text:
Originally published in March 2005 by Bryant Avey
InterNuntius Academe Presents:
Executive Summary
on the future of
Technology and Service Infrastructure
For the
Health Care Industry
Bryant Avey
InterNuntius, Inc.
The purpose of this paper is to provide information on changes taking place in the health care industry. It is not the intent of the author to promote, criticize, or single out any particular service, product, technology or company.
Health care organizations are undergoing a significant transformation to unify and improve the quality of health services. Two primary drivers fuel this transformation: First, the current health market is in constant flux, defined and redefined by new advances in products and services. This shifting in the market creates unparalleled opportunity for savvy health care organizations to maximize profitability. Second, the U.S. Government is taking a leadership role in establishing a framework to enable consumer decision-making, and to streamline the sharing of health information between discrete health organizations in the provision of quality health services.
At the foundation of these transformational changes is an integrated infrastructure known as the Federal Health Architecture (FHA), which has spawned additional initiatives, including Health Information Technology or HIT. In the report, Crossing the Quality Chasm, the Institute of Medicine (IOM) identified health information technology as one of the most significant tools available to improve healthcare quality. Further, the IOM, the National Committee on Vital and Health Statistics, and the President's Information Technology (IT) Advisory Committee have also recommended the development of a National Health Information Infrastructure to help improve safety, to reduce costs, and to enhance the quality of healthcare.
In July 2004, the U.S. Department of Health and Human Services published The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care: Framework for Strategic Action.[1] The stated goal of this 10-year plan is to transform the delivery of health care by building a new health information infrastructure, including electronic health records (EHRs) and a new network to link health records nationwide.
To capitalize on the changes in the health care market, organizations must:
- Gain an understanding of the Federal Health Architecture (FHA), and the Health Information Technology (HIT) initiatives;
- Gain insight on how organizations in the health industry are implementing HIT initiatives; and
- Evaluate the organization's position in the market and identify organizational capabilities for providing products and services for these emerging opportunities.
Federal Health Architecture (FHA)
Before a health care organization can utilize FHA to identify products and services for the market, an understanding of the goals and vision of FHA is needed. This section summarizes FHA and outlines the goals and vision of the architecture framework.
FHA is a multi-departmental business and technical architecture that facilitates:
- Identification of collaborative business opportunities that leverage existing efforts and investments
- Development of a performance measurement and outcome strategy
- Adoption of technical and data standards
- Development of specifications for how to implement those standards
FHA utilizes a process that promotes:
- Commitment to the use of standards
- Commitment to participating in development and implementation of specifications
FHA Goals:
- Improved coordination and collaboration on government Health IT solutions and investments
- Improved efficiency, standardization, reliability, and availability of comprehensive health information solutions.
Potential Opportunities of FHA:
- Complete and publish an enterprise architecture that facilitates interoperability leveraging Consolidated Health Informatics (CHI) and other data standards, software development standards, high security model, technical infrastructure standards;
- Immediately begin integration of HHS and other Dept's overlapping application and data systems, starting with business process and data standards;
- Target high priority business lines for developing collaborative technology solutions;
- There is the potential to reduce development costs by challenging private technology firms to develop applications compliant with the published architecture, ready for use by the government and by healthcare providers and manufacturers;
Federal Enterprise Architecture (FEA) and FHA Alignment
Health Information Technology (HIT)
As a component of FHA, the Health Information Technology framework is a strategic framework consisting of four (4) major goals, comprised of three (3) strategies for reaching those goals. The following section outlines the HIT goals and strategies for achievement.
Strategic Framework and Goals of HIT Initiatives[2]
- Goal 1: Inform Clinical Practice. Informing clinical practice is fundamental to improving care and making health care delivery more efficient. This goal centers largely around efforts to bring EHRs directly into clinical practice. This will reduce medical errors and duplicative work, and enable clinicians to focus their efforts more directly on improved patient care. Three strategies exist for realizing this goal are:
- Strategy 1. Incentivize EHR adoption. The transition to safe, more consumer friendly and regionally integrated care delivery will require shared investments in information tools and changes to current clinical practice.
- Strategy 2. Reduce risk of EHR investment. Clinicians who purchase EHRs and who attempt to change their clinical practices and office operations face a variety of risks that make this decision unduly challenging. Low-cost support systems that reduce risk, failure, and partial use of EHRs are needed.
- Strategy 3. Promote EHR diffusion in rural and underserved areas. Practices and hospitals in rural and other underserved areas lag in EHR adoption. Technology transfer and other support efforts are needed to ensure widespread adoption.
- Goal 2: Interconnect Clinicians. Interconnecting clinicians will allow information to be portable and to move with consumers from one point of care to another. This will require an interoperable infrastructure to help clinicians get access to critical health care information when their clinical and/or treatment decisions are being made. The three strategies for realizing this goal are:
- Strategy 1. Foster regional collaborations. Local oversight of health information exchange that reflects the needs and goals of a population should be developed.
- Strategy 2. Develop a national health information network. A set of common intercommunication tools such as mobile authentication, Web services architecture, and security technologies are needed to support data movement that is inexpensive and secure. A national health information network that can provide low-cost and secure data movement is needed, along with a public-private oversight or management function to ensure adherence to public policy objectives.
- Strategy 3. Coordinate federal health information systems. There is a need for federal health information systems to be interoperable and to exchange data so that federal care delivery, reimbursement, and oversight are more efficient and cost-effective. Federal health information systems will be interoperable and consistent with the national health information network.
- Goal 3: Personalize Care. Consumer-centric information helps individuals manage their own wellness and assists with their personal health care decisions. The ability to personalize care is a critical component of using health care information in a meaningful manner. The three strategies for realizing this goal are:
- Strategy 1. Encourage use of Personal Health Records. Consumers are increasingly seeking information about their care as a means of getting better control over their health care experience, and PHRs that provide customized facts and guidance to them are needed.
- Strategy 2. Enhance informed consumer choice. Consumers should have the ability to select clinicians and institutions based on what they value and the information to guide their choice, including but not limited to, the quality of care providers deliver.
- Strategy 3. Promote use of telehealth systems. The use of telehealth – remote communication technologies – can provide access to health services for consumers and clinicians in rural and underserved areas. Telehealth systems that can support the delivery of health care services when the participants are in different locations are needed.
- Goal 4: Improve Population Health. Population health improvement requires the collection of timely, accurate, and detailed clinical information to allow for the evaluation of health care delivery and the reporting of critical findings to public health officials, clinical trials and other research, and feedback to clinicians. Three strategies for realizing this goal are:
- Strategy 1. Unify public health surveillance architectures. An interoperable public health surveillance system is needed that will allow exchange of information, consistent with current law, between provider organizations, organizations they contract with, and state and federal agencies.
- Strategy 2. Streamline quality and health status monitoring. Many different state and local organizations collect subsets of data for specific purposes and use it in different ways. A streamlined quality-monitoring infrastructure that will allow for a complete look at quality and other issues in real-time and at the point of care is needed.
- Strategy 3. Accelerate research and dissemination of evidence. Information tools are needed that can accelerate scientific discoveries and their translation into clinically useful products, applications, and knowledge.
Vision for Consumer-centric and Information-rich Health Care[3]
FHA sets an overarching vision for improving the quality, safety, and service of health care, and also for using health care resources more efficiently. The key to realizing this vision lies in creating a consumer-centered, outcome focused, information rich strategy, which provides health care consumers with access to information required for good decision-making whenever and wherever care is provided.
Other Traits of Consumer-centric Health Care
- Portability, information follows the consumer
- Readily Available information (to consumer and physician) such as past medical history, laboratory results, radiographs, and current diagnoses, as well as history of medications and treatments
- Sophisticated decision-support tools that help identify treatments that are best suited to a given patient
- Medications ordered with computerized systems that eliminate handwriting errors and automatically check for doses that are too high, too low, or at risk of causing harmful interactions with other drugs.
- Prescriptions checked against the health plan's formulary; Out-of-pocket costs of the prescribed drug would be compared with alternative medications.
- Fewer medical errors
- Up-to date information on patients
- Less variation in care.
- Consumer access to physician comparison information regardless of geographic location, socioeconomic status, disease condition, or disability.
- Culturally sensitive health care
- Emphasis on timely access to specialists and enhanced clinical decision support so that no consumer or family would experience unnecessary delays in access to care.
- Care delivered electronically as well as in person. Telemedicine to enhance access to the best specialists when needed for a specific disease or treatment.
- Protection of medical records from unauthorized access.
Over the past three years, many communities, hospitals, clinicians, and consumer groups have taken the initiative and demonstrated breakthroughs in improving the health care system. In these communities, even at this early stage, the process of health care is being modernized – and the experiences of both clinicians and consumers are better because of the changes. Here are some examples:
- When arriving at a physician's office, a new patient does not have to enter his or her personal information, allergies, medications, or medical history, since this information is already available.
- Medical records and x-rays on a key chain drive that plugs into a USB port on a computer.
- Secure network for private consultations between consumer and physician avoiding unnecessary visits to emergency room and/or office visit
- Computerized prescription, where potential allergies and contraindications are shown immediately, and managed care authorization occurs instantly.
- Specialist remote monitoring of intensive care units in several different hospitals, providing coverage 24 hours a day, 7 days a week, reducing mortality, length of stay, and total cost of the ICU stay.
- A small number of cases of an unusual, sudden-onset fever and cough are instantly reported to public health officials from area emergency rooms, alerting authorities of a possible disease outbreak.
- Standardized health assessment offered via a personal digital assistant device and sent electronically to a central database, where it will be available for review and ongoing care in the decades to come by DoD and VA medical providers.
Automation of the health care industry through widespread use of HIT is a unique means of improving quality and reducing costs at the same time. HIT is also critical to transforming how health care is delivered. HIT has the potential to allow a real market to develop that would reward innovations in care delivery, make the health care system more responsive to consumers, and increase the active involvement of consumers in health and health care.
"HHS is constantly challenged to present integrated information for making management decisions, but we are hindered by not having our vast stores of data pulled together in a comprehensive way."
US Dept. of Health and Human Services
FHA Scope
The Federal Health Architecture is designed to be an industry-wide framework. The scope includes virtually every type and category of health organization from consumers, manufacturers, standards organizations, policy makers and regulators, federal, state, and county governments, researchers and labs, hospitals, clinics, physicians, and insurers. More relevant, any organization dealing with health issues will be required to submit and comply with the FHA and HIT architecture and technology standards.
The Diagram below illustrates the makeup of the Federal Health Architecture:
The architecture is made up of four layers. The foundation is built on measuring performance and outcomes. Each health organization will be required to submit quality and performance data to be shared with consumers, the industry, and to the public.
In order to measure performance, a number of technology standards are being developed to ensure quality and consistency. This third layer has resulted in standards which include data, messaging, and technology standards such as HL7, IEEE 1073, ebXML, DICOM, SNOMED, LOINC, and Web Services as well as network systems such PHIN/NEDSS, eLEXNET, SafetyNet, LEADERS, and EPANET. Together, these technology standards, as well as others being developed, will provide the infrastructure necessary to provide detection and monitoring of performance, open communication of health information, and transactional interfaces allowing for interoperability among the health community.
The second layer of the architecture is the data layer. The data layer contains the actual information and data constructs needed by each individual business or health organization. Additionally, the FHA is currently in the process of defining common data frameworks and expanding the requirements from HIPAA and Data Practices. The new data standards will enable the next generation of national health care information to be integrated and shared over the next 10 years.
The top layer of the architecture is the business layer. The business, or more specifically, the performance of the business, is the primary driver of the FHA. In order for FHA to achieve the broad integration, coordination, and participation of the health care industry, the core philosophies of the business must be refocused to an outcome-based, or business performance-based model, oriented around the improvement of health. The new orientation outlined by the FHA requires an alignment between an organization's Performance, Business, Services, Technology, and Data. To assist organizations in making the critical transition to a business performance-driven model, the FHA has outlined five (5) reference models. The reference models focus on aligning business practices and processes to facilitate the implementation and design of an FHA compliant organization.
FHA Reference Models
The five (5) FHA reference models are the culmination of over ten (10) years of Enterprise Architecture (EA) and Business Process Modeling (BPM) integration. In 1993, congress enacted the Government Performance and Results Act (GPRA). The motivation behind the legislation was "to improve the confidence of the American people in the capability of government by systematically holding…agencies accountable for achieving results." This federal level legislation was the first effort in 80 years to tie government resources to measurable results. In 1996, as a follow-up to GPRA, The Clinger-Cohen Act mandated a federal enterprise IT architecture. The Chief Information Officer's Council responded to this mandate with the Federal Enterprise Architecture Framework (FEAF), a solution based on a framework created by noted enterprise architect John Zachman. The efficacy of this framework is evidenced by the fact that it has been implemented by nearly every federal agency in some form including the U.S. Treasury Department (Treasury Enterprise Architecture Framework -TEAF), the U.S. Department of Interior (Interior Enterprise Architecture – IEA), and the U.S. Department of Health and Human Services (Health and Human Services Enterprise Architecture – HHS EA).
Enterprise Architecture Framework (EAF) Standards Evolution:
- The Government Performance and Results Act (GPRA) of 1993
- The Information Technology Management Reform Act (ITMRA) of 1996 ("Clinger-Cohen Act")
- The Federal Enterprise Architecture Framework (FEAF) of 1999
- Treasury Enterprise Architecture Framework (TEAF) of 2000
- Federal Health Architecture (FHA) of 2004
The FEAF has been an integral component of the FHA. It forms the foundation of the technology (TRM) and data (DRM) reference models. In addition to the technology and data reference models, FHA has expanded the Federal Enterprise Architecture to include a performance (PRM), business (BRM), and service (SRM) reference models.
The diagram below illustrates the hierarchy of the five (5) reference models:
Enterprise Architecture Reference Models
Each Reference Model represents one aspect, or one set of components, of the total Health & Human Services Enterprise Architecture (HHS EA) and Federal Health Architecture (FHA). The five models are: the Performance Reference Model (PRM); the Business Reference Model (BRM); the Service Component Reference Model, also known as the Service Reference Model (SRM); the Technical Reference Model (TRM); and the Data and Information Reference Model, also known as the Data Reference Model (DRM). The lowest-level components of the first four listed models are Business Sub-functions (BRM), Performance Indicators (PRM), Service Components (SRM), and Service Specifications (TRM). The DRM is not completed; however, Data-Type Specifications may be one of the smallest components of the DRM.
Performance Reference Mode (PRM)
The PRM is a "reference model" or standardized framework to measure the performance of major IT investments and their contribution to program performance. The PRM has three main purposes: help produce enhanced performance information to improve strategic and daily decision-making; Improve the alignment-and better articulate the contribution of-inputs to outputs and outcomes, thereby creating a clear "line of sight" to desired results; and Identify performance improvement opportunities that span traditional organizational structures and boundaries. The PRM attempts to leverage the best of existing approaches to performance measurement in the public and private sectors, including the Balanced Scorecard, Baldrige Criteria, Value Measurement Methodology, program logic models, the value chain, and the theory of constraints. In addition, the PRM was informed by current measurements through PART assessments, GPRA, Enterprise Architecture, and Capital Planning and Investment Control. Use of the PRM will populate the model over time. The PRM is currently comprised of four measurement areas: mission and business results, customer results, processes and activities and technology.
Business Reference Model (BRM)
The Business Reference Model is a function-driven framework for describing the business operations of an organization. This model provides an organized, hierarchical construct for day-to-day activities. While many models exist for describing organizations – org charts, location maps, etc. – this model presents the business based on functionalities: Business Areas, Lines of Business, and Sub-functions. These areas represent a departure from previous models that use antiquated, stove piped, business unit-oriented frameworks. The BRM is the first layer of the Federal Enterprise Architecture and it is the main viewpoint for the analysis of data, service components, and technology.
Service Reference Model (SRM)
The Service Component Reference Model (SRM) is a business and performance-driven, functional framework that classifies Service Components with respect to how they support business and/or performance objectives. The SRM is intended for use to support the discovery of enterprise-wide business and application Service Components in IT investments and assets. The SRM is structured across horizontal and vertical service domains that, independent of the business functions, can provide a leverage-able foundation to support the reuse of applications, application capabilities, components, and business services.
Technical Reference Model (TRM)
The Technical Reference Model (TRM) provides a foundation to describe the standards, specifications, and technologies to support the construction, delivery, and exchange of business and application components (Service Components) that may be used and leveraged in a Component-Based or Service-Orientated Architecture. The TRM unifies existing TRMs and electronic Government (e-Gov) guidance by providing a foundation to advance the re-use of technology and component services from an enterprise-wide perspective.
Data Reference Model (DRM)
The Data and Information Reference Model (DRM) is being developed. The DRM will describe, at an aggregate level, the data and information that support program and business line operations. The model will aid in describing the types of interaction and exchanges that occur between the Federal Government and its various customers, constituencies, and business partners. The DRM will facilitate collaboration and data exchange between Federal agencies and State and Local entities. The DRM will categorize the government's information along general content areas and decomposes those content areas into greater levels of detail. The DRM establishes a commonly understood classification for Federal data and leads to the identification of duplicative data resources. A common data model will streamline the processes associated with information exchange both within the Federal government between the government and its external stakeholders.
Using the Reference Models
The reference models provide a way to identify an organization's systems, services, lines of business, and performance measurement. Items are identified and decomposed into components defined in the five Reference Models, the Health & Human Services Enterprise Architecture (HHS EA) and the Federal Health Architecture (FHA). Using this information, organizations "score" baseline, yielding potential areas of improvement. The organization can then use the HHS EA's Component Registry to determine whether the components from the target architecture are already available at another office or agency, thus possibly reducing duplication of effort and related costs.
Applying FHA in the Marketplace
FHA, and the related reference models, provides a basis for establishing the architectural framework necessary for operating in the health care industry for the next 10 years. Equally important, the progress made through the conception and development of the FHA identifies key opportunities in what InterNuntius calls the Health Service Delivery Chain (HSDC). One of the core-level philosophies embedded into the FHA is the idea that a client's health should be viewed as a continuum of historical data including the following: health preservation, health preservation services, health events, health services, and health outcomes.
FHA and HIT are driving health providers and insurers to reestablish the roles, functions, and services offered along the continuum of client health (initially framed by HIPAA legislation). Various health providers and insurers have begun enhancing the health history continuum services model to include expanded service offerings throughout the continuum.
Case Studies: How Health Care Providers Are Discovering Opportunities Along the Continuum [4]
Health insurance giant, Aetna, is as a prime example of a health care organization that has expanded role and service offerings through use of health information technology. After losing some $266 million between 2001 and 2002, Aetna has spent the last 3 years implementing a major strategic objective, which yielded a 6% operating margin in 2003, and a rising pre-tax profit as percentage of sales of 9.3% in the 3rd quarter of 2004. An integral component of Aetna's success has been better data management and the creation of an Executive Information System (EIS). Prior to the initiative, Aetna had been using stale information to make actuarial assumptions about what was happening in health care. Those assumptions, based on stale data, were costing Aetna about $1 million per day. Aetna went through an extensive process to develop requirements for an integrated planning and performance data reporting system.
Aetna now has a 14-terabyte data warehouse of medical-cost and medical-quality data. The database links performance information to core business operations to create an integrated executive informatics system or EIS. The EIS system gathers performance data about financial P/L, cost trends, customer acquisition measures, claim information, medical-costs, finance, and quality-tracking information. A key function of the EIS is to standardize and reconcile the disparities of how data is tracked and stored between various systems throughout the Aetna organization. Not only is Aetna tracking the performance of clinics, physicians, surgeons, and other healthcare providers, but they also use EIS to track and measure internal performance. Managers now have weekly snapshots of how units are performing and can respond to issues prior to seeing the results from month-end or quarter-end periods.
Aetna looks to the EIS system and data warehouse to identify, among other things, surgeon performance records on health events (including data on the number of complications resulting from the surgeon's performance on specific procedures). In some of its newer insurance plans, Aetna steers members toward better surgeons through incentives such as more generous co-pays. Aetna has found that better performance results in less follow-up care and thus fewer claims. Additionally, Aetna has used their data warehouse to help identify some 160,000 examples of potential medical errors, thereby preventing health events that result in claims.
Other Program Examples[5]
The following examples describe other health history continuum products and services being offered by health insurance providers through implementation of FHA and HIT initiatives:
- August 2004, an insurer began paying primary care physicians at three medical treatment facilities for "web visits" with their patients. A large Eastern Massachusetts doctors' group, and an insurer, are experimenting with doctor/patient e-mail programs. At a hospital, patients can enroll in "Patient Site," an online system that allows them to schedule appointments, look up test results, and e-mail their doctors. The insurance provider only is paying doctors who use a standardized web visit form developed to provide secure online communication.
- A non-profit organization is focused on creating system-wide improvements in care delivery by linking physician payment and performance. This initiative, which includes a consortium of quality partners, health plans, and providers has two current projects underway – Physician Office Link (POL) and Diabetes Care Link (DCL). POL stresses the necessity and value of a HIT infrastructure in a physician's office to promote error reduction and quality improvements. Rewards are based on a physician's use of clinical information systems and evidence-based medicine; patient education and support; and care management. The intent is to establish a HIT infrastructure and link it to improvements in higher quality care. The intent is to test the effectiveness and impact of the HIT infrastructure by using HEDIS measures for patients undergoing treatment of diabetes. These proven measures will help the program assess the success of the POL.
Examples of Federal Funding for Health Initiatives in Minnesota
Several health care organizations in Minnesota have successfully applied for and received federal grants from the HIT or FHA initiatives. In 2004, the Federal Government spent more than $900 million on IT projects and programs related to HIT and FHA. In 2004, health organizations in Minnesota received a total of $1.75 million. The following are a sample of federally funded initiatives:
Title: A Community-Shared Clinical Abstract to Improve Care
Description: Plans the use of IT to enhance communication at care transitions and develops an implementation plan for a community- and patient-shared EMR abstract that will be available at the point of care.
Funding: Year 1 Funding: $181,202 (Estimated total funding: $181,202)
Grantee: Fairview Health Services, Minneapolis, MN
Title: HIT Strategic Plan of SW Minnesota Health Providers
Description: Develops a regional health IT strategic plan between 28 healthcare providers including a comprehensive needs assessment of all of the participating organizations, prioritization of needs, identification of health IT solutions to prioritized needs, and development of appropriate implementation plans.
Funding: $196,274 (Estimated total funding: $196,274)
Grantee: Granite Falls Municipal Hospital, Granite Falls, MN
Title: HIT-based Regional Medication Management Pharmacy System
Description: Implements an interactive video-conferencing system at rural hospitals to provide continuing education for pharmacist and pharmacy technicians as well as a model for bedside verification of medication administration and medication bar coding; also evaluates structure, process, and outcomes related to improvement of patient safety and more effective patient medication management.
Funding: $488,785 (Estimated total funding: $1,374,616)
Grantee: Clouquet Community Memorial, Clouquet, MN
Solid strategic partnerships between insurance providers, care providers, physicians, and other industry partners will be key to capitalizing on new opportunities presented from FHA and HIT initiatives. The business environment created by the Federal Health Architecture (FHA) encourages partnering among health service providers and establishing what InterNuntius calls value-add service networks (VASN). Developing VASNs is a key requirement to providing services along the health services delivery chain (HSDC). InterNuntius believes that HSDCs will serve as differentiators of health service organizations in the future. HSDCs leverage existing provider networks and through the use of FHA greatly expand the capabilities and value of a firm's service offerings.
Products to Services Continuum
The Health Services Industry, like so many industries, has become product focused. The ubiquitous nature of care procedures has had the effect of commoditizing health services. Many health, medical, and surgical procedures are volume-based. A primary indicator of this commoditization is that health services can now be easily "shopped" to find the best price. Another commodity indicator prevalent in the health industry is the standardization of prices and services. Health insurance providers set standard reimbursement rates for health service delivery based on the diagnosis and treatment of health conditions. Many insurance plans stipulate what procedures can be performed in the treatment of a health condition.
Pressure for insurers to provide performance and analytical information from their related care network providers will continue to build over the next three years. Competitive pressure will grow even more intense as insurers like Aetna and UnitedHealthcare begin to pull further ahead of competitors by providing additional services resulting from their Enterprise Architecture capabilities. Health insurance consolidation will increase as health insurance firms struggle to keep up with the heavy infrastructures and technology requirements necessary to implement aspects of FHA and HIT.
Minnesota-based UnitedHealthcare (UHC) provides their members with hospital comparison information on patient volume, unfavorable outcomes, mortality rates, length of stay, and average charges. UHC also provides Computer Physician Order Entry (CPOE) allowing physicians to enter orders and prescriptions on the computer to eliminate errors from hand-written orders. UHC claims to have reduced medication errors by some 88% as a result of CPOE and other initiatives from the Leapfrog Group.
As competition escalates between care providers in a services-as-products marketplace, the primary challenge for health service organizations is remaining profitable. The answer to profitability lies in operating with the proper mix of products and services. Research indicates that when an organization transitions from a products focus to a services focus, profitability is significantly improved.[6] In the book, S-Business: Reinventing the Services Organization, James Alexander states that top performing service businesses drive sales for products from a pure service offerings perspective. This is illustrated in Figure 4. Top service performers averaged a 61% gross margin and a 30% annual growth rate on their service offerings.[7] These findings suggest that a major key to profitability is focusing on coordinated service offerings to drive growth.
Marketplace Role
The first step in coordinating service offerings lies in identifying the role an organization desires to play in the marketplace. Health service organizations fall into one of four (4) roles in the marketplace.
Organizations function as innovators, specialists, solutions providers, or commodity service providers.
Figure 5 above, illustrates the four (4) roles a service organization plays in the marketplace. The x-axis (horizontal) of the quadrant depicts the level of service differentiation, while the y-axis (vertical) depicts the significance of the services offered.
Commodity Service Firm
The commodity services quadrant shows firms that provide services that are low in both significance and differentiation. Services provided by firms in this quadrant typically compete based on low costs. Consumers are both comfortable and familiar with these services. Commodity firms are characterized by a focus on cost, pricing, and efficiency. Consumers of commodity services shop to find the firm that offers the lowest or best cost. The typical corporate buyer of commodity services is the support group.
Solutions Provider Firm
The solutions firm provides an integrated services product to their clients. They are focused on full lifecycle solutions, are known for their breadth of knowledge and experience, and provide a single point of contact for a number of commodity and emerging services. Solutions firms must differentiate themselves by providing superior levels of services and solution packaging. Buyers of services from a solutions firm typically prepare an RFP and then evaluate the resulting proposals. Once a solutions firm is selected, negotiation is the key to making a wise purchasing decision.
Specialist Firm
A specialist firm differentiates themselves by providing world-class quality or breakthrough services. Specialist firms are focused on specific markets (vertical or horizontal) and are known for their depth of knowledge and services provided to their market of focus. To acquire services from the specialist firm, a subject matter expert will typically spend time investigating specialist firms to find the best fit.
Innovator Firms
Innovator firms pride themselves on their ability to continuously provide unique or breakthrough services of high significance or value. Innovator firms focus on clients and provide a wide-range of services that are unique and specific to individual clients. They are known for their innovation and their ability to pull together innovative solutions for specific issues faced by an organization. Top management typically hires or recommends the innovator firms and engages them by forming a partnership-style of relationship. Once partnered, the innovator firms retain the relationship for many years and reengage their clients at various levels for specific needs.
Role Erosion
While FHA and HIT will provide many benefits for care organizations by encouraging uniform standards and performance measures, the downside of the initiative is a loss of differentiation in the marketplace. The environment created by FHA and HIT will act as an accelerant of role erosion for care organizations that lack a carefully designed strategic plan. However, the opportunities represented by FHA and HIT will offset the effect erosion will play through industry standardization.
Figure 6 below, illustrates how products and services erode into mass-market adoption, standardization, and commoditization.
The Federal Health Architecture and the Health Information Technology initiatives will continue to impact the health care industry in a major way. New performance measures, technology standards, and data practices, are emerging and being implemented in the mainstream health marketplace. Opportunities exist to extend product and service offerings along the Health Services Delivery Chain.
To capitalize on the changes in the health care market, organizations must develop their strategic capabilities by understanding the impact of FHA and HIT on their organization, gain insight on how competitors are responding, and evaluate their position in the market to identify organizational capabilities for providing products and services for these emerging opportunities.
About the Author
Bryant Avey is the CEO and founder of InterNuntius, Incorporated. He spends approximately eighty percent of his time consulting InterNuntius clients and has over eight years of experience in the Health and Human Services Industry. In December 2004, Mr. Avey received a service recognition award from the Commissioner of the Minnesota Department of Commerce for his role in providing a strategy and architecture in the statewide eGovernment solution, eHEAT, for the Low Income Heating and Energy Assistance Program (LIHEAP).
Mr. Avey has developed white papers on employee retention and developed conference seminars for the International Association of Personnel in Employment Security (IAPES) on the topic of Branding Your Environment and Strategic Career Growth. He has also produced an audiotape for InterNuntius Academe Presents entitled Employee Retention in the D-Age Environment. The audio program covers several case studies of organizations that have excelled in creating winning employee environments.
Mr. Avey has been published in fourteen different publications including: Chief Executive, where his article was the CEO's Challenge of the month; International Personnel Management Association's IPMA News; the Hartford Business Journal; Four Corners Business Journal; Legal Management Magazine; The Professional Journal; Benefits & Compensation Solutions; Employee Assistance; The American Management Association's Manage Magazine; the Northeast Pennsylvania Business Journal; and Employee Benefit News.
Frequently Asked Questions (FAQ)
What does it mean to Auto-Adjudicate?
Auto-adjudication is the process of automatically approving, denying, or adjusting a claim transaction without human intervention.
What is an Electronic Health Record (EHR)?
An electronic health record is the generic term for all electronic patient care systems.
What is a Personal Health Record (PHR)?
A personal health record is an electronically accessible personal patient chart. The PHR contains information about each visit to a health provider including physician orders, lab reports, imaging and x-ray reports, immunization records, consent forms, and other medical record and medical history information.
What's Clinical Health Data Repository (CHDR)?
CHDR provides bi-directional exchange of health data and is integrated with the clinical decision support systems. Using CHDR clinical decision support applications, providers will be able to access and use relevant clinical data to make important medical decisions for their patients regardless of where the information resides.
How do I describe Enterprise Architecture?
Enterprise Architecture is a framework whereby an organization can identify its baseline and future components. More specifically, EA covers present and future lines of business, desired performance outcomes, data types, information technology, and the service channels through which an organization delivers products and services. EA consists of reference models, policies, and operating procedures.
What is the Federal Enterprise Architecture?
The FEA, established in 2002, is a business and performance-based process and model, or framework, to support cross-agency collaboration, transformation, and government-wide improvement. FEA defines work activities and technologies by components; hence, it is called a Component-Based Architecture (CBA). The FEA Program Management Office (FEAPMO) within the Office of Management and Budget (OMB) oversees the FEA. The FEA is the basis for the Health & Human Services Federal Architecture (HHS EA).
What is a Component-Based Architecture?
A Component Based Architecture (CBA) bases its design upon categorizing business, service, performance, technical, and data elements, at their lowest level, as components, and recognizing larger lines of business, service, and technology infrastructures as combinations of components. By defining and publishing these "groups of building blocks" in the Federal Enterprise Architecture (FEA), OMB has, as a primary goal, the reuse of components across the Federal Government. Secondary OMB hopes to increase efficiency, and program effectiveness, and reduce costs.
Is EA done just once for an organization?
No. The EA process is dynamic, with cycles of revision for the current architecture, the target architecture, and the plans of action and milestones to reach the target architecture. The Plan of Action is known as a Modernization Blueprint. Once an initial Modernization Blueprint is established, a continuing process leads to adjustments of that Blueprint. Further, a Maturity Model Self Assessment tool provides a way to evaluate an organization's achievements and identifies short- and long-range tasks necessary to maintain an excellent Enterprise Architecture.
What are the Department's committees associated with Enterprise Architecture?
Direct Enterprise Architecture teams are: The Interior Architecture Working Group (IAWG, the Architecture Review Board (ARB), the Interior Business Architecture Team (IBAT), and the Data Reference Model Steering Group (DRMSG). Enterprise Architecture is mentioned as a high priority in the Department's Strategic Plan and is discussed in other related committees: The CIO's committee, the Information Technology Management Committee (ITMC); the E-Gov Team, the DOI-wide E-Government initiatives' team that deals with the E-Government part of the President's Management Agenda (PMA); The IRB, the senior-management Investment Review Board that receives information from both the ITMC and the E-Gov Team. The IRB reports to the DOI-wide senior-level Management Initiatives Team (MIT), that in turn supports the MEC, the highest-level DOI Management Excellence Committee.
What Business Areas are included in the FEA?
The four Business Areas included in the FEA are: Service for Citizens, Mode of Delivery, Support Delivery of Services, and Management of Government Resources.
What are some of the transaction types that we can expect under the new architecture?
Six general types of business transactional relationship have been identified within the health services marketplace:
B2P – Business to Patient: Hospitals, clinics, and doctors offices provide service based transactions to patients. The patient relationship is unique to the healthcare market and is differentiated from relationships with members, employees, or consumers due to the unique HIPAA and patient information requirements.
B2M – Business to Member: Health insurance providers and other member-based health organizations provide transactional services to their members.
B2B – Business to Business: Businesses exchange data and transact business between themselves. This includes transactions between clinics, physicians, insurance providers, pharmacies, and other health network providers.
B2G – Business to Government: Businesses exchange data and transact business, claims, and services with various local, county, state, and federal governments.
B2E – Business to Employee: Business provide various services to their employees or provide employee assistance services for various customer's employees.
B2C – Business to Consumer/Client/Customer: Business is transacted directly with the end consumer, client, or customer. Transactions are specifically tailored for the consumer.
[1] David J. Brailer, MD, PhD, National Coordinator for Health Information Technology, "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care – Framework for Strategic Action," July 21,2004.
[2] Brailer, Framework for Strategic Action.
[3] Brailer, Framework for Strategic Action.
[4] David F. Carr, "The Aetna Cure," Baseline February, 2005, Case 155.
[5] Brailer, Framework for Strategic Action.
[6] James A. Alexander and Mark W. Hordes, "S-Business: Reinventing the Services Organization", Select Books, 2003
[7] Alexander, 2003, page 27


text: Goodwin is a lot of speed but still pretty raw. I think he'll be primarily a slot receiver and special teams return man. He's one of those guys where you just need to get the ball in his hands quickly so he can let his athletic ability do the rest. Austin is pretty much the same way but not as raw.

subset: commoncrawl


text:
Speaking of secondaries... my next kid was in my opinion the best player in Oklahoma St.'s secondary, and he was only a sophomore last year.
Forget about Markelle Martin... Justin Gilbert was the best player in OSU's secondary this past season, and the best player on the defense, period.
He finished tied for the team lead with 5 interceptions and had 10 PBU's. He's got the size you look for at about 6'0", 205 pounds... elite athlete with tremendous speed and smoothness in the hips.
What makes him special is his added return ability on special teams. He averaged over 27 yards/return last year with 2 touchdowns. He's probably the fastest player in the Big-12.
Outstanding kick returner with everything he needs to develope into a legitimate top 15 pick:
He burned Oklahoma here as a freshman:


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In the case of a comet, the tail is a long link of gas and dust that flow away from the nucleus and coma of the comet.
Deformation forces acting on a planet's crust.
The processes of faulting, folding or other deformation of the lithosphere of a planetary body, often the result of large-scale internal movements below the lithosphere.
The dividing line between the illuminated and the unilluminated part of the moon's or a planet's disk. The line of sunrise or sunset on a planet or its satellite. At dawn and dusk when the sun is lowest in the sky (low sun), topographic features cast their longest shadows. This reveals information about the size and shape of the objects casting the shadows. Therefore, features near the terminator are imaged in order to obtain morphologic information.
An extensive land mass.
The surface features of an area of land.
The inner solar system planets: Mercury, Venus, Earth, Mars, composed of rocky materials and iron, with a density between 4.0 and 5.5 grams per cubic centimeter.
Tile; terrain formed of polygonal pattern
The general appearance or character of a rock. (e.g. the size, shape, and arrangement of its constituent elements)
small domical mountain or hill.
Frictional heating of a satellite's interior due to flexure caused by the gravitational pull of its parent planet and possibly neighboring satellites.
The general configuration of a land surface.
A shape that resembles a doughnut or the inner-tube of a tire.
The hemisphere that faces backwards, away from the direction of motion of a satellite that keeps the same face toward the planet.
An object orbiting in the Lagrange points of another (larger) object. This name derives from a generalization of the names of some of the largest asteroids in Jupiter's Lagrange points: 588 Achilles, 624 Hektor, and 911 Agamemnon. Saturn's satellites Helene, Calypso and Telesto are also sometimes called Trojans.
The layer of the atmosphere from the surface to where the temperature stops decreasing with height.


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e-Campus Degree Programs
The e-Campus offers a set of wholly on-line master's programs, a set of on-line baccalaureate completion programs, and a limited number of blended (part on-line, part face-to-face) cohort programs at select remote locations. Students desiring admission to the e-campus for distant learners may not reside in the following twelve Texas Counties: Erath, Comanche, Hamilton, Palo Pinto, Hood, Somerville, Hood, Tarrant, Parker, Johnson, Hill or McLennan. Students residing within these counties may enroll in on-line and blended programs but must do so from one of the following campus locations: main Tarleton State University campus in Stephenville, Tarleton's Southwest Metroplex Center in Fort Worth, or the University Center at MCC in Waco.
Prospective students are highly encouraged to speak with an advisor prior to applying to The University.
NOTICE: Beginning Fall 2011, Distance Learners pursuing an undergraduate online completion degree will be charged a $300 Distance Education Program fee for each online course within the degree program. For more information about the Distance Education Program fee and other details about tuition and fees, please visit the Business Services Tuition Information page.
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- Master of Music in Music Education Fall 2012


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Hang tight!
Recipe by Jodi
"Traditional frozen custard recipe--sugar, eggs and milk are cooked, then combined with whipped cream, chilled overnight, and frozen in an ice cream maker."
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1 cup
white sugar
1 cup
2 cups
heavy cream
1 1/2 teaspoons
vanilla extract
1 tablespoon
fresh lemon juice
For the creamiest, most luxurious ice cream, cook this custard in the traditional method, bringing as close to 185 degrees as possible, but do not let it come to a boil. Remove from heat, strain, then add vanilla. Cool in ice bath, then chill mixture several hours or overnight before churning. Almost as good, and certainly a lot easier because you don't have to cook it, is simply to beat the eggs till light and fluffy, about 1-2 minutes, add the sugar, beat another minute, then add to cream mixture with vanilla. Whichever way you choose to do it, don't whip the cream. This will cause a lot of "overrun," or air volume, which you don't want. (This is what the inexpensive brands of ice cream do) I wanted a clean vanilla ice cream flavor, so I eliminated the lemon juice and, since I like my "frozen custard" super rich, I used half and half instead of the milk. So long as the step of whipping the cream is skipped, this is excellent ice cream.
If you like frozen whipped cream - this is the recipe for you!! Just not my idea of ice cream.
51 Ratings
i admit i changed this a bit by not whipping the cream at all and just putting it in and mixing it then putting it in the freezer, but when i did this it was just like Haagen-Daazs in my opinion - dense and rich thanks and i hope i didnt upset the creator by modifying it a bit!
Wonderful! I used skim milk as that was all I had at home and didn't whip the cream before combing everything. This is a nice, smooth ice cream. Doesn't have a filmy, fatty after effect. Also doesn't get as rock hard as other recipes I've tried. The lemon juice cuts the sweet slightly, making it a perfect homemade ice cream.
Very rich and creamy texture. I will definitely use this recipie again. I didn't whip the cream before mixing it together with the egg mixture because I wanted a more dense texture. I was very happy with the results. I also did not have enough lemon juice, so I just left that out. Wonderful recipie!!!
I agree with the user who said this was like frozen whipped cream. The flavor was fine but the texture was all wrong. It was so light and fluffy, not near rich and creamy enough. I noticed several reviewers said they did not whip the mixture at all. Perhaps I will try it again with out whipping.
Creamy texture, good flavour. Do not beat the cream.
I really like this recipe-itis a good basic ice cream recipe. I made it a few times and I used egg beaters and fat free half and half instead of heavy cream. I did not whip it either. I tried using Splenda instead of sugar, but it was not as good. It was just good to be able to make a fat free ice cream that was delicious!
* Percent Daily Values are based on a 2,000 calorie diet.
Vanilla Ice Cream I
Serving Size: 1/8 of a recipe
Servings Per Recipe: 8
Amount Per Serving
Calories: 338
Calories from Fat: 215
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- 4
- people in the U.S. have this name View Terry Mcginity on Whitepages
Meaning & Origins
As a medieval given name this is a Norman form of the French name Thierry, from Germanic Theodoric, from þeud 'people, race' + rīc 'power, ruler'. This was adopted by the Normans and introduced by them to Britain. In modern English use it seems at first to have been a transferred use of the surname derived from the medieval given name, and later to have been taken as a pet form of Terence.
|89th in the U.S.
Irish: variant of McGinty.
|53,667th in the U.S.
Nicknames & variations
Terri, Terrye, Terrie, Terre, Terra, Terria, Terrah, Terr, Terrry, Terree
Mcgill, Mcginnis, Mcginty, Mcginley, Mcginn, Mcginness, Mcgillivray, Mcgivern, Mcgirt, Mcgilvray


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1. Preheat oven to 350°F. Prepare cake batter according to package directions. Pour batter into a rimmed cookie sheet or jelly roll pan lined with wax paper. Bake 15-20 minutes or until cake is baked through. Cool completely. Cut lengthwise into 3 even pieces.
2. Warm fudge topping microwave for 1 minute to soften. Spread fudge over top of each cake piece.
3. Spread softened ice cream over 2 cake pieces. Stack cake and ice cream layers on top of the other.
4. Place remaining cake piece on top. Carefully wrap torte in plastic wrap and freeze 2 hours or overnight. Garnish with chopped peppermint candy prior to serving.
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At least for Day 1 of the 2011 LeFlore County Fast-Pitch Softball Tournament Monday night at the Poteau Area Recreational Complex, the seeding pretty much held to form.
The top four seeds — Poteau, Spiro, Panama and Heavener — all won their openers. The Lady Pirates were too much for the Howe Lady Lions, winning 15-0 as Brenna Vise pitched a perfect three-inning game. The other top-seed games were a little closer.
The Lady Razorbacks got a no-hitter from Taylor Eaves as they blanked the Wister Lady Wildcats 2-0.
The Spiro Lady Bulldogs had to hold off a late rally by the Pocola Lady Indians to win 4-3 and the Lady Wolves defeated the Talihina Lady Golden Tigers 6-3.
Tuesday night's championship semifinals had Poteau meeting Heavener and Spiro playing Panama. The two winners will play at 7:30 p.m. tonight in the winner's-bracket final.
In Monday night's opening-round games, seeding also held true.
No. 5 Talihina defeated No. 12 Leflore 9-1, No. 6 Wister beat No. 11 Bokoshe 12-0, No. 7 Pocola handled No. 10 Whitesboro 13-3 and No. 8 Howe blanked No. 9 Arkoma 12-0.
Tuesday's games saw six elimination games. In the first set of elimination games, Wister played Arkoma, Pocola faced Leflore, Howe battled Bokoshe and Talihina played Whitesboro.
The other two elimination games saw the Wister-Arkoma winner face the Pocola-Leflore winner, while the Howe-Bokoshe victor played the Talihina-Whitesboro.
The Wister-Arkoma-Pocola-Leflore survivor will play the Poteau-Heavener loser at 6 p.m. tonight, while the Spiro-Panama loser will face the survivor of the quartet of Howe-Bokoshe-Talihina-Whitesboro, also at 6 p.m. tonight.
The two 6 p.m. game winners will then play at 7:30 p.m. tonight for the right to get to the loser's-bracket final on Thursday night.
[1] http://www.poteaudailynews.com/sites/default/files/LEFLORETALIHINALCT.jpg
[2] mailto:email@example.com


text:
37 wins
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37 wins
Ash from Army of Darkness: Good...Bad...I'm the guy with the gun.
I'm saying 40.
I'm optimistic. Although we are like the ex-Sonics in that we'll be leaning on our youngsters a lot, we also have a group of wily veterans. Jack, Rasho, Foster, Murphy, Dunleavy and especially Daniels are solid guys for us that won't raise any eyebrows around the league. I'm very high on Quis this year. I think he has a career year, playing for his contract.
42 wins
In the interest of full disclosure, the giddiness of the draft and trades caused me to predict 45 wins in this thread:
but I the reasons why I dropped it to 35 are largely explained in this post:
Still happier going into this season than I have been for quite some time.
if we trade Tinsley for J.J. Redick
You're being redickulous.
If you get to thinkin youre a person of some influence, try orderin somebody elses dog around..
I will go again with 41 with most of those in the second half.
The best exercise of the human heart is reaching down and picking someone else up.
Wow, now that's a stretch and a half! The Thunder don't have the overall quality of players the Pacers have. Why should anyone being realistic think they can win 38-40 games? Being realistic, the Pacers have a good shot at winning 38-40 games. They have a better team than last year, so a few extra wins this season is realistic.
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29. Just like last year, I think a large number of you are vastly overestimating our overall talent level.
Why do the things that we treasure most, slip away in time
Till to the music we grow deaf, to God's beauty blind
Why do the things that connect us slowly pull us apart?
Till we fall away in our own darkness, a stranger to our own hearts
And life itself, rushing over me
Life itself, the wind in black elms,
Life itself in your heart and in your eyes, I can't make it without you
Last year, 15 picked fewer wins than the Pacers achieved, and 79 picked too many wins.
Why do the things that we treasure most, slip away in time
Till to the music we grow deaf, to God's beauty blind
Why do the things that connect us slowly pull us apart?
Till we fall away in our own darkness, a stranger to our own hearts
And life itself, rushing over me
Life itself, the wind in black elms,
Life itself in your heart and in your eyes, I can't make it without you
Don't ask Marvin Harrison what he did during the bye week. "Batman never told where the Bat Cave is," he explained.
The East is getting better, but this will be a fun team to watch. If TJ gets hurt though, it will hurt our win total considerably.
"As a bearded man, i was very disappointed in Love. I am gathering other bearded men to discuss the status of Kevin Love's beard. I am motioning that it must be shaved."
- ilive4sports
Take me out to the black, tell 'em I ain't coming back. Burn the land and boil the sea, you can't take the sky from me.


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European Commission launches consultation to assess impact of plastic waste, publishes Green Paper
12:13 PM MDT | April 5, 2013 | Francinia Protti-Alvarez
The European Commission has published a Green Paper entitled On a European Strategy on Plastic Waste in the Environment, to gather facts and views that will enable it to assess the environmental impacts of plastic waste and define a European strategy to mitigate them. The paper highlights the importance of plastic in many industrial processes and applications, and notes the need to manage plastic waste in a more effective way, with potential economic gains derived from higher recycling rates. The paper notes that the challenges posed by plastic waste are not...
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- Beauty at the Ballet
6:00PM to 9:00PM
The Springfield Ballet Company is excited to team up with GSCI once again to offer an exciting, hands-on workshop! Learn the basics and history of dance, view costumes, and receive a free ticket to the Springfield Ballet Company's performance of Sleeping Beauty! Who: Girls in grades K - 5 Date: Friday, April 12, 2013 Location: Hoogland Center for the Arts Time: 6:00 p.m. - 8:00 p.m. Fee: $20 per girl/$28 per adult Min/Max: 50/250 participants Sleeping Beauty will be preformed on April 27 and 28, 2013, at 2:00 p.m. at Sangamon Auditorium in Springfield. All girls who register for the event will receive a complimentary ticket to the show. Adults may come to the workshop for free but if an adult will be attending the performance of Sleeping Beauty, they must register and pay the adult cost. A registration flyer with additional information and registration instructions will be available closer to the date of the event. ...


text:
Thousands of Migrants Pour into Austria and Germany9/5/2015 12:11PM
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Even if you're not a tennis superstar, there are beauty and fitness trends you can pick up from the U.S. Open's top tennis stars. Town & Country's Micaela English explains. Photo: Getty


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Gain an introduction to the rich tradition of British literature as you earn high school credit. In this innovative online course, you'll examine major works of fiction and drama from some of Britain's great authors and develop critical reading skills.
In four units, this course covers two major authors from the British tradition. In Units 1 and 2, you'll read Joseph Conrad's novel Heart of Darkness and examine the author's classic use of symbolism and his exploration of the themes of imperialism, society versus the self, and innocence versus goodness. Then, in Units 3 and 4, you'll turn to the drama with a study of Shakespeare's tragedy Othello, considering motivation, characterization, and the theme of love versus duty.
Since the course is presented online, you can study wherever and whenever you want as you work at your own pace. You'll also benefit from the support of a dedicated and experienced instructor who will guide your learning throughout the course. It's a great solution for anyone who needs to complete this English requirement for high school graduation.
This course is offered through Career Online High School, a division of Smart Horizons Career Online High School, and is accredited by the Southern Association of Colleges and Schools (SACS). English III: British Literature and Composition, Semester 1, is a one-semester course, and can be completed in up to four weeks. Enroll in this convenient, affordable course, and start on your path toward completing your high school education.
Hours: 48 hours
Duration of Access: 4 weeks
Credit: 0.50
Credit Type: Carnegie Credit
Open Enrollment
Read Syllabus >Price
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Choose your Semester below then click "Continue" to proceed to the Enrollment Form.
Semester 1 Pretest - British Literature and Composition
Unit 1: Innocence vs. Experience: Heart of Darkness
Unit 2: Colonialism: Heart of Darkness
Unit 3: Characterization and Love: Othello
Unit 4: Drama and Tragedy: Othello
Semester 1 Test - British Literature and Composition
the complete Course Catalog >
Semester 2 Pretest - British Literature and Composition
Unit 5: Conformity vs. Rebellion: 1984
Unit 6: Imagery and Betrayal: 1984
Unit 7: Romanticism: Frankenstein
Unit 8: Theme and Characterization: Frankenstein
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Madonna to Get 'Unplugged' with Miley Cyrus
When Miley Cyrus takes the stage in New York City tonight (Jan. 28) for the latest edition of MTV's long-running Unplugged series, she'll be joined by someone who could teach even her a thing or two about controversial pop: Madonna.
CW Featured Artist – Madonna And Her Billions
As heard in "The Carrie Diaries." After a successful 2012, Madonna has progressed from being just your average millionaire to the first female billionaire of pop music. But the addition of the Material Girl into the billionaire […]


text: Manafest Updates Us On 'The Chase' 1 of 3 Manafest talks about the Rapzilla iPhone app, and his new album 'The Chase' About the AuthorChad Horton has co-owned and operated Rapzilla.com with Philip Rood since 2010, bringing with him a decade of music business experience. Horton is also the Director of Marketing for Syntax Creative, the largest independent digital distributor of Christian & Gospel music, among other genres. Originally from Northern California, Horton rooted himself in San Diego with his wife of nine years, as well as two beautiful daughters. View the discussion thread. blog comments powered by DISQUS back to top


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"Customer service is priority #1 at Rocky Mountain ATV/MC. We value our customers and strive to be the best shopping experience- when you buy from us, you are buying lifetime service."
-Dan Thomas, CEO and Founder
We take pride in offering no hassle returns. In the event of a return, please call, email or chat with us to receive a solution to the problem. For apparel that doesn't fit quite right, Click here to see our Fit Guaranteed Program.
We will stand behind all products we sell with regards to manufacturing defects in workmanship and material. Most products are limited to the manufacturer's warranty. However, we will do everything in our power to take care of the problem.
Live chat: Click here
(Leave email if after hours)
Call us: 1 800 336-5437
7am-7pm Mon-Fri 8am-4pm Sat (Mountain Standard Time)
Each review submitted enters you into a $100 gift card monthly drawing, and a $500 gift card quarterly drawing!
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Comments On Jul 28, 2013:A bit thick for race stacking in my opinion they get a little too blurry after about 8 tear offs or so but other than that they are great
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Comments On Feb 21, 2013:These googles are well made and have the rubber grip that keeps them from slipping on your helmet. Good price too!
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Comments On Oct 11, 2011:works as advertised,a must have, will save your googles and your money.
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Comments On Oct 29, 2010:Works just like it should, easy removal and doesn't interfere with your field of view. Will buy again.
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Comments On Feb 17, 2010:Have not used tear offs in a long time but raced a couple weeks ago and was glad to have them. They seem to fit many models of goggles
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Nb: infants must be under the age of 2 and
children must be under the age of 12 at the time of
Chalet St Clair is a beautiful and spacious 4 bedroom chalet finished throughout in old wood.
The front door leads into a large entry hall, which overlooks the double height living room and kitchen. A wooden staircase leads you down to this main living area, which enjoys a large fireplace, comfortable sitting area with cable TV (all UK terrestrial channels), dining area and high spec modern kitchen. French windows lead out on to a large balcony with beautiful views across the valley to the Weisshorn, Switzerland's 3rd highest mountain at over 4500m. Also on this floor is a sauna, a guest loo and a large double bedroom with en suite bathroom with bath and shower.
The chalet is located about 10 minutes walk from the village centre and there is a regular free shuttle bus that takes you to and from the lifts in just a couple of minutes.
lower ground floor there are three guest bedrooms. One double bedroom with en suite bathroom, and a second double bedroom which shares a shower room with a twin room. The latter can be converted to a triple room using a truckle bed. All bedrooms have an external door leading out into the garden.
Please Note: There is a damage deposit of 1,500 Swiss Francs to be paid on collection of the keys (approx 900 GBP).Chalet is only sold to parties booking the whole chalet.
Chalet owners would like you to feel at home in their home and to have the time to relax and enjoy your stay without the hassle of self-catering or the intrusion of a chalet girl. therefore provide you with the following services:
A welcome pack of groceries on arrivalAll bed and bath linen provided and beds made upDaily delivery of fresh bread and croissantsDaily maid serviceMenu of home-prepared meals, which can be delivered to the chaletConcierge to make reservations of restaurants, ski instruction, child care etc.Ski passes delivered to your chalet
Iglu acts as a travel agent for disclosed principals/tour operators, further details
of which will be made available at the time of booking. Your holiday contract will
be bound by the tour operators terms and conditions.
Prices are shown for a basic room or unit, can be subject to change and are indicative
until time of booking. Please call on 020 8544 7114 for prices for other travel
and room options for this property.
Prices shown are per person per week based on maximum occupancy. Descriptions and
quality ratings are provided by the Tour Operator (or one of the Tour Operators
where similar holidays are offered by more than one supplier). We reserve the right
to make minor adjustments to the description or rating based on staff and customer
feedback. For payments by credit card, a 2.5% credit card charge (4% for AMEX) will
be added to your invoice. If you pay by a UK issued debit card, there is no charge.
All bookings are subject to a £5 per person Passenger Admin Fee charged by Iglu.com.


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Over the past five years, the Mendon Schools Foundation has been able to fund an impressive number of requests from teachers seeking funding for a specific item.
If you are a commercial property owner, investor, or manager, you tend to have a lot on your plate when it comes to maintenance.
By Melissa CrawleyMore Content Now
I first fell in love with felt Advent calendars about six years ago when I saw a Christmas tree with 25 superbly decorated pockets at Pottery Barn.
WEEK IN RELIGIONAn evangelical Muslim preacher is being investigated by Pakistani police for allegedly making blasphemous comments about Islam in a viral video that began circulating earlier this month.
Mendon, White Pigeon, Sturgis, Three Rivers, Constantine and Bronson all sweep
A visual step-by-step that will teach you how to glaze a holiday ham from start to finish.
Tis the season to be jolly�and get fat. Fend off holiday weight gain with our practical tips.
A traffic signal at the intersection of South Nottawa and Congress streets will not be replaced with a four-way red flashing light in anticipation of second-phase reconstruction on South Nottawa Street, to begin next spring.
And then there were five.The finale of�Survivor's 29th season...
Michigan Strategic Fund has approved $12.5 million in grants to support the construction of a 550,000-square-foot pork processing facility.
- Events Calendar


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The core of All Things Meetings is a FREE FINDER SERVICE. Tell us what you need, we find it for you and introduce you directly to the Vendor. Could be a Hotel, Destination Management Company, free-standing event venue, AV Production, Mobile Event Applications, Lighting or Event Rental Company, Team Builder, Speaker, Entertainment, Group tickets, Caterer, Transportation Company, on-site travel staff… whatever… All Things Meetings. I have been in the business 38+ years and have owned All Things Meetings for nearly 14. We know everyone, everywhere. Then we get out of the way. This service is for do-it-your-self planners who just don't have the time at the moment to do all the research, or they have to plan something in an unfamiliar destination. It's a FREE SERVICE.
On the opposite end of the spectrum, if you need more than just a finder service, we provide Full Service Event Management. We work with you to develop the meeting or event, we hire the vendors, manage the budget, operate the program on-site, and basically do everything (with your step-by-step approval). In these cases we charge a management fee on a sliding scale. Some clients want one thing, some want everything.
In the middle… let's call it "CONTRACT WORK". We provide "human bandwidth" to help manage your event on an hourly fee basis. We attend your planning meetings, take whatever responsibilities you choose to give us, and make sure it happens. You still get the benefit of our contacts and experience. You sign vendor contracts and pay the bills. We are Planners/On-Site Travel Staff For Hire.
So, if you are involved in planning Meetings, Incentives, Board Retreats, Trade Shows, Road Shows, AV Production, Branding Experiences, Users Groups, Developer Conferences, Customer Events, Press Events, Holiday Parties…and every other event I forgot to mention, we can help. No complicated rfps to fill out… just send me a stream-of-consciousness e-mail and we'll get as many options as we can as soon as we can.
Anything we can help you with? Look forward to an opportunity to work with you.
Warm Regards,
Neil Cramer
415-673-2143 (office)
707-738-5627 (cell)


text: I've gotten to see Patterson play many times, when he was with Philly. He isn't a bad player and could be useful as a nickel/dime CB for Miami in the future. Sometimes a coach or coaching staff can make a big difference in a players development. Patterson regressed in Cleveland after playing well in Philly, I'm not sure why, but I suspect a difference in coaching. I was surprised Patterson got the call to start after just a few day's of practice. Patterson and McCann are IMHO, products of Coyles magic touch with DB's. Both McCann and Patterson could be to Miami what some of those Bengals DB's were before Coyle worked his wizardry on them. Patterson I think would have to restructure, if he's to stick around beyond 2012. But I really do like how both players have played and think they could be a big part of the solution moving forward. I still think Miami drafts a CB or Safety early in the 2013 draft. But for now I hope Miami has stumbled onto 2 useful players for the future.


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finally downloaded the gig and put it on my ipod, noticed pacific & cubik were the (98 versions), but In Yer Face (98 mix?) was well uptempo - loved it!
also just listened to the spain gig from 2003, the In Yer Face mix seems the same but slower than 96, more like the original tempo
funny that everyone says its got slower over the last few years, is there a gremlin in there that slows it down every 5 years?
i've just rerecorded Cobra, Cubik, IYF, Nimbus & Bird onto CD at faster tempo to put on the ipod - that'll keep me fitter cycling to them now


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Tim Duncan
5 Under-Appreciated Players In The NBA
Who are the most under-appreciated players in the NBA today? HE
Keidel: Tim Duncan, Spur Of The Moment
In the age of me over we ball, Duncan is a corrupt cliche – a winner.We judge stars by rings more than ever. The Heat didn't win; LeBron won. Kobe or Shaq won a decade ago. But when the Spurs win, Duncan is part of a greater whole, lost in a selfless, Vulcan coda.
LeBron Leads Heat To Game 6 OT Win
LeBron James led a title-saving charge, and now his crown will be on the line one more time in Game 7.
5 Things to Watch For In Game 6 of NBA Finals
Five things to watch for in Game 6 of the NBA Finals, as the San Antonio Spurs try to clinch their fifth title and end the Miami Heat's reign on Tuesday night:
Manu Ginobili Sparks Spurs To Game 5 Win
Manu Ginobili ran onto the floor as fans stood and screamed. He went to the bench, and they chanted his name. The sights and sounds of so many San Antonio spring nights were back Sunday — and the real party might be just a few days away.
Spurs KO Heat; Lead Series 3-2
The Miami Heat came back to the AT&T Center looking to take a 3-2 lead with the series set to return to South Florida. Instead, the Spurs' hot shooters stayed hot and San Antonio's 114-104 victory sends the series back to South Florida.
Big 3 Help Heat Even NBA Finals With Spurs
Miami Heat owner Micky Arison had a message as he walked to the winning locker room.
Heat Handle Spurs 109-93; Finals Coming Back To Miami
The Miami Heat entered Game 4 of the 2013 NBA Finals against the San Antonio Spurs knowing they couldn't lose and go down 3-1 in the series and have a chance of winning the Larry O'Brien trophy. But the Heat's Big Three responded like the three All-Stars that they are, combining for 82 points and lead Miami to a 109-93.
Heat Look To Build On Game 2 Momentum
After mauling the San Antonio Spurs in Game 2 of the 2013 NBA Finals, the Miami Heat will look to take a 2-1 lead in the series Tuesday night during Game 3 at the AT&T Center in San Antonio.
Sports Verdict: Bigger Impact In The NBA Finals? Chris Bosh Vs. Tim Duncan
Perhaps the most key matchup of this matchup will be Tim Duncan vs. Chris Bosh. Which center will emerge as the bigger impact player? Craig Carton joins the Sports Verdict set to debate!


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April 9, 2013
US 52 Project will restrict westbound traffic to one lane on Thursday
Motorists need to be aware of changes in traffic patterns
TIPPECANOE COUNTY, Ind. – The Indiana Department of Transportation (INDOT) announce US 52 westbound traffic will be restricted to one lane on or after Thursday, April 11 from Duncan to the Wabash River Bridge, weather permitting. Crews with Walsh Construction Co. will be constructing the concrete bridge approach. The passing lane (left lane) will be closed for approximately two and one half weeks. The restriction will then switch to the driving lane for the same time period. Motorists are encouraged to be aware of the changes in traffic patterns. This project should be completed by May 31.
Walsh Construction Co. was awarded the $11.3 million Major Moves road and bridge rehabilitation project. US 52 has been reconstructed from the Wabash River Bridge to just east of Beech Dr., which is north of Greenbush. The project also included overlay and rehabilitation work to the bridges over the Norfolk Southern and CSX Railroads. Other improvements as part of the reconstruction included shoulder, curbs and gutters, drainage structures, culvert, guardrail, and sign replacement.
INDOT reminds drivers to use caution and consider worker safety when driving through a construction zone. For the latest news and information about INDOT, please visit www.in.gov/indot or www.trafficwise.IN.gov .


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Sam Humphries and Francesco Biagini Ascent to 'Higher Earth' in Sold-Out Issue #2 [Preview]
On sale this week from BOOM! Studios is Higher Earth #2, continuing the new ongoing series by Sam Humphries (Sacrifice, Ultimate Comics: Ultimates) and Francesco Biagini (Elric: The Balance Lost). The book, whose first two issues have sold out at the distributor level, is


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Let me start off by asking if I should trade Ocho Cinco and Owen Daniels for Antonio Gates and Lee Evans. The guy wants Ocho Cinco from me and TE is the only spot that I really need to upgrade I think.
It's a 10 team league. Here's my team:
QB - Aaron Rodgers
WR - Marques Colston
WR - Ocho Cinco
WR - Donald Driver
RB - Jones-Drew
RB - Ryan Grant
TE - Owen Daniels
K - Janikowski
DEF - Baltimore
WR: Dez Bryant, Jerricho Cotchery
RB: Joseph Addai, Ricky Williams
QB: Carson Palmer
DEF: Chicago


text: News from the Heights If you need more information, call Le Moyne's Office of Communications at 315-445-4555 or contact via email Joe Della Posta or Molly McCarthy. Read past issues of the magazine Roundtable Discussion on "The European Crisis: The Spanish Perspective"On Thursday, March 6 at 6 p.m., Le Moyne College will host a roundtable discussion on "The European Crisis: The Spanish Perspective," which will examine the current situation in Spain in the context of the European Union and the American crisis. The roundtable is free and open to the public and will take place in Grewen Auditorium on the Le Moyne campus. The moderator will be Jim Joseph, incoming dean of the Madden School of Business.Spain is one of the European countries most affected by the economic crisis, a crisis not unlike that experienced in the U.S. recently. The analysis will be held from three different perspectives: the political situation, the financial one and the role of the media during this difficult time for the country.Members of the discussion will be:Pablo Beramendi, Ph.D., an associate professor of political science at Duke University. His interests include the political economy of redistribution and inequality, comparative federalism and decentralization and the determinants of political integration, with a special focus on advanced industrial societies and European politics. Dr. Beramendi is the author of the book The Political Geography of Inequality (Cambridge Studies in Comparative Politics) and the co-editor of Democracy, Inequality and Representation. Prior to coming to Duke, Dr. Beramendi was at Oxford University, the Maxwell School of Syracuse University and the Science Center in Berlin.José Manuel Calvo is assistant director of "El País," the most important newspaper in Spain. He began his professional career on the Cadena Ser radio station, one of the most popular in the country. He was a radio station correspondent in Brussels in 1986 and when he returned to Spain in 1991, he became the main editor of international news. He was the station's correspondent in Washington, D.C. from 1991 to 1997. In 1997 he began to work for "El País" as international editor, returning to Washington from 2003 to 2007 as a newspaper correspondent.Fernando Diz, Ph.D. is the M.J. Whitman Professor of Finance at the M.J. Whitman School of Management at Syracuse University. He is also the managing director of The Orange Value Fund, LLC and the director of the Ballentine Investment Institute, both at Syracuse University. With renowned investor Martin J. Whitman, he created a seminar on "Distress Investing" in 2002 and they co-wrote "Distress Investing: Principles and Technique," in the midst of the financial crisis. He just completed work on Modern Security Analysis: Understanding Wall Street Fundamentals, a new book co-authored with Martin Whitman and published in May 2013 by Wiley Finance. Dr. Diz got his Masters of Science and Ph.D. from Cornell University in 1986 and 1989, respectively.This round table is sponsored by the Madden School of Business, the Office of the Provost, the Foreign Languages Department, the Department of Political Science, the Department of Communications and the Spanish Club.posted on: 2/23/2014


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I'd like to buy some flint-lock era mini-figure guns for my collection, something like these guns. What I don't want is to pay the outrageous customs fees to get them to Canada. Does anyone know of either some Canadian makers or Canadian distributors?
Take the 2-minute tour ×
LEGO® Answers is a question and answer site for LEGO® and building block enthusiasts. It's 100% free, no registration required.
I have never paid customs fees on orders from BrickForge or BrickArms. The key is to ship via the US Postal Service. Shipping via couriers like UPS usually results in customs brokerage fees which is what drives up the cost.
I simply googled and found brickrepublic based in Pointe-Claire, Qc
Trick : I usually arrange with visiting/traveling folks to bring small packages in Canada and avoid the outrageous custom fees.
You may want to try Modern Brick Warfare. They have a ton of custom LEGO-compatible weapons.
We're looking for long answers that provide some explanation and context. Don't just give a one-line answer; explain why your answer is right, ideally with citations. Answers that don't include explanations may be removed.


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7 Jan 2008
|Printable version | Email to a friend
|So-so Ski Conditions This Week
It is not unusual for Vermont to have a January thaw but the one we're working our way through now seems much warmer than normal.
Today's high was around 50 degrees F (10 Celsius) and tomorrow's forecast is a few degrees higher. It will cool down to day time highs in the low 30's F by the end of this week but we are going to have several days of light rain, sleet, and a little snow for the next few days. The ski report we just received from Jay Peak describes the conditions as "spring like."
All the ski areas especially in northern Vermont have so much base built up that the conditions won't be terrible but if you have been reading how great the skiing has been in Vermont, don't expect those conditions to exist now.
The skiing this week won't be terrible but it won't be great either. By Saturday, conditions should be back to normal. Keep an eye on the weather forecasts.
(c) 2008 Jeff Connor Grunberg Haus
|posted by grunhaus at 23:01