have absolutely no time. We want to do an American Idol type audition. That's all we've got. Can you help us?" And we said, "You've called the right folks!" And so we kind of took their need, and Big Break was our response to it. So what we decided to do with, since they had a limited budget and couldn't really get experienced trainers because they didn't have the time to go about recruiting 90 experienced people, you know, the idea of the done in a day audition was perfect. So, we rented out the Marriott Marquis in Time Square and we had invited roughly 400 contestants to come in as their big break into the healthcare IT industry and they came kind of to a gauntlet of exercises. They came in, they did a speed interview, they had to do an open mic in front of the camera, and then they came into an audition room with a group of judges.
We then, you know, extended offers to 100 potential trainers of course as you go through the on-boarding and the background checks, and that we ended up with 90 consultants. Those 90 folks came from all walks of life. We had folks from educators, we had people from the IT field, we had people from the healthcare field, we had people from customer service, we had fresh graduates; Folks that had minimal work experience but they were all selected, one because they had the hunch to come out such an event and two, they really shown in the event. They came in, they worked with a lot of poise, they could give impromptu presentations, they did well in front of the camera and that's why we selected all of those folks. We got them all aboard, we trained them in Epic, they hit the classroom as Epic trainers, they went on to do the go-live event, as go-live, at the elbow support, go-live consultants. And now those folks, several of them were hired by our client at the end of the day, and they're now permanent full-time employees of the client. Several have come to work with us on other projects and then the rest of them are all dispersed out in the field. Some have gone to work for hospitals, some for consulting firms, some, a lot of them are on the go-live circuit, doing that. So that was really what Big Break originally was, an answer to a client's needs. We were so excited about the results, the client got great talent, they got it at a very economical price, their training and their go-live was a success. And then for all those folks that took that chance and, you know, kind of were our trial there, are now all out in the field working. So, very, very exciting. Now our second hospital that we did this for, we kind of had a better understanding about what Big Break could be.
And the second hospital, they liked all the benefits. It was a done-in a-day event, we could get good, strong, local talent, it was an economical alternative than getting experienced consultants. And this, our second particular hospital, was really wooed by the whole marketing idea. Wow, here's a great way to bear the name of our hospital, really promote that we want to build up our New Orleans community and we really want to invest in our own people versus bringing outsiders in. So, the next Big Break that we did has all the benefits of we did for the hospital in New York, but this one really got excited about the marketing aspect of Big Break.
And in the end of that Big Break, we actually hired 200 people because they have 8 hospitals to bring live over the next several years and these folks will be the trainers and also the go-live resources. So Big Break really started as an answer to a client concern and each time we've done this, clients get excited about different pieces of it. And we're gearing up right now, for our third Big Break. [pullquote] The first two were in the Epic world and the next one will be in the Cerner world so we're very excited about that.
HIT Consultant: So, there were no qualifications to apply for Big Break? Like no previous healthcare experience? They could just have a different variety of experiences and come in and audition and really have an opportunity to gain entry into the field?
Tiffany Crenshaw: You are absolutely right Fred, now there are certain qualifications that we were looking for in both. One is the basic technical acumen. So we have an online registration process that is fairly detailed to make sure that they have the basic click and point and being able to navigate through technical instruction. So technical acumen is good. Good communication skills, good grammar, great spelling. Just basic communication. We gathered that from looking at their resumes and that's also if they came in through the event, we got to see them. Presentation skills were paramount. In both cases, we had folks given presentations in front of big board rooms. We purposely, in both cases, also set, we kind of create this to be a gauntlet of activities that the candidates, the contestants have to go to. It has to be a little bit intimidating, so we need to see how people can work through in stressful situations. There's a lot of unknowns. A lot of things that pop up that people aren't expecting because that's what training life is like for the trainer. You never know what's going to happen when you pop up in into that classroom.
So, in addition to good communication skills, good technical skills, we need people that can really work in the unknown, can work in fast-moving environments. That can work with the unexpected. That was one of the third requirements that we were looking for there. And, then of course the presentation skills. In both cases and in future Big Breaks, we will say that healthcare or technology or training are preferred, but they're not required. Interestingly enough, in both Big Break events so far, over 50% of the applicants have had a bachelor's degree or higher. I think 30% had a master's degree or higher. And in both cases, we actually had positions that actually came out to Big Break to try just so they could make that move. So, you would be really surprised at the individuals who came out. We actually had quite a few who had healthcare IT background that came out for the first two because of the Epic experience and was trying to get their foot into the door with Epic. But I would say it was all over the gammet of what we got. Some that had experience, some that did not, some that had education and some that did not have it. So, very much across the board. But bottom line, the requirements were technical acumen, good communication skills, ability to handle the unknown and good presentation skills.
HIT Consultant: So, the individuals that were selected, are they guranteed a full-time job or did it depend on the client who was hosting the Big Break, so to speak? Are they starting off as temp-to-perm or is it just a temporary basis until they've proven themselves?
Tiffany Crenshaw: You know, I like to think of it as like the reality show that doesn't end. Folks, it's an elimination event. First they have to apply for the audition, and they either get to the audition or they get eliminated. They get to the audition and through various steps of the way, they either make it to the next step or they get eliminated. Once they start the position, they come to work for Intellect Resources on our payroll on a contract, hourly basis. Then the next step of elimination, is once they are done being a student, learning the product, learning the healthcare industry, learning how to be a trainer, they have to take a test, kind of the credentialing, and if they can't pass that, they'll be eliminated. The majority of people do.
But there are a handful of folks that can never make it into the classroom as a trainer. And then, once they make it into the classroom as a trainer, and then you roll into go-live, you don't need all the trainers to do the go-live, so there's kind of an elimination there. And then once you get through the go-live, most of the people go-live in the first couple of weeks, then people start whittling your team back and there's more elimination there. And then as with the first client, they ended up bringing 10 of those on throughout the summer and they used them in various capacities in the IT or kind of like a long extended, job interview. And then they hired 3 at the end of the summer, of their best and brightest and their favorite ones. So, I kind of laugh and say it's the reality show that never ends. And the same thing is very much happening down in New Orleans. People are eliminated at the application stage, throughout the audition stage, some folks, a hand full of folks that may get through the credentialing process and now all those folks are getting ready to step this week into the classroom as trainers. And as the project progresses and the client needs fewer and fewer folks, people will be eliminated throughout that and then they will choose their best and brightest to stay on. And we are very clear when we are doing the marketing of saying this is an elimination event, so it is a great way to encourage consultants to keep their best foot forward always. Get out there, do a great job, have great spirits, great attitude, work well with the team because those do well just get to keep on going. In both cases, we wrote the contract , the hourly contract for the first benchmark and we would just keep extending the people that did a great job.
HIT Consultant: Now what is Big Break doing to ensure that you're creating a community of people that are finally getting their foot wet in the industry and then kind of making sure they have some type of support after this?
Tiffany Crenshaw: That's really a good question on the support after. One of the things that we did for the first group, the New Yorkers, we created a LinkedIn Group of which we use to communicate with all of the folks. So there is a community of those first ones so that when we see job opportunities we'll put it up there and say "Hey guys these opportunities are out there" or interesting articles we might find in the industry. And then of course, they're all communicating amongst each other as well, posting similar things that they find, job opportunities and things that are going on in the industry. And then we've really stepped that up a notch with the New Orleans folks. We have, not, instead of LinkedIn, we've done everything on Facebook and we also have a FaceCamp of what we are doing all of those things. That is something that's evolving.
But right now, it's really through all that social media, keeping people connected and informed and giving them information and of course, we're trying to, when we have go-live events come up or contracts come up, our recruiters are very aware of who all the Big Breakers so they know who to call for certain projects and things that come up. Part 2 of this interview/podcast will be posted soon.
Written by Ahmed Mori at Care Cloud:
You wouldn't know it from the overwhelming amount of positive press it receives, but amplified use of technology in healthcare could be one of the driving factors behind the high cost of healthcare in the United States.
However, it's not the technology that you're thinking of.According to a new study from the Commonwealth Fund, the U.S. healthcare system is fraught with high obesity rates, higher prices and more extensive use of medical technology like MRIs and CT exams.
So, despite the fact that the U.S. system spends more on healthcare than 12 other industrialized countries included in the study, why doesn't it provide notably superior care? Or better yet, why is it spending so much?
High obesity rates and their associated medical costs represent a significant spike in healthcare costs. However, the country's young population and considerably smaller percentage of smokers relative to the other countries in the study could offset the obesity spending.
Higher prices are more difficult to tackle. If you compare the U.S. healthcare system to Japan's model – which controls healthcare costs via a government budgeted fee-for-service system that doesn't restrict access to patients to contain costs – you'll notice a rather stark contrast between the ways both systems operate, suggesting that the U.S.'s problems may lie at the procedural level.
When suggesting a remedy for America's backwards system, Commonwealth Fund president Karen Davis points to the Affordable Care Act.
"The United States must use all of the tools provided by [the ACA], including new methods of organizing, delivery and paying for healthcare that will help to slow the growth of healthcare costs, while improving quality," said Davis.
Things get a little murkier with technology, however, because much of the exorbitant spending in the sector is tied in to the fluctuating price of healthcare services. So in other words, an MRI in one clinic may be very differently priced in another. Your insurance plan also plays a prominent role.
While some of the abovementioned holes in the system are to blame, there is also the way in which technology-reliant healthcare services are delivered. However daunting the regulation of medical technology may seem, it's not a procedural impossibility.
After examining the results of the study, disorganization seems to be a major contributing factor.
Enter healthcare information technology. Sure, sometimes electronic health records and revenue cycle management systems are too readily touted as the panacea to healthcare's most pressing issues. But it's tough to deny that they're a huge step in the right direction, and they're built to keep doctors tidy.
These systems are improving the way healthcare is delivered, improving patient safety, ensuring higher precision in the medical billing cycle to ensure less money slips between the cracks at practices and hospitals, providing better access to imaging test results, and making medical offices virtually paperless – which could save the system over $150 billion yearly.
Tack on another $140 to $240 billion in healthcare savings and improved health outcomes over the next ten years directly as a result of ePrescriptions, and the outlook is vastly different.
A SureScripts study saw a 10% increase in first-fill medication adherence and higher prescription delivery rates, which translates to fewer doctor visits and reduced risks of hospitalization. Oh, and decreased healthcare costs, naturally.
Information technology in healthcare means the same work is performed with fewer resources, equating to efficiency savings. According to a RAND study, the potential savings for both inpatient and outpatient care could total in the hundreds of billions if most hospitals and doctors' offices adopted health IT.
So why not fight tech with tech?
Written by Deborah Robb, BSHA, CPC, Physician Management Consultant for TrustHCS:
The American Medical Association, not satisfied with HHS's push-back of the ICD-10 deadline to October 1, 2014, has protested again. Perhaps one of the reasons for their continued dissent is lack of guidance and support.
While much has been published about the implementation of ICD-10 for hospitals,the body of knowledge for physician practices and medical groups is sorely lacking. Vendor upon vendor is assisting hospitals, but who is helping the docs?
I readily admit the move from ICD-9 to ICD-10 is a huge undertaking. However, only diagnosis codes change for practices and groups, not procedure codes. And while physician payment is not driven by diagnoses codes, they are still required to show medical necessity. This is where practices must be thoroughly prepared to make the leap.
Specialty Matters
Family practice, hospitalists and internal medicine groups may have a more difficult time converting from ICD-9 to ICD-10. Specialists will find the transition much easier. Why?
Generalists see a large variety of patient conditions. So their documentation and support staff must be educated in all anatomy, physiology and disease processes—while specialists treat a limited sub-set of the patient population. Therefore their documentation needs to be refined in only a few key areas. And staff only needs to focus on one or two body systems.
To get started, CMS has prepared ICD-10CM information on their website. Now is a good time for practices to test the water with what to expect; and begin developing a training plan, even for single practitioner practices
7 Tips for Physician Practices and Groups
Our experts at TrustHCS have also provided some tips for practices and groups to ease the transition to ICD-10.
About Deborah Robb, BSHA, CPC
Deborah Robb is a Physician Management Consultant for TrustHCS where she is responsible for their Physician Practices business. Deborah has over thirty years of experience in healthcare and extensive experience in clinical settings inclusive of but not limited to hospitals, clinics, long-term care facilities, and free-standing home health agencies. Deborah possesses an extensive teaching background in medical coding and medical insurance. She is also a five time author in Medical Coding and Insurance for e-learning courses by Direct Learning.
Deobrah is the Founder and former President of the Hattiesburg, MS chapter of the AAPC. She has held the position of Medical Program Director for Antonelli College in MS. As Program Director, Deborah designed, implemented, and revised program curriculums for certification requirements. In addition, Deborah has implemented and monitored compliance with QA / CQI and PI programs in accordance with the guidelines and conducted contract-coding programs in which she enhanced the skill and knowledge levels of client employees so they could set for the National Certified Coding Exams.
Written by our advisory board member, Kara Nance, MD, FACP
No one can deny that healthcare is at a crossroads. Current thought leaders like Atul Gawande and Richard Baron have proposed that history will label our current time period as the "healthcare revolution". The introduction and adoption of electronic medical records will have an impact no less powerful than the cotton gin had during the industrial revolution.
If you are working in the medical field, you have felt the tension between the "change-makers" and the "change-resistors". Depending upon which camp you are in, you either love or hate what's happening in the field of medicine. If you talk to anyone in healthcare these days about EMR, mobile health, payment reform or ICD-10, you're bound to get a passionate response – sometimes positive, sometimes negative. Much like our political system, the two camps sometimes face a gridlock.
To help me understand the conflict going on in healthcare right now, I've looked to Dr. Helen Fisher's Personality Type Study which describes four broad basic personality types. She uses her data to help people find love on her internet dating site Chemistry.com. I propose that this same framework can help those working in healthcare to find common ground as well. After all, like marriage, we're all in this field for better or for worse, so we might as well figure out how to live together so that we can navigate these choppy waters and not overturn the ship!
Per Dr. Fisher, the two most basic personality types are "Explorers" and "Builders". Explorers are driven by the neurotransmitter dopamine which fills these individuals with enthusiasm, heightened energy, curiosity, creativity, spontaneity, optimism and the propensity to seek novelty and take risks. Builders, on the other hand, are calm, social, cautious, persistent, loyal, fond of rules and facts and orderly. These individuals are driven by the serotonin system. Given these biologic facts, it's obvious that Explorers are more likely to be "change-makers" and Builders are more likely to be "change-resistors". Asking an Explorer to be more like a Builder or vice-versa is like asking a zebra to change its stripes to spots – it's not going to happen.
Dr. Fisher's study shows that in the romantic world, Explorers are attracted to other Explorers and Builders are attracted to other Builders. We see this in the world of healthcare too. Explorers are the ones driving the healthcare revolution, and the Builders, given their much more calm and cautious nature, are putting on the breaks. Evolution has shown us that both character sets are important. Without the Explorer's impulsivity, tendency to value rewards more than fear consequences and propensity to try new things, we would not continue to evolve. Although it is true that Explorers often win big, they are also much more likely to suffer disastrous consequences. Explorers are the group most likely to come up with revolutionary ideas that lead to big changes or big business rewards, but a much higher percentage of Explorers than Builders may lose big too. We need the Builder's caution to balance the Explorer's impetuousness, but at the same time, we can't let the Builder's sometimes excessive caution and fear of change allow us to stagnate.
I'll reveal that I'm an Explorer that lives and works in a Builder's world. This unique, but sometimes lonely position, has given me the ability to truly understand what motivates both camps. A "radical academic" by nature, I came to the suburbs at the beginning of my child bearing years thinking I wanted to focus on motherhood and just be a "regular doctor". This suited me well when high levels of estrogen, prolactin and oxytocin induced by my four pregnancies suppressed my drive to explore new territory. But when my hormonal-induced fog began to clear, the "change-maker" area of my brain reactivated, and healthcare IT became my new drug and obsession.
What I've learned during my time in the suburbs is that most private practice physicians, especially primary care doctors, are Builders, which makes perfect sense. Builders tend to be affable, tactful, careful, orderly, precise, detail-oriented, persistent, patient, conscientious and have exceptional managerial skills. This absolutely sounds like the skillset I'd like my doctor to have! But this same group of people, while amazing providers can be a nightmare to those trying to encourage healthcare reform or the broad-scale adoption of HIT because they like routine, predictability, tend to be frugal and are wary of fast changes. Builders are more likely to hold tightly to the "right" way of doing things and can be closed-minded and stubborn. The Builder's realism and caution can also sometimes morph into deep pessimism or fatalism, which leads them to strongly believe that nothing will ever change for the better.
As I began to see the revolutionary changes EMR would bring to healthcare, I initially suffered from many delusions. I believed that with the right product and optimized workflow scenarios, any physician office could successfully implement the new technology. I mistakenly thought that the ability to do away with paper, collect structured data and ultimately reduce costs while improving outcomes would automatically appeal to everyone! As I reflect on my actions during that time period, I can only laugh at my naiveté. I was completely oblivious to the fact that many of my fellow physicians were NOT exhilarated by this opportunity for change, and actually dreaded it. But like a bull in a china shop, I was going to prove how wonderful it was. Needless to say, my first big exercise in change management could have gone better.
An entire industry of "implementation specialists" has evolved to help manage the pain that comes from transitioning from a paper-based to an electronic healthcare system. What many of these experts forget though is that effective change only happens when the system is ready to embrace it. Large corporate organizations have recognized this and actually employ many people in full time "organizational readiness" positions. But with healthcare being so strapped for financial resources, this critical piece of the journey is not often put in place even when monumental changes are anticipated.
The stages of change are often described as pre-contemplative, contemplative, preparation, action and maintenance. I think many working in healthcare these days are frustrated because attention is not being given to the necessary elements for successfully navigating each stage. So much has been written about change management, but I've gained my deepest knowledge of the process from the Harvard MBA professor Dr. John Kotter who wrote Leading Change. It's a great place to start for those trying to steer healthcare innovation.
The inspiration for this posting came from watching my 12-year-old daughter experience the turmoil of a middle school girl. Adolescents are so awkward because they are changing so rapidly. We're seeing the same in healthcare. Some days are exhilarating, and some days everyone wants to regress and throw tantrums. As a mother and a healthcare "change maker", my hope is to continue to study, learn and help others develop the skillsets to navigate this choppy time.
Contact Kara Nance, MD:
About Kara Nance, MD, FACP:
Kara currently works in private practice in Rolling Meadows, IL. Dr. Nance approaches the care of her patients with a very holistic attitude that targets the many factors that contribute to overall wellbeing. In addition to her clinical practice, Dr. Nance is passionate about electronic medical records and the establishment of electronic health exchanges. She consults with local physicians, hospitals, and medical groups about transitioning over to electronic medical records. Kara also participates in advocacy activities relating to primary care. As a Fellow in the American College of Physicians and a member of the ACP's Northern Illinois Council, Dr. Nance frequently travels to Washington to lobby for important issues in health care reform.
Partner's Healthcare, the state's largest healthcare provider in Massachusetts is currently in negotiations with Epic Systems to replace it's existing number of various electronic health record systems that was built in-house with a single EHR solution. The transition is expected to cost over $600 million over 10 years will move Partners in the right direction towards a more integrated, statewide system for sharing medical records. Epic Systems will allow each patient a single up to date record that is accessible by all Partners providers.
The majority of Partners current systems was developed starting in the 1980s at Massachusetts General Hospital and Brigham and Women's Hospital before the two institutions formed Partners and when there were no products on the market that could meet the hospitals' needs. The hospitals have separate but related inpatient systems, distinct from those used by many of their affiliates.
Dr. David Blumenthal, Partners chief health information and innovation officer states, "The result is, when patients move from one place to another, their information often does not follow them in a complete form or as promptly as we'd like. Under the new system, data for a patient who is referred from a primary care office to an orthopedist, has surgery, and later is discharged with home care would be contained "all in the same record and all available in real time.'' Blumenthal also stated,"the Epic system would make Partners better prepared to share data because it has a uniform interface for outside systems, rather than different "docking stations'' for data."[pullquote] "the Epic system would make Partners better prepared to share data because it has a uniform interface for outside systems, rather than different "docking stations'' for data."[/pullquote]
The potential move to Epic shows the commitment Partners is making towards information exchange; however, the move to Epic does not come with some key challenges. The transition to a new electronic health record system will not be easy for physicians and others who are already accustomed to their current systems. Physicians who have their own homegrown operation may also lose some of their control being forced to use Epic for a more streamlined system.
For Epic Systems, this would be a huge win that would make them the most dominant EHR vendor in Massachusetts further displaying the domination of Epic in the market.


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All Items : Glassware : Depression : Companies : Hocking : Pre 1950 item #1178012 (stock #LA100292)
Packrats Plunders
$20.00---SOLD, Thank you Ralph
$20.00---SOLD, Thank you Ralph
Princess Footed Candy with lid in Glow-in-the-dark-green. Stands about 8 ¼" high to top of finial on lid and is just as nice as the day it came from the factory. I find no damage, of any type on this beautiful candy dish or it's lid. Made by Anchor Hocking from 1931-1935. Thank you very much for looking & please feel free to ask any questions that arise. This item will also be on display at Lincoln Antique Mall, Lincoln Mo. So please check with me regarding availability if interested.

subset: commoncrawl


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Dungeon Siege III for PC, Xbox 360, and PS3
Torn asunder, the delicate balance of power between the kingdom of Ehb's powerful factions has fallen apart
Torn asunder, the delicate balance of power between the kingdom of Ehb's powerful factions has fallen apart. As one of the few remaining members of the disgraced protectors of the land, the 10th Legion, it is up to you to rebuild the once great Legion and stop Ehb from falling into darkness. Joined by a group of unique companions, you will travel through the striking land of Ehb defeating all manner of villains and beasts through a combination of heroic abilities, screen shaking magic and pure cunning. Dungeon Siege III blends action gameplay, a robust RPG system featuring a large selection of abilities, an extensive multiplayer component and the depth of story Square Enix and Obsidian Entertainment are known for.
See All ImagesDungeon Siege III Images
See All NewsDungeon Siege III News
Dungeon Siege III DLC Revealed
Square Enix has announced a robust downloadable content pack for Dungeon Siege III will be available in October. It will introduce several hours of g
Dungeon Siege III Now Available
The highly anticipated action-RPG Dungeon Siege III makes it debut today. For the first time in the franchise's lifetime, players who enjoy dungeon-c
Dungeon Siege III 'Launch' Trailer
The newest Dungeon Siege III launch trailer should get your loot piñata flowing.
Nerds Playin' Consoles 'Dungeon Siege III' Gameplay PT. 3
Nerds Play'n Consoles (NPC) concludes their Dungeon Siege III preview walkthrough in heroic, or somewhat stupid fashion...and learn a valuable lesson at the end.
Nerds Playin' Consoles 'Dungeon Siege III' Gameplay PT. 1
Nerds Play'n Consoles (NPC) takes a first look at Dungeon Siege III and gives their initial impressions in this voiced over walkthrough
Dungeon Siege III 'Demo' Trailer
Join forces to experience the true power of the legion in Dungeon Siege III
New Dungeon Siege III Character Revealed
Square Enix and Obsidian have revealed the last of the four playable characters in their upcoming action RPG, Dungeon Siege III. The new character is


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Great Gift Ideas for Under $20 [LIST]
Has your holiday shopping stalled? Run out of money? Can't find the perfect gift? Overwhelmed by how much is still left? We've got the solution! Here are 9 hilarious websites to help!
This is like an awesome flee market online
Deal Extreme has nifty gadgets and cute crap
Dry Ice delivered -- perfect for lobster fisherman, chemistry sets, & teenagers
Ever wish you could send someone a bucket of poop? There are lots of reasons why. These people will do it for you!
This popular site has everything for kids and the kids at heart
Women's clothing for under $15
The smartest invention of all time -- currently in the running for the Nobel Prize


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Smack!Wednesday, October 6th, 2010
The Port Orchard to Bremerton foot ferry is a great way to avoid driving or biking around Sinclair Inlet when you just want to get to downtown Bremerton from south Kitsap. As a bonus, you get a few moments on each side for sea creature viewing. You're almost guaranteed to see plumose anemones, giant pink stars, mussels and barnacles on pilings and floating structures. You're likely to see a kelp crab and a seaweed or two.
On one occasion, I thought I was watching a sick/disoriented smelt or herring in its death throws. That turned out to be a half truth. It was actually a squid working on a recent catch. It's unusual to see them at the surface in the daylight.
To ring in October, I peered over the ferry pier on the Bremerton side to see my first big marine jelly smack! As I watched, the flood tide propelled hundreds of moon jellies over, under and around the man-made structures of the Bremerton ferry docks and marina.
The animals are beautiful. They are nearly clear except for the four leaf clover shaped reproductive organs at their center. The characteristic jellyfish pulse is also gracefully mesmerizing.
An observant and curious boater took a great picture of a dense smack of moon jellies at the Brownsville marina on August 11th of this year. The image worked its way around UW Aquatic and Fisheries Sciences department, and received several responses. One referred to the recent (July, 2010) conference… Third International Jellyfish Blooms Symposium.
Our region's own Jenny Purcell of Western Washington University organized the first session listed on the conference page and provided a session summary that really hits on the complexities of jelly blooms.
Globally, blooms impact economies and the environments that support them. Lots of factors can go into creating blooms, including climate change, altered salinity and excess nutrients/food. Murkier water and low oxygen can also favor jellies over their fish competitors. Even manmade structures in the water can create extra habitat for to support the jellyfish life cycle. Fishing can also remove some of their predators and competitors.
The life cycle of a jelly is a strange (though not uncommon) combination of sexual and asexual reproduction and of planktonic (floating in the water) and benthic (attached to a surface in the water) forms. The jellies we see floating around are the adult male or female medusa. The boys put their sperm into the water (like many marine critters). The girls use the sperm to fertilize eggs that they brood until the larvae are released into the water. The larvae soon find a shaded place (that's why man-made structures come in handy) to settle and grow into a polyp – like a tiny anemone. That polyp divides into a budding colony and each bud breaks off to grow into a new medusa. You might check out the Jelly Zone for more about jellies.
But why is an aggregation of jellyfish called a "smack". I don't know, any ideas? Sarah Asper-Smith of Alaska found odd group names so intriguing that she illustrated an ABC book with unusual names for each letter called Smack of Jellyfish. It comes out in November. Good stuff.
With my wife and oldest son's help, we came up with a few aggregation names we feel should catch on…
bull kelp bed –> a flogging
sand dollar bed –> a treasure
urchin bed –> a thorn
crab aggregation –> a drool
dogwinkle snail gathering –> a pound
Is anyone with me? Please comment with your own inspired new name for an aggregation of something. Have a jolly jelly day! JEff
Jeff Adams is a Washington Sea Grant Marine Water Quality Specialist, affiliated with the University of Washington's College of the Environment, and based in Bremerton. You can follow his Sea-life blog, email to firstname.lastname@example.com or call at 360-337-4619.


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Longtime University of Miami football coach Don Soldinger never had a retirement party.
But what he will have Thursday night, he figures, will be the party of his life.
Soldinger, 68 and going strong, will be one of seven Hurricanes greats inducted into the UM Sports Hall of Fame at Jungle Island.
They told me, Youve got three minutes to give your speech, the famed assistant running backs coach said. I said, Bro, how am I supposed to do that in three minutes? I was at UM for 16 years and have lived in this town my whole life. Im taking eight to 10 minutes.
Heaven help the person who pulls him off stage prematurely.
I was planning on working forever, said Soldinger, who coached and mentored running back greats such as Edgerrin James, Clinton Portis, Frank Gore and Willis McGahee not to mention tight ends Alfredo Roberts and Rob Chudzinski and linebackers Micheal Barrow and Winston Moss earlier in his career. I never wanted to be anywhere else. I never used this as a stepping stone to get a better job or leave this town. I love this town and I love this university.
Being honored with Soldinger on Thursday: quarterback Ken Dorsey and his center, Brett Romberg; two-time diving champion Bryan Gillooly; All-American pitcher Jay Tessmer; golf coach Norm Parsons; and power hitter Ed Contreras.
I couldnt believe it when I heard I was voted in, Dorsey said while driving Wednesday from Charlotte, N.C., where he is the new quarterbacks coach of the Carolina Panthers, to his home in Tampa. From there, he was to pick up his wife, former UM soccer player Jordan Sims, before heading to Miami. Ive been a Heisman Trophy finalist two times, won the Maxwell Award and played in the NFL. But this is by far the biggest thrill Ive ever had.
While Dorsey was winning a national championship in 2001, compiling a 38-2 record as a starter and setting UM and Big East records for touchdown passes (86) and passing yards (9,565), the gruff, but big-hearted Soldinger was mentoring the players that to this day revere him. They stay in touch, send him plane tickets to watch them and speak to students or camps if he asks.
In two separate stints, Soldinger coached for one spring under Howard Schnellenberger, who hired him, then under Jimmy Johnson for five years. He returned to UM in 1995 under Butch Davis and then Larry Coker. Coker fired him along with current offensive line coach Art Kehoe and two other assistants three days after UMs 40-3 loss to Louisiana State in the 2005 Peach Bowl.
It still stings.
When youre 64-10 during your last six seasons, and have two national titles and a career record of 157-37, you dont think youre going to get fired, he said. Worst we were was 9-3. Probably one of the best runs in college football history.
Born in Miami Beach, Soldinger graduated in 1962 from Southwest High, where he was a tight end, defensive end and tackle, and played basketball and ran track. He went on to coach Southridge High to two state football titles and had a 104-35-1 record there in 12 seasons as head coach.
Today, the 6-3, 230-pound Soldinger, married 44 years to Phyllis, lifts regularly and cycles more than 100 miles a week. He is the godfather to the son of current offensive line coach Kehoe, whom he used to meet in the office at 6:45 a.m. daily to walk 3.1 miles around the campus perimeter before they had their daily football meetings.
Donnie is one of my best friends and one of the best people Ive ever seen coach in my life, fellow UM Sports Hall of Famer Kehoe said. Loyal, hard-working, great friend, great Hurricane. He was a big part of all the winning we did at this place.
Phyllis Soldinger, who met Don when the two were taking a summer course at Miami Dade College (he graduated from Memphis State and she from Florida State), said her husband was sitting at his computer when he got the call about being voted into the Hall.
He said, Youre not going to believe this, she said. And of course, I totally did. It makes all the sense in the world.


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Welcome To Spirit HalloweenX
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Embrace your super powers when you wear this officially licensed Cartoon Network Ben 10 child costume. The 100% polyester, white and black shirt features the official Ben 10 logo and comes complete with khaki green pants and a silver Omnitrix wrist device.
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Be anything but typical on Halloween when you wear this officially licensed Ben 10 Alien Force child costume. The 100% polyester jumpsuit is styled to look like a shirt, pants and green and white jacket along with an Omnitix.
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Take action on Halloween when you decide to dress in this officially licensed Ben 10 Omniverse Child Costume. The white, green and brown jumpsuit features an attached hood and comes complete with a special Omnitrix device!
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text: Grand Teton National Park Officials are planning on a proposed re-route of the northern section of the Moose-Wilson road. For much of its nine-mile stretch, the narrow road winds between steep hills on one side and wetland habitat on the other. The road is frequently congested with cars that stop to look at bears, moose, and other animals that live by the road.


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A moody tavern. An extraordinary cocktail. The easy lapping of bay water against the banks of the Inner Harbor. Duckpin lanes. Old Bay. For all of these things, and for so many more, people love Baltimore. People feel how they feel about this place for their own reasons. But in the spirit of sharing the love, we asked some of the city's best-known personalities to reveal something that makes them fall for Baltimore. Take this list as personal suggestions, from one neighbor to another. Read more ...
September 26th : noon - 8 p.m. ...
September 27th : 8 p.m.
September 30th (Alan Alda ) ...
Daily (New permanent exhibit)
Sundays and Saturdays : 10 a.m. - 7 p.m. (ends October 19th)
September 25th : 8 p.m.
Upscale burger joints are now serving adventurous, exciting and sometimes outrageous burgers.
You shouldn't. No one should. But sometimes you just have to eat like there's no tomorrow, or no swimsuit season.
Sunday morning is no time for compromises. Find the brunch you want, and if your friends don't approve, go alone.
It takes a good bartender to fork over a cold brew with a smile. It takes a great bartender to know your drink before you utter a word.
Want a frothy, sweet confection that's perfect for the balmy days of spring and summer?
There are many ways to take advantage of the weather, but few are as fun as a leisurely lunch, dinner or drinks outside.
We can't offer you gambling advice, but we can tell you how to make your way around Maryland Live Casino.
It used to be easy to name the 10 best unsigned Baltimore bands. That was before the word got out about our boiling-over music scene.


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Before I even got preg with Katlyne we had her name all picked out and the same goes for Casey. With Casey it took us months to come up with a middle name but finally we found something that worked and also to give honor to his grandfather. (My older boys have my Dad's name somewhere in their name and didn't want to copy a middle name or anything SO it was time for DH Dad to copy his middle name- at least it wasn't his first name Eugene [:D])
Moderator Grief and Loss
Mommy to
Drew(13)PE 37 wks
Ky (11)PE 34 wks
~i~ Katlyne(12/9/02-04/02/03)25 wks
Casey Looking at Aug
Katlyne's Tribute Site


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The technical curriculum of this program will take place at Triangle Tech in Pittsburgh, Erie, Greensburg, DuBois, Sunbury, or Bethlehem, Pa. The technical curriculum will account for 28 to a maximum of 30 credits. In addition to the technical curriculum, students will complete 35 credits of core curriculum courses to complete the requirements of the Associate of Applied Science degree from Clarion University.
There is something very satisfying about using tools and the skills of your hands to turn raw lumber into homes and businesses. Your first day on the site, there's just a foundation in the ground. When you pack up your tools at the end of each day, you can see your contribution toward a home or building.
You will learn modern construction methods along with age-old traditions of craftsmanship. You will be prepared for a great career and a bright future, with the educational background to move into management positions.
Employment Opportunities
Graduates are prepared for employment as entry-level carpentry and construction technicians, working in residential or commercial construction.
Job Outlook
The following job prospect information is provided by the Bureau of Labor & Statistics. This information reflects national projections made for 2006-2016.
Construction, with 7.7 million wage and salary jobs and 1.9 million self-employed and unpaid family workers in 2006, was one of the nation's largest industries. Construction also maintains the most consistent job growth. About 64 percent of wage and salary jobs in construction were in the specialty trades, primarily plumbing, heating, and air conditioning; electrical; and masonry. Around 24 percent of jobs were mostly in residential and nonresidential construction. The rest were in heavy and civil engineering construction
Job opportunities are expected to be excellent for experienced workers. The number of wage and salary jobs in the construction industry is expected to grow 10 percent through the year 2016, compared with the 11 percent projected for all industries combined. Employment in this industry depends primarily on the level of construction and remodeling activity which is expected to increase over the coming decade.
Carpentry, with average job growth, coupled with replacement needs, create a large number of openings each year. Job opportunities should be best for those with the most training and skills. Employment of carpenters is expected to increase by 10 percent during the 2006-16 decade. The need for carpenters should grow as construction activity increases in response to demand for new housing and office and retail space, and for modernizing and expanding schools and industrial plants. A strong home remodeling market also will create demand for carpenters. Moreover, construction of roads and bridges as well as restaurants, hotels, and other businesses will increase the demand for carpenters in the coming decade.
Curriculum Highlights
Tools and Safety
Blueprint Reading
Construction Sitework
Floor Framing
Wall Framing
Roof Framing
Drywall Installation and Finish
Interior Millwork
Cost Estimating
Construction Contracts
Construction Remodeling
Cabinet Making
Related Trades
Stair Construction
Exterior Finishes
Roofing Techniques


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Good insurance news: Northeast wasn't hit by a hurricane
The declaration that Sandy was a tropical storm means many residents of the Northeast will pay lower deductibles on insurance claims.
Residents of New York, New Jersey, Pennsylvania, Connecticut and Maryland may be surprised to find out they were not hit by a hurricane just before Halloween.
Sandy was a "post-tropical cyclone," with sustained winds of less than 74 mph, when it came ashore Oct. 29. The distinction is important because it means that people who suffered storm damage to their home will pay the regular deductible for their insurance claims, not the higher hurricane deductible.
Most homeowner insurance policies set a deductible for regular losses at a set amount, usually $500 or $1,000. Many policies in coastal states set a deductible that is a percentage of the home's value as the deductible for claims stemming from a hurricane.
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So if your hurricane deductible is 5% and your home is worth $500,000 -- not unusual in the hard-hit areas -- you could find yourself responsible for paying the first $25,000 for repairs.
While Sandy was a hurricane for most of its trip up the East Coast, it had lost hurricane strength by the time it hit the Northeast. (The distinction doesn't make any difference for North Carolina, where the higher deductibles are triggered by "named storms.")
The declaration of non-hurricane status was made by governors or other officials in the affected states after the National Weather Service ruled that Sandy was not a hurricane when it came ashore.
The Insurance Information Institute has answers to some questions about storm coverage. U.S. News & World Report also has some guidelines if you want to prepare now for future damage.
One tricky insurance distinction is going to be a lot more difficult to parse: Was damage caused by wind and rain or by flooding? Damage caused by wind and rain is covered by homeowner or windstorm policies. But to be covered for flooding, homeowners need a separate flood insurance policy. Homeowners who suffered damage from both wind and flooding may find themselves in arguments with their insurance company or in court.
The governor declaring that sandy was not a huricane is a complete joke. I work in insurance and this will be a disasater for everyone in the end. Also, while I feel horribe for the homeowners losses, and see how wonderfull it is that they pay the lower deductble, I also warn that the insurance companies will be put under such finanancial stress over this, that they will probably see many insurers going under, leaving, and raising rates in the future. I live in Florida so I have lots of experience with this. Paying only $500 or $1000 deductible for a loss of this kind is just not sensible.
I live in the New Orleans area. I have to say, I was devastated and cried for weeks. My only son lost the home he had purchased the year before. You people that have never experienced a Hurricane, should keep your mouths shut. I have been paying into the "Citizens Insurance " for over 7 years,even though I live in central Louisiana now. It became a state law that every Louisiana homeowner has to pay it, no matter who their insurance company is. We did not get the option not to pay our deductible, because sadly Katrina was a Hurricane. Over 2000 people lost their lives. Even 1 life is too many. I send my prayers to New Jersey, know this, it takes time, but you will recover.
These are not the droids your looking for, move along, move along !
So whats next the folks out west don't have wildfires anymore just flamable forest fog?!!!!
Or the People in New Orleans don't get flooed anymore they just have a moisture encroachent??
My car wasn't stolen is was just relocated by a friend I never met while he showed me his firearm??
Man this rabbit hole is deep!
I cannot believe what I am reading! Unless you have been through it you have NO idea what these people are going through. I survived Katrina across the lake from New Orleans. We received a 26 foot storm surge, not a levee break. We lost everything, went through hell with FEMA, insurance companies and contractor. For those of you who have not lived through it, a tropical storm, depending on the way it comes in and how long it stays over your area, can cause a tremendous amount of damage. A recent example is Issac, a Cat 1. Again, if you haven't been through it you have no idea what these people are going through and should keep your uninformed comments to yourself! God Bless these people. It will be a long time before life is back to normal for them, if ever.
P.S. The reason it was considered a superstorm was because it was heading into a nor'easter. It had nothing to do with the storm's category rating.
Much of the damage was done by flooding and that's not covered by homeowners insurance. Most of the people in that area do not have flood insurance, so much of the damage will not be covered by any insurance.
The folks up there, however, will get hit by the insurance companies. After the 2004 – 2005 storm seasons many people in Florida received non renewal notices as insurance companies stopped offering homeowners insurance in the state.
The few that remained raised prices significantly, so people who were paying $400 - $500 a year were now having to pay that amount each month as rates increased 1000% over night.


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Kingdom Hearts Live Wallpaper
50,000 - 100,000 downloadsAdd this app to your lists
+ By pidroh
Please give me feedback on what you would like to see in this wallpaper, since it's quite simple right now!
How to use it: press menu and select Wallpapers => Live wallpapers and pick it!
To change the wallpaper you need to select it and then press the "Show in Wallpaper" button. If the button doesn't show, then you need to unlock that wallpaper with Kingdom Points, which you can get with free tasks!
If you're using this app, could you give me a good rating? Some people seem to hate it for some reason... T_T
Now with more modes, you can even unlock Riku!
(To unlock the extra stuff you need an internet connection and to complete a free task, it may not work on all devices. I'm trying to come up with a solution for this!)
Optimized to not waste battery time, Sora'll never get tired of jumping forever and ever, as he waits for Kairi. Or something.
The permissions asked are used for the unlocking service and nothing else!
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*Fixed some crashes people wore experiencing
New Wonderland back!
Completely changed the unlocking scheme, should now work on all devices!
Gave away 50 Kingdom Points for free to all users, so you can start up by unlocking a wallpaper INSTANTLY, if you have an internet connection!
Select the wallpaper in the spinner and then press the "Show in Wallpaper" button to change the wallpaper. The button only shows if you have that wallpaper unlocked!
(64 stars)
I like a game of it. I cant see the character when its under my finger
(64 stars)
This is awesome
(64 stars)
At first I thought it didn't work because the open button didn't pop after installing it all you have to do is go to your live wallpapers and its right there all you have to do is look.
(64 stars)
I reckon its pretty fun. Could be better but its free so who cares about a few problems
(64 stars)
Hi i have LG L3 and there is nothing happening it doesn't even have an open button in the playstore
(64 stars)
I couldn't find the app to actually use the wallpaper. I did everything in the book but it doesn't even show in my downloaded applications list. Deleted it immediately because I don't need a virus on my phone.
(64 stars)
Luv this


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Krass Judgement was founded in mid 1990's by Ray Duran. Ray had played in a variety of cover bands for many years but after time, he grew tired of playing covers. Being a huge fan of the underground metal scene, Ray wanted to stick to his love of a heavier more brutal sound. Ray started writing his own material and Krass Judgement was born. After going through some struggles with the band line up, Krass Judgement released their first CD "You Got This". Upon the release of their first CD the band performed their first live show opening up to a sold out crowd for Overkill. The band spent some time heavily promoting their name and the new CD while working their way up to bigger and better shows in the Northern Va. area. Along the way the band hit a few bumps in the road with more line up changes but was soon ready to start writing new material for their second album "We Bring It". By this time Krass Judgement had built a wide spread fan base in the Northern Va. area. Metal fans loved Krass Judgement's unique sound as well as the bands in your face thrash riffs. With the death of the "grunge" scene and the wake of the "alternative" scene, Krass Judgement was a refreshing sound to a then struggling metal scene.
By now Krass Judgement had built their way up in the local scene, playing numerous shows across Virginia, North Carolina, New York and Maryland. Gaining respect from many local venues which brought them the opportunities to play with National Acts from Kreator to Soul Fly and many more nationally recognized Metal bands.
Two years after the release of "We Bring It', the band was ready to start recording again. During the recording process the band hit another snag in the road and was again faced with line up changes but, Ray forged ahead and recorded a CD of old songs with all new members. The new members brought a new and fresh spark to Krass Judgement and made the new release "Redo's" faster and more brutal then anything the band had release previously. Holding that momentum, Krass Judgement also released a live CD "Live From Stairway East" as a teaser of what fans would be seeing with a new and reformed Krass Judgement.
The band has seen its up's and down's but continues to grow musically. After a few years of more line up changes and constantly playing shows up and down the east coast, Krass Judgement has forged themselves into one of the most unique metal bands around. With their heavy grooves and their rip-your-face-off riff's the band has made themselves a staple in the local metal scene.
Intent in not giving up Krass Judgement released their newest album "Praying For A God That Never Comes" in April of 2010. Undeniably, this is the bands most brutal and skilled CD to date. This CD kicks you in the teeth and keeps kicking, never letting up for a second. Praying for a God That Never Comes has gotten numerous excellent reviews from local media and fans alike.
With a now thriving Metal scene, Krass Judgement is a force to be reckoned with. The band is continuing to belt out the most brutal thrash metal your ears have ever encountered. There is no doubt that Krass Judgement will leave their mark on the metal scene.


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June 11, 2013, 9:17 AM — Marketo says it has created tools that put it far ahead of rival marketing automation software vendors by making it much easier to run targeted campaigns, and more effective ones to boot.
The new capabilities go into general availability Friday in two versions, a basic version at no additional charge to existing customers and a paid edition for power users, Marketo CEO Phil Fernandez said in an interview prior to Tuesday's announcement.
Until now, marketing automation software allowed users to build a degree of sophistication into their ad campaigns by setting up a series of rules, Fernandez said. For example, a gaming company could decide to send out an emailed loyalty offer to all male customers in their early to mid-twenties who have bought at least three games in the past year, according to Fernandez.
The problem has been difficulty in taking the targeting down to a more individual level. This requires increasingly complex rule sets and just doesn't scale up well as marketers try to reach more people individually, Fernandez said.
Marketo's new customer engagement technology, some 18 months in the making, seeks to automate the prioritization and delivery of marketing content, by applying proprietary algorithms to a massive database of its clients' customer data.
In turn, marketing staffers using Marketo focus on building out "content streams" for a given campaign, which may consist of a variety of emails, Twitter messages, Web pages and other types of communications, Fernandez said.
Meanwhile, through cookies, clickable buttons in emails and other means, Marketo's technology keeps track of which pieces of content a particular user may have already viewed, and stops the campaign from sending a duplicate message.
The paid version of the customer engagement toolset allows for more sophisticated scenarios, such as by introducing elements of real-time targeting. For example, rather than send an email to all of those gamers at the same time, the system could instead send a loyalty offer to a particular customer moments after they reach a specific number of purchases, Fernandez said.
Marketo isn't promising customers it has created magic, however. "We don't make the claim that this product is delivering exactly the right message at any time or that nobody ever seems the same message twice," Fernandez said. But internal testing against Marketo's previous-generation software showed that targeting precision had gone up by a factor of three, he added.
"It's way better," he said. Over time, Marketo's "way better" advantage will get "squeezed out and it will be a battle of inches," he added. "Right now, it's a battle of football fields."


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Mycophenolate Mofetil 250/500mg
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Generic Biaxin is in a group of drugs called macrolide antibiotics. It is used to treat many different types of bacterial infections affecting the skin and respiratory system. It is also used together with other medicines to treat stomach ulcers caused by Helicobacter pylori.
All informations on this page are taken from public sources such as search engines (yahoo.com, google.com, bing.com). However, if you think any data on this page violates your copyright, please send an message from "Contact webmaster" page and the links and descriptions of full page will be removed.
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By 2050, the United States Centers for Disease Control and Prevention (CDC) estimates that one in three people in the U.S. could have diabetes. Each year, the number of people with type one and type two diabetes increases.
Elizabeth Seaquist, M.D., Medical School, recently spoke with KSTP-TV about diabetes research and how the disease's prevalence can be decreased.
Seaquist also wrote an article for The Journal of the American Medical Association (JAMA) titled, Addressing the Burden of Diabetes.


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Florida Museum Guide: Armed Forces Military Museum, Largo
Currently the museum has completed displays reflecting WWI, an extensive display of Japanese memorabilia associated with the WWII attack on Pearl Harbor, displays of the USMC in the South Pacific, D-Day landings, German Third Reich, Korean War and 8063rd M.A.S.H memorabilia. The Armed Forces Military Museum walks you through military history from a WWI trench to the flight deck of the Japanese aircraft carrier Akagi.
2050 34th Way North, Largo, 727-539-8371, www.armedforcesmuseum.com
2050 34th Way North, Largo, 727-539-8371, www.armedforcesmuseum.com
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Nick Kelsh: Making Everyday Moments Special:
Prior to this incident, Kelsh did a personal project on photographing children in Ireland; the offspring of people who got killed in the "troubles." He remembers being brave enough to go into bad neighborhoods and knocking on doors. "I was 19," he says. "People were friendly because I was young, and Irish people love Americans." When he came home, he got these images published in a magazine called Camera 35. He says, "The piece was called something like 'Faces of Death.'"
Inventing Himself
One of his books features some beautiful nature images with writings by the late Rachel Carson. Kelsh says that Carson, who wrote about environmental issues in books such as Silent Spring, "believed that saving nature was the key to our salvation." He discovered one of her books in a used book store, and decided he wanted to work on a new edition of her book, The Sense of Wonder. He tracked down her former editor and publisher, and presented his idea for the book, which included colorful photos of nature alongside images of children enjoying the outdoors. He discovered in one of her old letters that, coincidentally, this had been her vision too: "I accidently did the book that Rachel would have wanted."
Lightening His Load
Wisdom to Live By
To see more of Nick Kelsh's work, visit www.kidsbykelsh.com or www.kelshwilson.com.


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by Kyrie Dragoo
National Dissemination Center for Children with Disabilities (NICHCY)
Heard on the News: Exciting results today from a research study showing that children who have…
Heard Around Town: Have you thought about XYZ intervention? It just might work for your child….
Sound familiar? Ever had your interest piqued by such news of research with children who have disabilities? We know we have.
Education research is great, because it can help us find new (and hopefully better) ways of doing things, such as educating our children with disabilities. But when your research sources are friends, the internet, or the popular press, how do you know if you can trust that information? Here are five factors to keep in mind when considering research findings.
1 | Consider the source.
Where did you hear about the research? Somehow it's easier to accept research as truth when the claims are supported by personal testimonies. A personal story engages the emotions and makes the information seem already "verified." But it's important to recognize that not all research claims deserve your trust. Use the enthusiasm and interest sparked by the personal story to pursue a more complete understanding of the research at hand.
2 | Investigate for biases.
Who conducted the research? What organization/institution are they affiliated with? Do they have an agenda? Do not assume that, because a person is a doctor or claims to be an authority, they automatically merit your trust. Knowing if researchers are affiliated with a trusted university, institution, or government agency is helpful. If, however, you find out the research was produced or funded by a group with a political or commercial agenda, the researchers may have been inclined to only release findings that support that group's interest.
3 | Publication matters.
Where were the findings published? Research published in a peer-reviewed research journal carries much more credibility than those published elsewhere. You can be more confident that the research claims are trustworthy if they've been reviewed by other researchers before being published.
4 | Find out who and how many.
Who participated in the study? Find out more about the types of people who took part in the study. How closely do the participants resemble your person of interest—your students, your child? The closer, the better.
How many people participated? In general, you want a large and diverse pool of participants. A study conducted with a small number of people can yield misleading results that don't generalize to the rest of the population. In fact, the smaller the sample size, the harder it is to conclude that the study's outcomes were because of the intervention being examined.
Exception! It's helpful to know, however, that there are plenty of examples of high-quality research with small samples. Single-subject research (which, as the name suggests, involves a small number of individuals) is common in special education research, and is particularly useful in studying interventions for students with rare disorders.
5 | Location means a lot.
Where was the research conducted? If you live in the U.S., you'd probably wonder if a classroom intervention study conducted in Papua, New Guinea is actually relevant to you. And that would be a good thing to wonder about! But also be cautious about studies that have been conducted in substantially different settings from where you live or teach. That can make the study's results less relevant to your particular situation.
Looking for more?
Visit our Research Center. It's full of research results that may be helpful to you and yours.
Research Basics
Learn all about education research– how it's conducted, how to read and understand a research article, sources of research on special education and disabilities, which research you can trust, and where to find it.
Research Summaries
What classroom strategies, behavioral supports, and other educational interventions have strong foundations in scientific research to inform and guide practice?
Evidence for Education
NICHCY's online Evidence for Education modules and downloadable PDFs explore the best evidence-based practices education has to offer.


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The Stealth is a must for hotel rooms and late night practicing. Pitch and articulation are excellent.
While having a shape and feel similar to a "Rittich" style mute, the #45 retains the warm sound associated...
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Matches found in Motorcycle News
MCN Staff,
17 September 2013 17:05
The arrival of the updated 2013 Bonnevilles marks 55 years since the launch of the original. What better time thank now, to revisit classic Triumph Bonnies? brightcove.createExperiences();
21 June 2013 15:03
Triumph has given the popular Speed Triple 1050 a light refresh with a new blue colour available along with some minor cosmetic changes including a clear rear light and accessories now fitted as standard.The iconic Speed Triple has been around in the current form since 2010 and this is the first time the bike has been altered. It's expected this ...
MCN Staff,
04 June 2013 17:49
Triumph has announced special editions of its Sprint GT, Thunderbird, Tiger Explorer and Street Triple Models. The mid-range tourer, the Sprint GT, sees a host of new features including heated grips, touring screen, gel seat and top box/back rest pad, all fitted as standard. The remaining models all now sport a wider choice of paint schemes, with the Thunderbird now available in Lava ...
Jon Urry,
01 May 2013 07:00
The Tiger is the unsung hero of the Hinckley triumph range. Where the iconic Speed Triple is the bike that captures the headlines, believe it or not the Tiger has been merrily going about its business in the background for twenty years, which makes it Triumph's longest continuously running model. Where the Sprint and Daytona models have come and gone ...
15 March 2013 08:30
Simon Warburton, Triumph's Product Manager "Even though the Tiger 1050 is the oldest bike in our range now, there are still people buying it, albeit not anywhere near the numbers it sold before, so we thought there's still space for it. It is a little bit of a gamble and we could've discontinued it, but we thought they'd still be ...
Michael Neeves,
12 February 2013 10:35
We're riding the mountain roads near Barcelona on the new £9599 Tiger 1050 Sport, Triumph's adventure-styled sports tourer. It's an updated version of the Tiger 1050 that's been with us since 2007 and has another 10bhp, more torque, more stable steering geometry and better comfort. It has 120 new parts, including new swingarm, wheels, bars, seat and styling. With all the ...
08 November 2012 14:00
The current Triumph Street Triple, the British firm's best selling machine in the past five years (they've sold 50,000), weighs just 189kg, full of fuel and ready-to-go, which is bugger-all. This new version, available in dealers in the middle of November is lighter still. Weighing a piffling 183kg it's going to strike fear into its main rival: the 211kg Suzuki ...
Phil West,
03 September 2012 11:24
This is Triumph's new XC version of its Explorer 1200 – the surprise unveiling and one of the highlights of the weekend's Triumph Live at Mallory Park. Built as a more, rugged, off-road orientated version of the Explorer (in a similar way to its smaller Tiger 800 and Tiger 800 XC double act) and undoubtedly aimed squarely at BMW's R1200GS ...
20 July 2012 13:41
The new Triumph Tiger Explorer 1200 has beaten its arch rival the BMW R1200GS into second place in the latest sales charts. Figures just released by the Motorcycle Industry Association show 806 of the new three-cylinder Triumphs have been sold so far this year – 153 more than BMW's ubiquitous adventure bike. Mind you, if you add the sales of ...
Andy Downes,
10 May 2012 13:37
Triumph's all-new 1200cc Trophy is still months away from being officially launched but an MCN reader managed to get the best shots yet after seeing the bike hidden behind a McDonald's. The Trophy is Triumph's assault on the class-leading BMW R1200RT, Honda's venerable ST1300 Pan European and Yamaha's FJR1300. It is also likely to steal sales from the more expensive ...
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Welcome to CCVA!
The Council for Certification in Volunteer Administration advances the profession and practice of volunteer resource management by:
- Articulating core competencies for the profession of volunteer administration
- Certifying individuals who demonstrate knowledge and competence in the leadership of volunteers.
- Advancing standards of ethical practice
- Promoting professional development and education
CCVA sponsors the CVA (Certified in Volunteer Administration) credential, the only international professional certification in the field of volunteer resources management. Originally developed by the Association for Volunteer Administration (AVA) several decades ago, the program is intended for individuals who lead and direct volunteer engagement in all types of organizations and settings.
Read more about the CVA program.
CCVA also manages the CAVS (Certified Administrator of Volunteer Services) certification, a program especially for leaders of volunteers in healthcare settings. This program is sponsored by the Association for Healthcare Volunteer Resource Professionals.
Next Testing Window: October 5-11, 2014. Register NOW!
Read more about the CAVS program.
What's the difference between these two credentials?
Read a brief comparison of the CVA and the CAVS programs.
News & Highlights
Wondering if this program is for you? Read our Top Ten Reasons to Consider CVA Certification.
Not sure if you're ready...?
If you are thinking about pursuing the CVA certification, but aren't sure if you are ready, use our Self-Assessment Tool. This is a helpful way to evaluate your level of knowledge and experience related to each of the core competencies on which the CVA credential is based.
Want to help promote the CVA credential to your peers and colleagues? Our Marketing Toolbox makes it easy, including PowerPoint slides with talking points, sample articles, testimonials, and tip sheets.
New and Improved CVA Renewal Requirements and Options in effect as of January 2014.