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Adoption of routine telemedicine in Norway: the current picture
Paolo Zanaboni1*, Undine Knarvik1 and Richard Wootton1,2
1Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway; 2Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
Background: Telemedicine appears to be ready for wider adoption. Although existing research evidence is useful, the adoption of routine telemedicine in healthcare systems has been slow.
Objective: We conducted a study to explore the current use of routine telemedicine in Norway, at national, regional, and local levels, to provide objective and up-to-date information and to estimate the potential for wider adoption of telemedicine.
Design: A top-down approach was used to collect official data on the national use of telemedicine from the Norwegian Patient Register. A bottom-up approach was used to collect complementary information on the routine use of telemedicine through a survey conducted at the five largest publicly funded hospitals.
Results: Results show that routine telemedicine has been adopted in all health regions in Norway and in 68% of hospitals. Despite being widely adopted, the current level of use of telemedicine is low compared to the number of face-to-face visits. Examples of routine telemedicine can be found in several clinical specialties. Most services connect different hospitals in secondary care, and they are mostly delivered as teleconsultations via videoconference.
Conclusions: Routine telemedicine in Norway has been widely adopted, probably for geographical reasons, as in other settings. However, the level of use of telemedicine in Norway is rather low, and it has significant potential for further development as an alternative to face-to-face outpatient visits. This study is a first attempt to map routine telemedicine at regional, institutional, and clinical levels, and it provides useful information to understand the adoption of telemedicine in routine healthcare and to measure change in future updates.
Keywords: telemedicine; adoption; routine use; implementation; decision making
Received: 10 September 2013; Accepted: 12 December 2013; Published: 9 January 2014
Global Health Action 2014. © 2014 Paolo Zanaboni et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Glob Health Action 2014, 7: 22801 - http://dx.doi.org/10.3402/gha.v7.22801
Telemedicine, the use of communications networks for delivering healthcare services and medical education from one geographical location to another (1), has been shown to work, to be effective in many clinical areas (2, 3), to be sustainable (4), and, in some cases, to be cost-effective (5). As a consequence, telemedicine appears to be ready for wider adoption in healthcare systems (6). Decisions about the institutionalization of telemedicine are usually taken by healthcare regulators, governments, and authorities (7), and research findings are useful to support evidence-based policy making (8). Despite the great potential of telemedicine, its adoption in routine healthcare has been slow, uneven, and fragmented (9, 10). Several telemedicine applications appear to be promising candidates for widespread use, but they remain at the early adoption stage (11). Implementation has often been problematic (12), and utilization remains limited in many settings (13), with a consequent disconnection between policy, practice, and research (14–16).
Norway is a country with a long interest in telemedicine, where testing of new applications has been conducted since the 1990s in the form of pilot projects or small-scale services (17). A survey conducted in 1998 identified 102 telemedicine programs in Norway, mainly in the radiology, psychology, dermatology, pathology, and otolaryngology specialties. Some of the programs had passed through the project phase and become fully operational, others had lacked staff with the motivation and time to carry them further, and finally some were deemed to be of limited use (18). During the 2000s, significant resources were directed to the development of telemedicine services, with the aim of achieving high-quality and cost-effective healthcare. In 2003, the Norwegian Centre for Telemedicine (NST) conducted a survey of telemedicine activities in Norway. The survey showed variations between health regions with respect to both the type and the number of activities, and it found that telemedicine was provided as a routine service only to a minor degree (19). In 2005, the Northern Norway Regional Health Authority initiated a review to clarify which telemedicine services could be escalated into large-scale use. Candidates for large-scale implementation included teleradiology, digital communication and integration of patient records and education, teledialysis, emergency medicine, telepsychiatry, teledermatology, pediatrics, district medical centers, teleophthalmology, and teleotorhinolaryngology (20). More recently, the Norwegian Ministry of Health commissioned the NST to recommend telemedicine services which were ready for large-scale implementation in the health service, together with the necessary actions to secure a successful dissemination of the services (21). Despite this monitoring activity, a comprehensive picture of the current adoption and level of use of routine telemedicine in Norway is still missing. Moreover, a framework for reporting telemedicine utilization at national and global levels is still lacking.
We conducted a study to explore the current adoption and utilization of routine telemedicine in the Norwegian healthcare system at national, regional, and local levels, and to discuss the potential for wider adoption. Routine use is defined as an application which has entered everyday use, typically after a minimum of 1 year in service (22). We did not focus on telemedicine services implemented as pilot projects. The findings of this study aim to bridge the gap between research, policy, and practice (23), thus supporting both decision makers about defining proper action strategies to integrate telemedicine in healthcare systems and practitioners about implementing it in routine clinical practice.
We used two different and complementary approaches to collect information about routine telemedicine in Norway. A top-down approach was used to collect official data on the national use of telemedicine from the Norwegian Patient Register (NPR). A bottom-up approach was used to collect complementary information through a survey conducted at the largest publicly funded hospitals in Norway.
National data
The NPR is a central health registry that was established in 1997 and is run by the Norwegian Ministry of Health. The NPR was established to provide data for planning, evaluation, and financing of publicly funded specialized healthcare, and also for medical and health services research. The NPR contains data regarding outpatient care delivered by hospitals with activity-based financing. Therefore, only telemedicine contacts that are reimbursed to hospitals are included. In Norway, a 'telemedicine contact' is defined as the use of videoconferencing to perform an outpatient consultation, examination, or treatment at a distance. This means that the contact between patient and physician takes place simultaneously in two different locations (24). The use of store-and-forward telemedicine, such as the transmission of still images, is not covered by any reimbursement scheme in Norway. Contacts occurring by telephone, short message service (SMS), or similar means are not considered as telemedicine contacts. The reimbursement of a telemedicine contact delivered via videoconference is equal to that of a traditional outpatient visit.
A formal request was sent to the NPR in February 2012 to obtain data regarding telemedicine activities. This study did not involve human participants. We collected anonymized information on the number of telemedicine contacts. No personally identifiable data related to individuals were collected. Ethical approval from the Regional Ethics Committees and consent were therefore not required, according to the Norwegian Health Research Act (25) and the Personal Data Act (26). The request was approved by the Norwegian Ministry of Health, and completed data were delivered in August 2012. Data were stratified for health regions (northern Norway, central Norway, western Norway, and south-eastern Norway), by hospital, by year (2009, 2010, and 2011), and by clinical specialty. Adoption was expressed as the percentage of the number of adopters over the potential users (27). In addition, the potential number of cases where telemedicine could be used instead of a traditional face-to-face visit was estimated. Data on the number of outpatient visits were thus collected from the NPR.
Local data
Since data from the NPR only cover telemedicine contacts for which a reimbursement is possible (i.e. where videoconferencing is used), we conducted a survey at the largest publicly funded hospitals in Norway to collect complementary information on the routine use of telemedicine. We selected five hospitals in the four health regions: the University Hospital North Norway in northern Norway, the St. Olavs University Hospital in central Norway, the Haukeland University Hospital and the Stavanger University Hospital in western Norway, and the Oslo University Hospital in south-eastern Norway. All of these hospitals are hospital trusts and are connected with local hospitals.
In our survey, telemedicine services were classified according to the type of technology or modality into:
- Synchronous services (use of videoconferencing);
- Asynchronous services (use of email and/or other electronic messaging); or
- Both synchronous and asynchronous services;
and according to the nature of the consultation into:
- A telemedicine consultation (assessment, evaluation, treatment, or management of a patient) between a specialist and another specialist, a doctor, and/or other health personnel; or
- A home-monitoring service between the patient and doctor.
First contact was made at the Regional Health Authority, the information and communications technology (ICT) department, the clinical divisions, or the integrated care department. A list of people involved in the provision of telemedicine (clinicians, nurses, advisors, ICT professionals, and heads of departments) was then provided by our first contact. At the University Hospital of North Norway, due to the presence of the NST as a competence center, the survey was based on a list of telemedicine services and contact persons provided internally. The data collection period lasted from May 2012 to the end of November 2012.
The contacts identified were asked to answer a questionnaire, either through interview or by email, which was structured as follows:
- Medical field
- Short description of the telemedicine service
- Is it a routine service or a project?
- Which other institutions are involved?
- How long has the service existed (approximately)?
- How many times did you provide the telemedicine service in 2011 (approximately)?
- When was the last time you provided a telemedicine service?
- Is it a synchronous or asynchronous service, or both?
- Is it a telemedicine consultation or a home-monitoring service?
The survey did not involve collecting data about human participants. We collected anonymized and qualitative information on routine services. No personally identifiable data related to individuals were collected, and no information was obtained from the Electronic Health Record (EHR) systems of the hospitals. According to the Norwegian Health Research Act (25) and the Personal Data Act (26), ethical approval and consent were thus not required for the survey. All interviewees were asked and approved that the results of the survey would be publicly available and published.
National data
Data regarding the routine use of telemedicine contacts were available for 2009, 2010, and 2011. The overall use of telemedicine followed an irregular trend over 3 years. The level of use decreased considerably from 2009 to 2010, and then it increased again in 2011 (Table 1). All four health regions in Norway reported use of telemedicine, with a consequent 100% adoption at the regional level. In 2011, 54% and 45% of the overall telemedicine contacts were reported in northern Norway and western Norway, respectively, thus representing almost the whole national activity. Central Norway and south-eastern Norway showed low levels of activity. In 2011, there were 4.9 million outpatient visits in the four health regions. There were 1,827 telemedicine episodes (i.e. 0.04% of the total). Northern Norway reported the highest relative use of telemedicine contacts, according to the total number of face-to-face visits.
The four health regions deliver healthcare services through 28 hospitals (Appendix 1). Nineteen out of 28 hospitals reported that they had used telemedicine during the 3-year period, with a consequent 68% adoption at the institutional level. However, some hospitals did not use telemedicine continuously over the period. The number of hospitals providing more than 50 telemedicine contacts every year decreased from nine in 2009 to only three in 2010 and 2011. The University Hospital of North Norway in northern Norway and the Stavanger University Hospital in western Norway covered most of the telemedicine contacts in 2011 (90%). These two hospitals had also the highest relative use of telemedicine compared to the total number of face-to-face outpatient visits. The other hospitals delivering routine telemedicine provided little telemedicine activity.
The main use of telemedicine was for neurosurgery (Table 2). Neurosurgery was the only clinical area with a relatively high use of telemedicine compared to the total number of outpatient visits (5.5% in 2009). Other clinical specialties also reported the use of telemedicine, but only in the range of a few hundred cases every year. These included physical medicine and rehabilitation, cardiovascular diseases, eye diseases, skin and venereal diseases, female diseases and obstetrics, children's diseases, and orthopedics. A lower level of telemedicine activity was reported for the remaining clinical areas. The use of telemedicine in relation to the clinical specialties differed from hospital to hospital (Appendix 2). Six hospitals had 10 or more clinical areas involved in the provision of routine telemedicine.
Local data
A total of 75 telemedicine services were identified in the survey. Of these, 50 were excluded because they were not routine services but still pilot projects. Of the remaining 25 routine telemedicine services, eight were operational at the University Hospital of North Norway, three at the St. Olavs University Hospital, eight at the Haukeland University Hospital, two at the Stavanger University Hospital, and four at the Oslo University Hospital. The 25 routine services were implemented in several clinical fields (Table 3). Most routine telemedicine was delivered through synchronous services via videoconference. The remaining services were asynchronous or used a combination of both synchronous and asynchronous technologies.
These telemedicine services were provided from the large hospitals to institutions at different healthcare levels (Table 4). Most services (12 out of 25) operated with other hospitals at the secondary care level, either belonging to the same health trust or in other health trusts. The second category of telemedicine services (8 out of 25) operated at the primary care level, serving general practitioners, district medicine centers, nursing homes, and homecare. The remaining services were provided to oil platforms and ships.
Some routine telemedicine services had been in use for more than 15 years (Table 5). Maritime medicine has been used in Norway since 1949, when medical guidance was given by telephone, and since the early 1990s images have been sent from ships to hospitals for diagnosis. Teledermatology started in 1998, when dermatological images were first sent by general practitioners to hospitals. Telepathology has existed since the late 1990s. Few telemedicine services (four out of 25) became operational in 2012.
The majority of routine telemedicine services (21 out of 25) provided teleconsultations for the assessment, evaluation, treatment, or management of patients. Three services were delivered as home monitoring, while one service consisted of both teleconsultations and home monitoring.
Telemedicine services in secondary care
In pulmonary medicine, videoconferencing was used, together with clinical data on lung function and CT images, for the assessment of patients with lung diseases in local hospitals. Specialists analyzed this information and made suggestions about additional examinations, treatment, and time for surgery. A similar service was used in cardiology, in which electrocardiography (ECG) and coronary angiography were evaluated. In oncology, decision support regarding chemotherapy treatment and symptom management was provided to local hospitals and district medicine centers via videoconference. Videoconferencing was also used by radiotherapy departments to communicate with other hospitals for assessment, procedures, and administration of patient cases. The same principle for decision support and second opinions was provided by hospitals within several fields, such as gynecology and obstetrics, where the patient pathway (e.g. pre-operative assessment) and distribution of tasks were discussed, and patient's information (e.g. X-rays) exchanged electronically. In pathology, videoconferencing was used to discuss kidney biopsy cases between hospitals. Pathology departments could also send sections from digital microscopes for postoperative diagnosis of cancer. In neurology, telestroke was used to assess patients' conditions after acute stroke and support thrombolysis. In nephrology, renal departments at specialist hospitals provided teledialysis to remote satellite dialysis units without nephrologists via videoconference. In dermatology, for instance, second opinions were provided by a specialist hospital to a rehabilitation hospital via videoconference for the assessment of patients with bedsores. In psychiatry, regional hospitals used videoconferencing to cooperate regarding the admission of patients to the regional security department. A decentralized on-call service via videoconference was used for adults with mental health problems, and a similar service was provided to regional child and adolescent psychiatry centers. Finally, the surgical department of one hospital offered a service for burn injuries with national responsibility in this field to other national hospitals. Digital images of the damaged area were transmitted electronically, and specialists gave advice on whether patients should be transferred and on which type of treatment should be provided. The numbers of teleconsultations reported are summarized in Table 6.
Telemedicine services for primary care and homecare
In pulmonary medicine, a decentralized telemedicine service was provided for chronic obstructive pulmonary disorder (COPD) patients at risk of exacerbation. Patients were monitored remotely with a briefcase equipped with a laptop, alarms, a spirometer, and a pulse oximeter, and via two-way videoconference. In 2011, 730 teleconsultations were performed by one hospital for 73 patients. In cardiology, telemedicine services were provided for patients with disturbance in heart rhythm and severe heart failure, and for patients with implantable defibrillators and pacemakers, serving approximately 300 patients per year. In orthopedics, videoconferencing was provided to evaluate patients before or after a hospital stay near their homes. Another service was offered to a district medical center for patients injured or undergoing surgery. X-rays were transferred electronically and integrated into the Electronic Patient Record (EPR), and teleconsultations with specialists allowed referrals and follow-up via videoconference. Teledermatology is one of the oldest telemedicine services in Norway, and it is used by general practitioners to send digital images to specialists for diagnosis and treatment. Another service was provided by an outpatient clinic for wound treatment in home nursing. Pictures of leg ulcers taken with digital cameras or mobile phones were sent together with assessments and questions through an Internet-based program.
Telemedicine services for oil platforms and ships
Telemedicine was used in emergency medicine by hospitals to support 34 oil platforms in the North Sea with diagnostic help, clinical evaluation, and guidance. Communication was provided via videoconference, and biological parameters were transmitted and visible on monitors at both sites. Telemedicine was also used to provide medical support to ships over large distances, serving approximately 1,000 patients per year. Previous transfer of images has been replaced by videoconferencing, which is used by the doctor on call.
Potential for wider adoption and utilization
While all the four health regions in Norway reported the use of routine telemedicine, its adoption at the institutional level reaches 68%. Due to the long experience in implementing telemedicine services nationally and due to current evidence of telemedicine's benefits globally, we believe that telemedicine in Norway can be potentially adopted by all 28 publicly funded hospitals, which represent all the potential users in secondary care. Most telemedicine contacts (90%) included in the registry were provided by two hospitals in northern Norway and western Norway, as confirmed by the survey. This might be the result of contextual factors, such as long distances, which characterize those regions. We therefore assume that the level of use of telemedicine is generally higher in countries or areas characterized by major geographical needs. Despite telemedicine being widely adopted in Norway, its level of use locally is still low. Data at the institutional level (Appendix 1) show that the delivery of telemedicine contacts represents up to about 1% of the total number of face-to-face outpatient visits. In most hospitals, however, the relative level of use of telemedicine is much lower. A few examples about the use of telemedicine teleconsultations compared to face-to-face visits can be used as reference. In neurology, store-and-forward telemedicine via email was used to handle just over one-half (54%) of the GP referrals (28). In dermatology, for trials using videoconferencing, the mean proportion of patients who avoided travel was approximately 70%, while for trials using store-and-forward telemedicine it was 43% (29). These data suggest that there is the potential to avoid a substantial proportion – maybe even half – of face-to-face visits to outpatient clinics by using telemedicine. Several of the Norwegian hospitals delivering routine telemedicine have services in 10 or more clinical areas. This means that when telemedicine is adopted by a hospital, it is more likely that services are offered through the whole organization. Neurosurgery is the field with the highest relative use of telemedicine, where the delivery of telemedicine contacts represents about 5% of the total number of face-to-face outpatient visits. This level might, in principle, represent a potential target by hospitals in other clinical areas.
There are few studies regarding the routine adoption of telemedicine in healthcare systems around the world, and no comprehensive data on telemedicine activities in Norway have been published before. In a recent study, Mars and Scott (30) identified 210 reports of telemedicine services, 77 of which provided sufficient data to calculate the number of consultations per site per week as a metric to compare the level of usage. The average use was low: 1.8 consultations per site per week. Data collected from the NPR show an average use of routine telemedicine in Norway of 2.7 consultations per healthcare organization per week in 2011, but the rate per site was not available. We also compared (Table 7) the use of routine telemedicine in Norway with that in other statewide telemedicine networks (31–37). The use of telemedicine in Norway is low compared to that in other, similar contexts (Fig. 1). Assuming the same rate of teleconsultations per inhabitant as in the Ontario Telemedicine Network (34) or the Alaska Federal Health Care Access Network (32), the use of routine telemedicine in Norway could increase to 78,500 or 116,665 teleconsultations every year, respectively. International comparisons regarding telemedicine activity can also be useful in terms of clinical specialties. In a recent systematic survey of the state of teledermatology in the United States, the median number of teleconsultations per site in 2011 was 3,650 and 1,200 for health maintenance organizations (HMOs) and government-associated programs (38), respectively, a higher use compared to routine teledermatology in Norwegian hospitals (Table 6).
Fig. 1. Comparison of telemedicine activity among different statewide networks. Closed symbols are non-Norwegian networks; the open symbol is Norway.
Routine telemedicine services
The NPR has the principal advantage of being a centralized database at the national level, thus making possible systematic, reliable, and efficient data collection from all publicly funded hospitals. However, data from the registry only cover telemedicine contacts for which a reimbursement is possible (i.e. where videoconferencing is used). Our survey provided complementary, more qualitative, and detailed information on the routine use of telemedicine. The numbers of teleconsultations identified in the survey are consistent with those collected from the NPR. The University Hospital of North Norway, for instance, reported 848 episodes in the NPR (Table 2) and about 700 in the survey (Table 6) in 2011. This means that the results from the survey are representative of the current use of telemedicine at the five hospitals.
Most routine telemedicine services identified in the five largest public hospitals connected hospitals at the same healthcare level, while there were fewer telemedicine services connecting secondary care with primary care (e.g. general practitioners) and only limited routine telemedicine in home monitoring. Despite the lack of comparable data globally, we believe that the preponderance of specialist telemedicine services is common in many countries. Moreover, the majority of the telemedicine services were synchronous and used videoconferencing, while fewer services were asynchronous. This might stem from the reimbursement scheme currently in use in Norway, which represents an implementation factor. However, asynchronous services in telemedicine technologies are also used to support decentralized services, offering to specialists more flexibility related to response time as well as a more optimized basis for decision making.
One of the telemedicine services with the highest activity was provided for pulmonary medicine by the largest Norwegian hospital (Oslo University Hospital) (Table 6). This service consisted of teleconsultations via videoconferencing with six minor hospitals in the same region to evaluate patients for lung surgery. Two home-monitoring services can also be distinguished due to high volumes. The Haukeland University Hospital in the Western Norway Regional Health Authority remotely followed 370 patients with implantable cardioverter defibrillators (ICDs) at home. ICDs are monitored automatically, and specialists can access patient data from any available PC. Another home-monitoring service was used by the Stavanger University Hospital in the Western Norway Regional Health Authority to follow up on COPD patients discharged from the hospital, to prevent readmissions, and to detect exacerbations early. A well-used service (both synchronous and asynchronous) was run by the Norwegian Centre for Maritime Medicine at the Haukeland University Hospital. Radio Medico Norway has been providing medical guidance to ships by telephone since 1949, currently serving 1,000–1,200 patients a year. In the 1990s, most commercial ships were equipped with a digital camera, and transfer of pictures via e-mail became an efficient support mechanism for medical diagnoses. In August 2012, videoconferencing was installed at the center and on a mobile PC to be used by the doctor on call, while ships were provided with ultrasound, ECG, an ophthalmoscope, and a high-definition camera.
Implementation factors
Although analysis of the factors affecting adoption is beyond the scope of the present study, we speculate that the routine use of telemedicine can be related to implementation factors, such as organizational, contextual, and policy issues, which act as facilitators, or barriers, for the integration of telemedicine in healthcare organizations and clinical practices (13, 39–41). Over the years, Norway has developed several plans for the promotion of ICT in healthcare. These strategies supported investment in standardization (e.g. EPRs), with a consequent positive impact on the further implementation of telemedicine. Videoconferencing between healthcare institutions is delivered inside the Norwegian Health Network, which provides a high level of security. The routine use of videoconferencing by the health personnel can be observed by the growing number of these services. The diffusion of picture-archiving and communications systems (PACS) in hospitals made teleradiology an integral part of routine clinical practice, so that today the term 'teleradiology' is not in use any longer. Reimbursement policies represent another facilitator, or barrier, for the diffusion of telemedicine services. Norway was the first country to develop a specific reimbursement for telemedicine in 1996, for both synchronous and asynchronous services, with a consequent rise of telemedicine activities in the subsequent decade. However, more recent policies limit reimbursement to the use of videoconferencing, thus affecting the trend regarding use of telemedicine activities in the last few years. In addition, the current reimbursement scheme does not produce any incentive for general practitioners, which represents a further obstacle to the implementation of telemedicine, especially for services connecting secondary care with primary care. These considerations are in line with findings from other studies. The lack of success of telepsychiatry in Australia, for instance, might be due to both insufficient reimbursement and the consequence of not addressing other conditions required for the successful integration of telemedicine into routine clinical practice (42). In contrast, the provision of teledermatology in the United States is supported by different payment methods, including private payers, self-payers, Medicaid, Medicare, HMOs, and contract-based services (38).
We acknowledge some limitations in our study. Data in the NPR contain only telemedicine contacts for which a reimbursement was possible (i.e. where videoconferencing was used) and a request for payment was forwarded to the regional authority. All other telemedicine activities (e.g. store-and-forward) are excluded. Moreover, comparable data were available for only 3 years. As a consequence, we were not able to identify a longer term trend of telemedicine activities over the last decade. The main limitation regarding the survey was related to the volume of routine telemedicine services identified. We decided to conduct the survey at the five largest hospitals from the four health regions in Norway. However, there are also other smaller hospitals which deliver routine telemedicine. These can be included in future work. Moreover, hospitals in Norway do not currently have a formal overview of their telemedicine services, thus making a survey difficult, especially for large and complex healthcare organizations such as those included in this study. However, after conducting this study, the hospitals became aware of the importance of having a clear picture of their telemedicine activity and are willing to have this included in future updates.
Future implications and framework for reporting of telemedicine utilization
The present study is a first attempt to map national routine telemedicine with objective and up-to-date information of its usage at regional, institutional and clinical levels. Previously, such a comprehensive picture in Norway was missing, and a framework for reporting of telemedicine utilization at the national and global levels was lacking. Moreover, little published data exist for international comparison, and no other study has reported comparable details. The dearth of similar data from other countries made it difficult to report our results for international comparison. It would therefore be premature to comment on the rate of telemedicine usage in Norway relative to that in other countries or networks (Fig. 1). Further work is needed to obtain more comprehensive data from around the world, from both high-income countries and low- and middle-income countries, and to monitor the uptake of telemedicine from year to year in those countries.
We believe that future studies would be much facilitated by recording and reporting data in a standardized fashion. This study provides a baseline to measure changes in future updates to give a more complete picture on the adoption of telemedicine in the Norwegian healthcare system and to report further implementation of telemedicine services. The methodology used in this study can be extended to other countries, including low- and middle-income countries, to provide additional insights about how the adoption of routine telemedicine can vary across different healthcare systems and policies, thus contributing to a common platform which can inform and support evidence-based health policy and practice, both locally and globally.
Good-quality and timely data from health information systems are the foundation of all health systems. However, too often data sit in reports, on shelves, or in databases and are not sufficiently utilized in policy and program development, improvement, strategic planning, and advocacy (43). Where available, central health registries can provide useful and detailed data regarding the use of routine telemedicine nationally. We therefore recommend the use of these sources. However, the example of the NPR shows that these data might cover only part of the overall telemedicine usage. A framework for reporting telemedicine utilization, including a combination of different methods (e.g. quantitative and qualitative), allows one not only to assess more aspects but also to corroborate the findings, which results in more robust conclusions (44). Where limited data are available from health information systems, a survey conducted at the hospital level is able to embrace the whole spectrum of telemedicine activities which are part of the routine practice of healthcare professionals. A survey based on standardized questionnaires can be used to identify routine telemedicine services and to collect, for each service, a standard minimum dataset including the medical field, a short description of the telemedicine service, the type of technology or modality (synchronous, asynchronous, or both), the type of equipment and technical requirements, the nature of the consultation (e.g. telemedicine consultation or a home-monitoring service), the level of implementation (e.g. a routine service or project), the institutions involved, the first year of operation, the average caseload (telemedicine episodes) in the previous year, and the last provision of the telemedicine service. Due to country-dependent issues, information regarding organizational, contextual, and policy issues must also be reported together with data from registries and surveys to facilitate international comparison and detect similarities and dissimilarities between high-income countries and low- and middle-income countries, which may have different resources and healthcare systems.
The present study provides objective and up-to-date information regarding the adoption of routine telemedicine in Norway at regional, institutional, and clinical levels. We reported both quantitative data collected through a national registry, and more qualitative and detailed data regarding routine telemedicine services collected through a survey. Routine telemedicine in Norway has been widely adopted. The percentage of hospitals adopting telemedicine is high, and examples of routine telemedicine can be found in several clinical specialties. However, the level of use of telemedicine in Norway is rather low, with significant potential for further development as an alternative to face-to-face outpatient visits.
Our research findings contribute to bridging the gap between policy and practice regarding telemedicine services and therefore improving the current debate concerning the routine use of telemedicine in healthcare systems. On one hand, decision makers, governments, and healthcare authorities can monitor and take effective policy actions about the adoption and utilization of telemedicine services at the healthcare system level. On the other hand, health practitioners can be informed better about the benefits of adopting telemedicine in their practice and access targeted incentives which can result in an increase in the number of outpatient visits performed through telemedicine. We believe that these actions might lead to a positive change in the future use of routine telemedicine in Norway, thus moving from face-to-face visits to teleconsultations via videoconferencing as has occurred in some settings elsewhere.
We thank the Northern Norwegian Regional Health Authority for funding the study (grant SFP1008-11) and the Norwegian Patient Register for providing data.
Authors' contributions
PZ performed the analysis on the data from the Norwegian Patient Register. UK conducted the survey on the five largest Norwegian hospitals. RW conceived, initiated, and coordinated the whole study. All of the authors equally contributed to write, revise, and approve the last version of the manuscript.
Conflict of interest and funding
The authors declare that they have no competing interests.
- Sood S, Mbarika V, Jugoo S, Dookhy R, Doarn CR, Prakash N, et al. What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Telemed J E Health 2007; 13: 573–90. PubMed Abstract | Publisher Full Text
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- Miller EA. Solving the disjuncture between research and practice: telehealth trends in the 21st century. Health Policy 2007; 82: 133–41. PubMed Abstract | Publisher Full Text
- Cusack CM, Pan E, Hook JM, Vincent A, Kaelber DC, Middleton B. The value proposition in the widespread use of telehealth. J Telemed Telecare 2008; 14: 167–8. PubMed Abstract | Publisher Full Text
- Johnsen E, Breivik E, Myrvang R, Olsen F. Benefits from telemedicine in Norway; 2006. An examination of available documentation. Available from: http://person.hst.aau.dk/pbe/HISkursus/hoeykom_report.pdf.
- Uldal SB. A survey of Norwegian telemedicine. J Telemed Telecare 1999; 5: 32–7. PubMed Abstract | Publisher Full Text
- Knarvik U, Bach B, Lindberg PC, Halvorsen Engeseth K, Skorpen S, Lyngved K, et al. Telemedk@rt 2003 – a survey of telemedicine activities in Norway; 2004. Available from: http://www.telemed.no/getfile.php/86872.357/Telemedk%40rt2003.pdf [cited 15 January 2004].
- Norum J, Pedersenwz S, Størmer J, Rumpsfeld M, Stormoww A, Jamissenzz N, et al. Prioritisation of telemedicine services for large scale implementation in Norway. J Telemed Telecare 2007; 13: 185–92. PubMed Abstract | Publisher Full Text
- Normann T, Breivik E, Skipenes E, Christiansen EK, Knarvik U. Bringing telemedicine into routine service – prerequisites and actions; 2011. Available from: http://www.telemed.no/getfile.php/1742174.357.vpvfpebvdr/Rapport_Telemedisin+i+rutinedrift_02-2011.pdf [cited 20 May 2011].
- Jackson DE, McClean SI. Trends in telemedicine assessment indicate neglect of key criteria for predicting success. J Health Organ Manag 2012; 26: 508–23. PubMed Abstract | Publisher Full Text
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- Helse-og omsorgsdepartementet. LOV 2008-06-20 nr 44: Lov om medisinsk og helsefaglig forskning (helseforskningsloven); 2008. Available from: http://www.lovdata.no/all/hl-20080620-044.html [cited 20 June 2008].
- Justis-og beredskapsdepartementet. LOV-2000-04-14-31: Lov om behandling av personopplysninger (personopplysningsloven); 2000. Available from: http://www.lovdata.no/all/nl-20000414-031.html [cited 14 April 2000].
- Rogers EM. Diffusion of innovations. New York: The Free Press; 1983.
- Patterson V, Humphreys J, Henderson M, Crealey G, Patterson V, Humphreys J, et al. Email triage is an effective, efficient and safe way of managing new referrals to a neurologist. Qual Saf Health Care. 2010; 19: e51. PubMed Abstract
- Wootton R, Bahaadinbeigy K, Hailey D. Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review. BMC Health Serv Res 2011; 11: 185. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
- Mars M, Scott R. Telemedicine service use: a new metric. J Med Internet Res 2012; 14: e178. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
- Alkmim MB, Figueira RM, Marcolino MS, Cardoso CS, Pena de Abreu M, Cunha LR, et al. Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil. Bull World Health Organ 2012; 90: 373–8. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
- Blanchet K. The Arizona Telemedicine Program. Telemed J E Health 2005; 11: 633–40. PubMed Abstract | Publisher Full Text
- Brewer R, Goble G, Guy P. A peach of a telehealth program: Georgia connects rural communities to better healthcare. Perspect Health Inf Manag 2011; 8: 1c. PubMed Abstract | PubMed Central Full Text
- Brown EM. The Ontario Telemedicine Network: a case report. Telemed J E Health, 2013; 19: 373–6.PubMed Abstract
- Kokesh J, Ferguson AS, Patricoski C. The Alaska experience using store-and-forward telemedicine for ENT care in Alaska. Otolaryngol Clin North Am 2011; 44: 1359–74. PubMed Abstract | Publisher Full Text
- Meyers L, Gibbs D, Thacker M, Lafile L. Building a telehealth network through collaboration: the story of the Nebraska Statewide Telehealth Network. Crit Care Nurs Q 2012; 35: 346–52. PubMed Abstract | Publisher Full Text
- Oliveira TC, Bayer S, Gonçalves L, Barlow J. Telemedicine in alentejo. Telemed J E Health 2014; 20: 90–3.
- Armstrong AW, Wu J, Kovarik CL, Goldyne ME, Oh DH, McKoy KC, et al. State of teledermatology programs in the United States. J Am Acad Dermatol 2012; 67: 939–44. PubMed Abstract | Publisher Full Text
- Hage E, Roo JP, van Offenbeek MA, Boonstra A. Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review. BMC Health Serv Res 2013; 13: 19. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
- Hendy J, Chrysanthaki T, Barlow J, Knapp M, Rogers A, Sanders C, et al. An organisational analysis of the implementation of telecare and telehealth: the whole systems demonstrator. BMC Health Serv Res 2012; 12: 403. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
- Sanders C, Rogers A, Bowen R, Bower P, Hirani S, Cartwright M, et al. Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study. BMC Health Serv Res 2012; 12: 220. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
- Smith AC, Armfield NR, Croll J, Gray LC. A review of Medicare expenditure in Australia for psychiatric consultations delivered in person and via videoconference. J Telemed Telecare 2012; 18: 169–71. PubMed Abstract | Publisher Full Text
- Nutley T, Reynolds HW. Improving the use of health data for health system strengthening. Glob Health Action 2013; 6: 2001.
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Kestrel Nova
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this wiki
The Kestrel Nova was a freighter captured from pirates at Taanab by the Jedi c. 4000 BBY.
Ulic Qel-Droma disguised as a smuggler, piloted this ship to Empress Teta, in order to infiltrate the Krath.
- Tales of the Jedi: Dark Lords of the Sith 4: Death of a Dark Jedi (First appearance)


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This venue is out of business
This party/event/art space is "dedicated to the idea that the differences among us should be celebrated, but that our shared humanity, in the end, unites us as one." That being said, anyone and everyone, regardless of race, shape or sexual orientation, is welcome to hang at Love's various theme nights, including Mystic Strictly Reggae as well as Full Service, a disco and techno party.
- Good for Groups
- Bar
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For US Health Care Professionals Only
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Health Care Provider-Generated Ideas for Process Improvement
Information to help you establish or refine your vaccination process
This case study was written by the physician who developed a
comprehensive process to improve adult vaccination rates
across a highly complex, progressive health system in the
Case Study: Progressive
Integrated Delivery System
Integrating vaccination into your daily routine.
Alix G. Casler, MD of Orlando Health Physician Associates
Alix G. Casler, MD of Orlando Health Physician Associates
Dr. Casler shares how her organization implemented staff training and empowerment to significantly improve adolescent vaccination rates
Compilation Case Study
Health Care Provider Ideas for Improving Vaccination Rates*
This document provides a summary of strategies
used by several health care organizations to
establish their effective vaccination processes.
*Merck does not guarantee that your use of this information will help you achieve your vaccination goals.


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text: News DLECTRICITY / News 2nd April 2014 THANK YOU OPEN CALL APPLICANTS! The DLECTRICITY open call is officially closed. Thanks to everyone … learn more 26th March 2014 Last Week to Apply for DLECTRICITY OPEN CALL FOR PROPOSALS | Submission Deadline: March 31, 2014 … learn more 11th March 2014 FAQ update – Your Questions Answered! We've received some very interesting questions from potential Dlectricity applicants. … learn more 7th March 2014 Open Call FAQ now available! Get the details on applying, including projector rental costs and … learn more 17th February 2014 Open Call Info Session this Saturday DLECTRICITY will hold an info session on Saturday, February 22nd, … learn more 6th February 2014 CALL FOR ENTRIES – APPLY NOW! The DLECTRICITY 2014 Open Call for Entries is ready, click … learn more Pages:Previous12345678Next


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Regulation of Endothelial Progenitor Cells by Short-Term Exercise (EPC-Ex)
This study is ongoing, but not recruiting participants.
University of Maryland, Baltimore County
Baltimore VA Medical Center
University of Maryland
Information provided by (Responsible Party):
Steven J. Prior, Ph.D., Baltimore VA Medical Center
ClinicalTrials.gov Identifier:
First received: July 23, 2010
Last updated: January 13, 2016
Last verified: January 2016
- Full Text View
- Tabular View
- No Study Results Posted
- Disclaimer
- How to Read a Study Record
Endothelial Progenitor Cells (EPCs) are circulating cells released from bone marrow which are important for maintaining cardiovascular health. The prevalence of cardiovascular disease in older adults is associated with reduced circulating EPC numbers. Studies have shown reduced EPC number and function in old vs. young individuals, and endurance exercise training increases EPC number and function in young adults. Oxidative stress adversely affects endothelial cells and preliminary evidence indicates that oxidative stress negatively affects EPC function. Conversely, regular exercise reduces markers of oxidative stress and may enhance EPC function in older adults. The investigators hypothesize that older endurance-trained athletes and matched sedentary individuals will have markedly divergent EPC function and that altering the physical activity levels of both groups will move them to intermediate points between these two extremes. The investigators also propose that the investigators can "mimic" the effect of exercise training on EPC function in cell culture by altering intracellular levels of a key enzyme and a signaling molecule which the investigators have shown to regulate EPC function with respect to exercise training in young individuals.
Cardiovascular Disease
Other: Exercise Training
Other: Exercise Cessation
|Study Type:
|Study Design:
|Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Masking: Open Label
|Official Title:
|Regulation of Endothelial Progenitor Cells by Short-Term Exercise
Resource links provided by NLM:
MedlinePlus related topics: Exercise and Physical FitnessU.S. FDA Resources
Further study details as provided by Baltimore VA Medical Center:
Primary Outcome Measures:
- Baseline Endothelial progenitor cell number [ Time Frame: Day 1 ]
- Final Endothelial Progenitor Cell Number [ Time Frame: Day 15 ]
Secondary Outcome Measures:
- Baseline Endothelial Reactivity [ Time Frame: Day 1 ]
- Final Endothelial Reactivity [ Time Frame: Day 15 ]
|Estimated Enrollment:
|Study Start Date:
|July 2011
|Estimated Study Completion Date:
|November 2017
|Primary Completion Date:
|November 2014 (Final data collection date for primary outcome measure)
|Assigned Interventions
|Experimental: Sedentary Older Adults
Other: Exercise Training
2 weeks of daily aerobic exercise training
|Experimental: Older Endurance Athletes
Other: Exercise Cessation
Stopping all exercise for 2 weeks
|Ages Eligible for Study:
|50 Years to 80 Years (Adult, Senior)
|Sexes Eligible for Study:
|Accepts Healthy Volunteers:
Inclusion Criteria:
- 50-80 years of age, BMI = 18-35 kg/m2, non-smoking, women must be postmenopausal
Exclusion Criteria:
- history of cardiovascular/cerebrovascular disease, diabetes, cancer, renal, liver disease, HIV; uncontrolled hyperlipidemia/hypertension
Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.
Please refer to this study by its ClinicalTrials.gov identifier: NCT01169831
Please refer to this study by its ClinicalTrials.gov identifier: NCT01169831
|United States, Maryland
|University of Maryland, Baltimore & Baltimore VA Medical Center
|Baltimore, Maryland, United States, 21201
Sponsors and Collaborators
University of Maryland, Baltimore County
Baltimore VA Medical Center
University of Maryland
|Principal Investigator:
|Steven J Prior, Ph.D.
|University of Maryland
More Information
Additional Information:
Additional relevant MeSH terms:
ClinicalTrials.gov processed this record on February 24, 2017
Additional Information:
|Responsible Party:
|Steven J. Prior, Ph.D., Assistant Professor, Baltimore VA Medical Center
|ClinicalTrials.gov Identifier:
|NCT01169831 History of Changes
|Other Study ID Numbers:
|Study First Received:
|July 23, 2010
|Last Updated:
|January 13, 2016
Additional relevant MeSH terms:
Cardiovascular Diseases
ClinicalTrials.gov processed this record on February 24, 2017


text:
Yorkshire Pudding
|1 1⁄2 Tablespoon, softened (unsalted)
|Skim milk
|1⁄2 Cup (8 tbs)
|1 Large
|All purpose flour
|1⁄2 Cup (8 tbs), sifted
|1⁄8 Teaspoon
Preheat the oven to 500F.
Grease an 8"x 8"x 2" baking pan with 1/2 tablespoon of the margarine and place the pan in the oven while you prepare the pudding batter.
In a medium size bowl, combine the milk, egg, flour, and salt.
Using an electric mixer, beat the batter at high speed for 1 minute or until smooth.
In a small saucepan, melt the remaining tablespoon of margarine over moderate heat; add it to the batter and beat 30 seconds longer.
Pour the batter into the heated baking pan and bake, uncovered, for 20 minutes or until golden and firm (do not open the oven door during the baking period).
Cut into 4 squares and serve immediately.
Recipe Summary
Rate It
Nutrition Rank
Nutrition Facts
Serving size
Calories 125 Calories from Fat 53
% Daily Value*
Total Fat 6 g9.2%
Saturated Fat 1.2 g6.2%
Trans Fat 0 g
Cholesterol 53.4 mg17.8%
Sodium 95 mg4%
Total Carbohydrates 14 g4.5%
Dietary Fiber 0.42 g1.7%
Sugars 1.6 g
Protein 4 g8.4%
Vitamin A 5.3% Vitamin C 0.49%
Calcium 4.5% Iron 5.4%
*Based on a 2000 Calorie diet


text:
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Inter Residence
Find Hotel Rates
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Wego searches multiple travel sites so you can find and compare the best rates.
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Based on reviews from across the web.
Inter Residence Hotel Details
Check-in: 12:00
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text:
A large fire broke out, Tuesday morning, in natural growth next to the communities of Ora and Even Sapir in the Judean Hills, west of Jerusalem.
Three firefighting companies from Jerusalem and five from Beit Shemesh brought the blaze under control. There were no reports of injuries.
Tags:Jerusalem, Beit Shemesh, Fire Fighting, Judean Hills, Even Sapir, Ora


text:
It looks like a nice plicata. I particularly like the purple arrow
streaks on the falls. With good
growth and such good rebloom, that one should be a winner.
Francelle Edwards Glendale, AZ Zone 9
-----Original Message-----
From: email@example.com
Sent: Saturday, August 02, 2003 7:00 AM
To: email@example.com
Subject: [iris-photos]REB:Seedling
I'm not sure I really approve of
summer rebloom! This seedling has now produced the 5th summer stalk this
year! Stalks 1-3 bloomed in July and stalks 4-5 will bloom in
August. Will there be anything left for the fall bloom? Guess I
will have to count mature plants to see.
1510-1Re: Planted spring 2001. Survived late frost in 2002, but didn't spring
bloom. July 2002=1 stalk, spring 2003=2 stalks, July 2003=3 stalks, Aug
2003=2 stalks. Clump still looks full and healthy! (LOL! )
Picture. This was taken last weekend. I cut a bloom to take to the
rhizome sale. Unlike the yellow seedling, this picture is a bit too
dark. It was taken outside and there was too much morning shadow.
I'll do better by spring. Thought you might like to see it anyway!
Betty W. in South-central KY Zone 6
(Mike, this is probably the strongest rebloomer I'm getting out of Innocent


text:
watch video >>
The fans are not the only ones amped to see this fight. This Saturday, April 24th, Jose Aldo & Urijah Faber meet in one of the most exciting matchups in history. Aldo vs Faber can be seen Live on Pay watch video >>
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Takeya Mizugaki spoke with the media about his WEC 52 match up with Urijah Faber in Faber's bantamweight debut. watch video >>


text:
Wavecom Fastrack Supreme 20
This project received 3 bids from talented freelancers with an average bid price of $673 USD.Get free quotes for a project like this
Project Budget$250 - $750 USD
Total Bids3
Project Description
I have a GSM Modem (Wavecom Fastrack Supreme 20) that I need to put into use for a new project.
I will connect the modem to a Windows XP computer and the modem needs to be able to receive SMS messages that will contain a two word text message separated with a space, the first word will be a pin code that needs to be verified using a previously uploaded code list in excel, this list will be updated every day, if the code is correct then the phone number of the sender, the pin code, time and date and the second word of the message need to be saved in a excel sheet that needs to be sent by e-mail every 30min (configurable time period). If the code is incorrect, then the modem need to reply to the sender with an error message.
Only one time can each pin code be used, so after validation the code has to be [url removed, login to view] I should also be able to send SMS messages from this modem.
That is it.
Skills Required
Looking to make some money?
- Set your budget and the timeframe
- Outline your proposal
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Still no luck. I check ebay everyday.
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Message Boards - Boba Fett Fan Club → Posts by Trask7
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Still no luck. I check ebay everyday.
Trying to locate this poster for my son. We have been taking him since 2006 and got the poster every year but 2010 and that happened to be the year they used Boba Fett. I have never seen one on ebay and looking or any information or point of contact.
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For teams/groups >> Live, online writing masterclasses
Learn from anywhere
For: Larger teams that need to be on the same page but are in several cities or sites, anywhere in the world.
Group size: 12-20 people per session (all from your company – one division or a mix)
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For individuals >> Live, online writing masterclasses
Learn from anywhere
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Technology requirements: A PC or Mac computer per person, broadband internet access, USB headset (OR speakerphone and quiet room). Full list >>
Tailoring: Yes, but limited to the individual.Upcoming dates & pricing
When virtual writing training beats real-world
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Seriously engaging online writing coursesYou'd be surprised how effective an online virtual writing course can be in the hands of our skilled facilitators. Unlike an in-person class, our online trainers can:
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As with all our courses, trainees receive detailed feedback and analysis from a professional writer on one of their writing samples, and a 100+ page, full-colour course manual – a valuable post-course reference and study tool.
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It's not about the writing.
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Writing is more about
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We'll make you better at both.
See upcoming online courses.


text:
NC Wildlife Resources Commission
staff and partners can also offer follow-up technical assistance to communities
who have participated in Green Growth workshops.
We can provide technical assistance including:
To request technical assistance,
contact us.
or firstname.lastname@example.com.
Partners for Green Growth
This is a cost-share funding
resource offered by the N.C. Wildlife Resources Commission's (NCWRC) Green
Growth Toolbox program. The goal of Partners for Green Growth is to provide support
for local government planning projects that consider wildlife and natural
resource conservation in land use and development planning, incentives and
We encourage you to share your
ideas with us ahead of all deadlines.
For projects that qualify, the Partners for Green Growth program
will reimburse cost-share funds up to
$20,000 and will provide 80 hours of technical assistance from North Carolina
Wildlife Resources Commission (NCWRC) wildlife biologists. Projects that
request funds up to $10,000 are preferred so that we may fund more projects.
The funding request can only be up to 65 percent of the entire project cost and
35 percent non-federal in-kind match (cash match is not necessary) is required to make up the
remaining total project cost. In-kind match is explained in the detailed application description (link below).
Project Idea Submissions are due by May 31,
2016. Applicants that qualify to submit an invited application will be notified
by mid-June. Invited applications are due August 9, 2016. All projects should
begin by October 1, 2016 and be completed by September 15, 2017.
Eligible applicants are local governments (North Carolina counties and
incorporated municipalities) and Councils of Government. Partnerships between
local governments and non-governmental, non-profit (NGO) conservation-related
organizations are also eligible. Local government project applications are
Click here to download the detailed application description and forms for the current funding cycle.


text:
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Graph.h ModeX Graphics Library
Graph.h is a graphics library for ModeX graphics in TurboC. ModeX is a 320x240 screen mode with 256 indexed colors out of 262,000. There are four graphics pages available. Must use in TurboC and in DOS. main.exe demonstrates graph.h's abilities.
Green Telnet
Green telnet is a modified telnet client/server that enables the client to go to sleep without losing its telnet session. This material is based upon work supported by the National Science Foundation under Grant No. 0520081.
Group 2 Pintos Project
This is a class project for William and Mary's CSCI 444/544 class, OS
GwToolkit by thiyagu
This provide a full graphics support and windowing environment to the C Programmer. every C Programmer Must have this Kit to make their Program More Interactive and More User friendly and a Event Driven approach to C Program support to the C Programmer
Supporting software for a school research paper to analyze a corpus for letter frequency and word properties.
HOPPscore - Protein Structure Quality
HOPPscore is a simple application for evaluating the structural quality of theoretical or experimental protein structures. Protein are evaluated by comparing structure fragments to a reference dictionary of fragments from high resolution structures.
HPC test
High Performance Computing test
Open Source IM and voice client using Jabber and SIP protocols, with great audio quality thanks to speex and a nice and clean interface. Programmed in Java and C++. It supports chat, voice and file transfers.1 weekly downloads
Hidden world game engine
High BDP n/w and TCP - RT perf ana
RealTime perf analysis of TCP's congestion control mechanisms using modified kernel.
High Energy Physics Tool
The High Energy Physics Tool calculates decay rates and cross sections of tree-level processes. It makes use of computational code from the CalcHEP package, and includes a GTK+ GUI.
Hometask of ITstep VV4-01B group
here we host some of our simple hometasks from ITStep, and our ideas
IEM_IT_2008_Image Processing
My project on Image Processing have three parts.In the 1st part we design Visual Encompression.It is mainly used to send an secret image over the unsecured network.2nd part is of Digital Watermarking.3rd part is Steganography.
Infix to Postfix Converter
Infix to Postfix Converter & Calculator
Iniciação Científica
Scientific Initiation Project, a program linked with the Scientific Initiation Fellowship of UESC (Universidade Estadual de Santa Cruz).
InoFace Using OpenCV
Face Detection, Face Tracking, Eye Detection, Nose Detection, Mouth Detection, OpenCV, WebCam
Input Abstraction Layer
Input Abstraction Layer (IAL) makes special keys (e.g. multimedia keys, function keys found on notebooks) "just work". IAL provides a daemon which can enhanced by modules. These modules are sending events via D-Bus to the clients.
Interações inter moleculares
Busca das interações intermoleculares entre uma proteína e um ligante a partir de arquivos pdb's.
Interest(ing) Calculator
Interest(ing) Calculator is useful in calculating Financial Parameters of loans/deposits.Loan/Deposits have four variables.They are, Principal,Interest Rate,Term,Installment.IC helps to calculate any one variable, if you know the other three variables.4 weekly downloads
Interix development tools
A collection of development tools and build environments for Interix using the Microsoft compiler. Aims to facilitate interaction between Visual Studio, Microsoft build and GNU tools. Ex Visual Studio Addins, shell scripts, makefiles and library patches.
Internet Protocol Network Multipathing
Internet Protocol Network Multipathing(done in linux) IP network multipathing was introduced in the Solaris 8 OE update 2 (10/00) software release. This feature enables a server to have multiple network ports connected to the same subnet.
Getting rid of the endian problems as well as the the multitude of numerical formats existing on different systems. say goodbye to #ifdef BIGENDIAN ... or #ifdef THAT_OS_FLOAT
Library for calculating model jet engines
Keowi wars
An 3D space ship game, as a re-make of the original space invaders. Using 3D models for the ships, and raw terrain files. It is an Ogre 3D based project, Ode library for the physics, FMOD for the music layer and RakNet for the network layer.


text:
Ready to elect a CEO to the McWhite House?
October 14, 2010
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text:
Full profile →'">
The author is a Forbes contributor. The opinions expressed are those of the writer.
Just yesterday I told you of the One Quarter Of American Consumers (who) Are Brand Loyal. That indeed is a very telling statistic which came from a survey conducted by Ernst & Young. Today comes the results of another survey, this one done jointly by Acxiom and Loyalty360, which sheds some light on why so few consumers are brand loyal. And it all comes to down one word.
com·pla·cen·cy - a feeling of quiet pleasure or security, often while unaware of some potential danger
I give you exhibit A:
That's right boys and girls, 60% of all the respondents - who were comprised of executives in both B2B and B2C companies from a cross section of industries, dedicate less than 20% of their marketing budget to customer retention.
See where I'm going here with the whole "complacency" thing?
The 60%/20% statistic is even more telling when you factor in the 80/20 rule which many brands adhere to and states that the top 20% of customers drive 80% of a brand's sales and profits.
The findings also make mention of a study done by Bain Consulting which found the average company loses 20-40% of its customers every year. Reducing customer attrition by a mere 5% can improve a business's bottom line profits by 25-85%.
Exhibit B comes in the form that nearly 75% of respondents indicated that less than half of their employees focus on driving retention marketing programs.
There is some good news to report as nearly 60% of respondents plan on increasing their marketing retention budget over the next two years.
Of course I wonder what about the other 40%. What are they doing?
But I digress.
So why the low numbers when it comes to retention?
Why aren't more marketers and brands focused on retaining the customers they already have? Presumably these are the loyal customers so it makes me wonder aloud what is these marketers and brands are thinking by not concentrating more on keeping the customers they currently have "on the books" especially when you consider it costs six to seven times more to gain a new customer than to keep an existing one according to Bain Consulting.


text:
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Optical Illusion 3D Artwork
Don't blink.
Look at a point in the center.
Just enough to prevent you from focusing.
Try to look 'through' the image without focusing.
Do not blink as you stare, let your vision blur.
The image will then become three dimensional and jump off your screen.
Persist and it will work for you!
If you can retain the illusion you can try to touch the designs that leaps from your screen...
its really cool! ; )
Fun Facts:
Unlike Dogs, Cats do see in Color, although not exactly the way Humans do.
In tests, Cats appeared to distinguish between the low to mid light wave spectrum (higher frequency), meaning Cats responded to the colors purple, blue, green and yellow range.
Copyright © 2009- 2011 Tomitheos Photography - All Rights Reserved
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15 comments
Taken on January 28, 2009


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Newegg.com - A great place to buy computers, computer parts, electronics, software, accessories, and DVDs online. With great prices, fast shipping, and top-rated customer service - once you know, you Newegg.
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This review is from: Mushkin Enhanced Reactor 2.5" 512GB SATA III MLC Internal Solid State Drive (SSD) MKNSSDRE512GB
Pros: This Hard drive Rocks I also have Mushkin Enhanced Stealth 16GB (2 x 8GB) in my new gaming system I,am building I ,am going to get other one and Raid them together so it should really Rock for gaming also going to add other 16 gb of muskin memoery so with the 32 gb and two 512 ssd o ya this should scream , also it,s made in the good old U.S.A you rock muskin
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text:
Yahoo! Sportacular Pro
Universal App – Optimized for iPhone and iPad.>
App Details
Track this app for price drops.
- Version 2.1.1
- Release date Aug 17, 2009
- Size 11.43 MB
- Age 4+
- Genre Sports
- User Ratings 3.15 (5 votes)
App Store Description
The Yahoo! Sports scores app - Fast, personalized and easy access to live scores and information on your favorite teams, players and leagues. Includes free game alerts plus the latest news from Yahoo! Sports. Go "Pro" for the same experience without the banner ads.
• Customize your alerts and get instant reminders via push notification for specific events, like game start, scoring plays, red-zone or close game situations
• Fan check-in lets you mark your location as your team's turf and start a battle with rivals, competing to claim as much of the country as possible
• Get coverage of sports action from MLB, NBA, NHL, NFL, MLS, NCAA, NASCAR, Tennis, Sprint Cup, and Nationwide Series games and events
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• Get coverage of the golf leaderboards and schedules, including PGA, LPGA, PGA Champions, EURO PGA, and PGA Nationwide
• Connect with friends and fans during games via Facebook® sharing results or reactions
• Track your favorite players or fantasy teams by creating custom groups
• Predict the winners and compare your picks with the Sportacular community
Sportacular is the trademark or registered trademark of Citizen Sports and Yahoo! Inc. All other trademarks are the property of their respective owners.
Follow us on Twitter! (www.twitter.com/sportacular)
And Facebook (http://www.facebook.com/pages/Sportacular/36208991073)
Privacy Policy: http://www.citizensportsinc.com/inc/privacy.html
Terms of Service: http://www.citizensportsinc.com/termsConditions.html
What's new in version 2.1.1
Bug fixes and performance improvements!
Yahoo! Sportacular Pro is a universal iOS app available in the App Store for $1.99 (Ads free) with no in-app purchases. The app is compatible with all devices running iOS or later. To download the Yahoo Sportacular Pro app click the button below to go to the app's download page.
Developer site: Yahoo! Sportacular Pro support
If you've enjoyed using the app, please rate and review it on the App store and in the comments section below.
iPhone Screenshots
Recent Reviews
Enjoyable to use. I have followed many MLB games on my phone bedside of the blackout policy or other time commitments.
Almost There. Will give it 5 stars once they include college hockey.
Great way to follow all the action!. I really like the upgrade. Easy to switch sports, leagues, etc.
Configuration. This app is one of the best on the market. I only wish that they would upgrade the latest one to show you both the spread and the
total on the same page, instead of having to select a game to get bot
Great app.. Great app, thank you for continuing to support the pro app.
Share This App
Download Yahoo Sportacular Pro App Latest Version on Android and iOS. You can get it directly on your device or download the app to your PC or Mac computer then install the app on your tablet or smart phone.