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Defining a Health Information ExchangeThe United States is facing the largest shortage of healthcare practitioners in our country’s history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati based HIE and one of the largest community based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases communication can be achieved but the process is cumbersome and often ineffective.”United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.History of Health Information ExchangesMajor urban centers in Canada and Australia were the first to successfully implement HIE’s. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it’s third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.In the United States one of the earliest HIE’s started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.In Tennessee Regional Health Information Organizations (RHIO’s) initiated in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri Cities region was considered a direct project where clinicians interact directly with each other using Carespark’s HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the midsouth eHealth Alliance is a RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.Seventeen US communities have been designated as Beacon Communities across the United States based on their development of HIE’s. These communities’ health focus varies based on the patient population and prevalence of chronic disease states i.e. cvd, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety and efficiency due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mississippi, just south of Memphis, was granted a $100,000 grant by the department of Health and Human Services in September 2011.A healthcare model for Nashville to emulate is located in Indianapolis, IN based on geographic proximity, city size and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center and Shalom Health Care Center Inc. In addition, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange 2) Improving long term and post acute care transitions 3) Consumer mediated information exchange 4) Enabling enhanced query for patient care 5) Fostering distributed population-level analytics.Regulatory Aspects of Health Information Exchanges and Healthcare ReformThe department of Health and Human Services (HHS) is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions and Tennessee is part of Region IV headquartered out of Atlanta. The Regional Director, Anton J. Gunn is the first African American elected to serve as regional director and brings a wealth of experience to his role based on his public service specifically regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast area.The National Health Information Network (NHIN) is a division of HHS that guides the standards of exchange and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities and state HIE’s (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to care programs for chronic patients leading to continuity and finally timely public health alerts through agencies like the CDC based on this information.12 The Health Information Technology for Economic and Clinical Health (HITECH) Act is funded by dollars from the American Reinvestment and Recovery Act of 2009. HITECH’s goals are to invest dollars in community, regional and state health information exchanges to build effective networks which are connected nationally. Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. To date 56 states have received grant awards through these programs totaling 548 million dollars.History of Health Information Partnership TN (HIPTN)In Tennessee the Health Information Exchange has been slower to progress than places like Maine and Indiana based in part on the diversity of our state. The delta has a vastly different patient population and health network than that of middle Tennessee, which differs from eastern Tennessee’s Appalachian region. In August of 2009 the first steps were taken to build a statewide HIE consisting of a non-profit named HIP TN. A board was established at this time with an operations council formed in December. HIP TN’s first initiatives involved connecting the work through Carespark in northeast Tennessee’s s tri-cities region to the Midsouth ehealth Alliance in Memphis. State officials estimated a cost of over 200 million dollars from 2010-2015. The venture involves stakeholders from medical, technical, legal and business backgrounds. The governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing the office of eHealth initiatives with oversight by the Office of Administration and Finance and sixteen board members. By March 2010 four workgroups were established to focus on areas like technology, clinical, privacy and security and sustainability.By May of 2010 data sharing agreements were in place and a production pilot for the statewide HIE was initiated in June 2011 along with a Request for Proposal (RFP) which was sent out to over forty vendors. In July 2010 a fifth workgroup,the consumer advisory group, was added and in September 2010 Tennessee was notified that they were one of the first states to have their plans approved after a release of Program Information Notice (PIN). Over fifty stakeholders came together to evaluate the vendor demonstrations and a contract was signed with the chosen vendor Axolotl on September 30th, 2010. At that time a production goal of July 15th, 2011 was agreed upon and in January 2011 Keith Cox was hired as HIP TN’s CEO. Keith brings twenty six years of tenure in healthcare IT to the collaborative. His previous endeavors include Microsoft, Bellsouth and several entrepreneurial efforts. HIP TN’s mission is to improve access to health information through a statewide collaborative process and provide the infrastructure for security in that exchange. The vision for HIP TN is to be recognized as a state and national leader who support measurable improvements in clinical quality and efficiency to patients, providers and payors with secure HIE. Robert S. Gordon, the board chair for HIPTN states the vision well, “We share the view that while technology is a critical tool, the primary focus is not technology itself, but improving health”. HIP TN is a non profit, 501(c)3, that is solely reliant on state government funding. It is a combination of centralized and decentralized architecture. The key vendors are Axolotl, which acts as the umbrella network, ICA for Memphis and Nashville, with CGI as the vendor in northeast Tennessee.15 Future HIP TN goals include a gateway to the National Health Institute planned for late 2011 and a clinician index in early 2012. Carespark, one of the original regional health exchange networks voted to cease operations on July 11, 2011 based on lack of financial support for it’s new infrastructure. The data sharing agreements included 38 health organizations, nine communities and 250 volunteers.16 Carespark’s closure clarifies the need to build a network that is not solely reliant on public grants to fund it’s efforts, which we will discuss in the final section of this paper.Current Status of Healthcare Information Exchange and HIPTNTen grants were awarded in 2011 by the HIE challenge grant supplement. These included initiatives in eight states and serve as communities we can look to for guidance as HIP TN evolves. As previously mentioned one of the most awarded communities lies less than five hours away in Indianapolis, IN. Based on the similarities in our health communities, patient populations and demographics, Indianapolis would provide an excellent mentor for Nashville and the hospital systems who serve patients in TN. The Indiana Health Information Exchange has been recognized nationally for it’s Docs for Docs program and the manner in which collaboration has taken place since it’s conception in 2004. Kathleen Sebelius, Secretary of HHS commented, “The Central Indiana Beacon Community has a level of collaboration and the ability to organize quality efforts in an effective manner from its history of building long standing relationships. We are thrilled to be working with a community that is far ahead in the use of health information to bring positive change to patient care.” Beacon communities that could act as guides for our community include the Health and Hospital Corporation of Marion County and the Indiana Health Centers based on their recent awards of $100,000 each by HHS.A local model of excellence in practice EMR conversion is Old Harding Pediatric Associates (OHPA) which has two clinics and fourteen physicians who handle a patient population of 23,000 and over 72,000 patient encounters per year. OHPA’s conversion to electronic records in early 2000 occurred as a result of the pursuit of excellence in patient care and the desire to use technology in a way that benefitted their patient population. OHPA established a cross functional work team to improve their practices in the areas of facilities, personnel, communication, technology and external influences. Noteworthy was chosen as the EMR vendor based on user friendliness and the similarity to a standard patient chart with tabs for files. The software was customized to the pediatric environment complete with patient growth charts. Windows was used as the operating system based on provider familiarity. Within four days OHPA had 100% compliance and use of their EMR system.The Future of HIP TN and HIE in TennesseeTennessee has received close to twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIO) need to be full scalable to allow hospitals to grow their systems without compromising integrity as they grow.21and the systems located in Nashville will play an integral role in this nationwide scaling with companies like HCA, CHS, Iasis, Lifepoint and Vanguard. The HIE will act as a data repository for all patients information that can be accessed from anywhere and contains a full history of the patients medical record, lab tests, physician network and medicine list. To entice providers to enroll in the statewide HIE tangible value to their practice has to be shown with better safer care. In a 2011 HIMSS editor’s report Richard Lang states that instead of a top down approach “A more practical idea may be for states to support local community HIE development first. Once established, these local networks can feed regional HIE’s and then connect to a central HIE/data repository backbone. States should use a portion of the stimulus funds to support local HIE development.”22 Mr. Lang also believes the primary care physician has to be the foundation for the entire system since they are the main point of contact for the patient.One piece of the puzzle often overlooked is the patient investment in a functional EHR. In order to bring together all the pieces of the HIE puzzle patients will need to play a more active role in their healthcare. Many patients do not know what medicines they take every day or whether they have a living will. Several versions of patient EHR’s like Memitech’s 911medical id card exist, but very few patients know or carry them.23 One way to combat this lack of awareness is to use the hospital as a catch-all and discharge each patient with a fully loaded USB card via case managers. This strategy also might lead to better compliance with post in patient therapies to reduce readmissions.The implementation of connecting qualified organizations began earlier this year. To fully support organizations to move toward qualification the Office of National Coordinator for HIE (ONC) has designated regional education centers (TN rec) who assist providers with educational initiatives in areas like HIT, ICD9 to ICD10 training and EMR transition. Qsource, a non-profit health consulting firm, has been chosen to oversee TNrec. To ensure sustainability it is critical that Tennessee build a network of private funding so that what happened with Carespark won’t happen to HIP TN. The eHealth Initiatives 2011Survey Report states that of the 196 HIE initiatives, 115 act independently of federal funding and of those independent HIE’s, break even through operational revenue. Some of these exchanges were in existence well before the American Recovery and Reinvestment Act in 2009. Startup funding from grants is only meant to get the car going so to speak, the sustainable fuel, as observed in the case of Carespark, has to come from value that can be monetized. KLAS research reports that 54% of public HIE’s were concerned about future sustainability while only 35% of private HIE’s shared this concern.Hospital Implications of HIP TN (A Call to Action)From a Financial perspective, taking our hospital into the future with EMR and an integrated statewide network has profound implications. In the short term the cost to find a vendor, establish EMR in and outpatient will be an expensive proposition. The transition will not be easy or finite and will involve constant evolution as HIP TN integrates with other state HIE’s. To get a realistic idea of the benefits and costs associated with health information integration. we can look to HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in productivity reduction. Specific areas of savings include paper or fax costs $5 versus $0.25 electronically, virtual health record savings of $50 per referral, $26 saved per ED visit and $17.41 per patient/year due to redundant lab tests which amounts to $52 million for a population of 3 million patients. In Grand Junction Colorado Quality Health Network lowered their per capita Medicare spending to 24% below the national average, gaining recognition by President Obama in 2009. The Santa Cruz Health Information Exchange (SCHIE) with 600 doctors and two hospitals achieved sustainability in the first year of operation and uses a subscription fee for all the organizations who interact with them. In terms of government dollars available, meaningful use incentives exist to encourage hospitals to meet twenty of twenty five objectives in the first phase (2011-2012) and adopting and implement an approved EHR vendor. ARRA specified three ways for EHR to be utilized to obtain Medicare reimbursement. These include e-prescribing, health information exchange and submission of clinical quality measures. The objectives for phase two in 2013 will expand on this baseline. Implementation of EHR and Hospital HIE costs are usually charged by bed or by the number of physicians. Fees can range from $1500 for a smaller hospital up to $12,000 per month for a larger hospital.Perhaps the most compelling argument to building a functional Health Information Exchange is patient and community safety. The Healthbridge reduction in disease outbreak detection of 3-5 days is a perfect example of this safety benefit. Imagine the implications in the case of a rampant virus like avian or swine flu. The goal is to avoid a repeat of the 1918 influenza outbreak and ultimately save the lives of our most at risk. Rick Krohn of Healthsense makes the case for a socially responsible HIE that serves those who are chronically ill, uninsured and homeless. As the taxpayers ultimately bear the societal burden for our country’s healthcare coverage, the need to reduce redundancies, increase efficiency and provide healthcare worthy of the United States is imperative. Right now our healthcare is in the Critical Care Unit it’s time to stabilize it through operational excellence starting with our hospital. Let’s rebuild the Tower of Babel and enhance communication to provide our patients the healthcare they deserve!

1.) Online business directories are very beneficial for small businesses. You just have to know how they work.An online business directory is a website submission service that allows your small business’s website to be added to a specific category where it can be searched for by interested visitors. These searchable online directories allow their visitors to search for websites and businesses that they find interesting or that they want to learn more about. Listing your small business on an online directory increases your website’s visibility on the web and helps to create inbound links to your business’ website. Online directories make it easy for people to find what they are looking for. All they have to do is jump online, which means that people could find your business’ website from their home, office or even while traveling.2.) Want to know how online business directories work?The concept of online directories is actually a pretty simple one. Online directories are very similar to the printed Yellow Pages in the real world, only these listings are only online. (Actually Yellow Pages.com is now also one of the biggest online directories as well.)An online business directory is just a listing place for a number of websites. Any type of website could be listed in an online directory. Some online directories are huge and cover every topic that someone could create a website for, while others are very small and specific to a specific niche. This means that online directories will direct you to just about any website that you want to find. All you have to do is perform a search in the online directory for a specific topic, or browse through the various categories until you find the type of websites you are looking for. When you perform a search you will be given a list of all of the websites that relate to your search term. You will be presented with a number of links to these websites and each link will have a short description of what you are likely to find on the website. You can read the descriptions and choose to click on the website that best suits you.3.) Being listed in an online business directory can give your small business more exposure!Exposure is important for all business marketing strategies. After all, the more people who are exposed to your business the more people are likely to utilize your business’s services. If online viewers aren’t able to see your website, they likely don’t even know it exists and they probably aren’t going to purchase your products or services. Listing your business’ website in online directories helps your website to gain exposure. Thousands of people use online directories every day to find things they are interested in. These are people who are actively searching for websites that are directly related to your products or services. They are already looking- all you have to do is make it easy for them to find you. Online directories will expose your business to more online visitors, which could increase traffic to your website.4.) Being listed in an online business directory can also boost your SEO efforts!Online directories offer several search engine optimization, or SEO, benefits as well. Firstly, these online directories offer you more inbound links. When an online visitor sees your website link in an online directory, they will be able to click on it and be instantly re-directed to your website. This is a great way to increase traffic. It is a great way to improve your status in the eyes of search engine crawlers, too. The more backlinks that a search engine crawler can find, the higher they will rank your website. This is especially true of authoritative online directories. Being linked to a major online directory, such as Google My Business, will give your website more relevancy in the eyes of Google’s search engine crawlers. This will result in a higher page ranking on the SERP. As you know, a higher search engine result page rank you get, the more people are going to click on your website link.5.) Where’s the best place to start looking at online directories you should be in? Start with your competitors!You will probably want to consider listing with the top 10 online business directories, as these will be used by a lot of people and will offer higher relevancy and authority in the eyes of search engines. Google My Business is a large general-interest directory that you will want to list your small business with. If your website sells tangible goods, you may also want to consider listing it in comparison shopping websites and product listings directories. Studies show that 42% of consumers will look at a comparison shopping website before they decide to purchase a specific product.The best way to figure out which specific online directories your small business should be listed in is to start with your competitors. Take a look at your local and niche-specific options and figure out if your competition is already listed. If they are, you need to be listed too. If they are not listed, you want to list your website anyway as a way to beat them to the punch. In some situations it may not make sense for you to have a listing in a specific online directory, even if your competitors are listed in it. Your goal should be to be listed in every relevant and niche-specific directory you can find as well as many of the major directories, but not so many directories that you appear as spam.6.) Listings are important, but they’re just the beginning. You also want to make sure you have reviews!Local listings in online business directories are a great way to market your company and get the word out about your business and what you do. However, if you don’t have any positive reviews within those local listings they can do more harm than good. This is because when reviewing all the different businesses within your industry or category, users will always look to the reviews to give them a better idea of the service and quality of product they can expect. And if you don’t have any reviews but your competition’s page is filled with positive reviews, you’re sending customers directly to them instead of to you. You can get more reviews by using surveys, providing incentives, having a tablet with the review site already up to hand over to customers, responding to reviews already up, and by knowing when and where to refer customers.7.) Remember that once you’re listed you need to track, track, track!It will probably take some time to see the results of listing your small business’ website in so many online directories, but eventually you will see results. The best way to find the perfect combination of online directory listings for your business is to use some sort of tracking or analytics system. You will want to be able to see how many people clicked on your website links from within the directory and if your website has shown increased traffic since then. You will want to stop wasting your time with online directories that are not producing results and increase the time and effort you spend on online directories that are productive.In summary, here are 3 critical reasons why your business must take advantage of the top online business directories to help you get more customers.

Maximize Exposure: Every day potential customers are searching for businesses in your area to help solve their problems. And more times then not they’re finding these businesses on online directories.

Social Proof: When prospects find a business online they read reviews to make sure they’re making a good decision. Having customers post positive reviews on your listing will build tremendous credibility and prove to everyone that you’re a reliable business that can be trusted.

Low Cost: Most of the top online business directories are free to use. Making it one of the best marketing values your business can have.

Now is your chance to finally profit and save big from the largest market shift in history. That is the Travel Industry Shift from the Brick & Mortar to the online Click & Mortar.Are you ready for a good time off rate for your next vacation? If you are watchful for the cheaper prices, mull over using the internet and booking online using an online travel website. These online travel websites are becoming in demand with holidaymakers and travelers nationwide.Usually, you will come up with cheaper rates, cheaper prices in airline and traveling fares. Online travel websites are qualified to accommodate their clients with cheaper pricing because their over-heads are normally less than your standard travel agency who maintains a big staff, have to pay a lease for their office space and have to furnish equipment for the travel industry. Utilizing the internet, travel entrepreneurs can cut their expenses by spending exclusively over the internet or by telephone.Online travel websites are providing instant communication over the internet, where conventional travel agents have to check and research travel information. So, travelers are benefiting from instant travel information, services and the convenience of booking all travel online and not needing to leave the home or work place to book their travel.Now travel enthusiasts can use these online travel websites to select their own vacation destinations, stops, routes, dates, and basically plan their own vacation to fit their particular needs. As you continue to read this article, you will find my resource box at the bottom with a link that will show you how you can profit big from this huge market shift in the travel industry. This is made possible with your very own online Booking Engine website.So, there are numerous advantages for travelers to use online travel websites instead of a conventional travel agency. Online travel websites will allow you to plan and select your vacation or destination and then select the most affordable flights or passage to your selected vacation destination. Select an online travel agent with industry experience, this means that they will have sufficient expertise and knowledge, contacts and additional to guarantee you get the least expensive deal possible.Use the internet to set up your next vacation, save yourself time, money and gain from the convenience of online shopping and booking. Online travel websites are becoming a big business in the travel industry. These online websites have practical, informative and helpful websites for their patrons to compare prices and find useful information on their vacation destination and their selected online travel website’s choices and services in the travel industry.Join the travelers of the world and originate your plans and bookings for travel and vacations by using an efficient, professional online travel agent. Save money, time and take advantage of creating your own vacation structure. Decide on the best vacation for you, and let professional online travel websites get the cheapest travel rates available.I hope you have gotten some good ideas from this article and are able to use them.