Rebuilding the Tower of Babel – A CEO’s Perspective on Health Information Exchanges

Defining a Health Information Exchange

The 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 Exchanges

Major 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 Reform

The 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 HIPTN

Ten 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 Tennessee

Tennessee 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.

Impacts of Information Technology on Society in the New Century

In the past few decades there has been a revolution in computing and communications, and all indications are that technological progress and use of information technology will continue at a rapid pace. Accompanying and supporting the dramatic increases in the power and use of new information technologies has been the declining cost of communications as a result of both technological improvements and increased competition. According to Moore’s law the processing power of microchips is doubling every 18 months. These advances present many significant opportunities but also pose major challenges. Today, innovations in information technology are having wide-ranging effects across numerous domains of society, and policy makers are acting on issues involving economic productivity, intellectual property rights, privacy protection, and affordability of and access to information. Choices made now will have long lasting consequences, and attention must be paid to their social and economic impacts.

One of the most significant outcomes of the progress of information technology is probably electronic commerce over the Internet, a new way of conducting business. Though only a few years old, it may radically alter economic activities and the social environment. Already, it affects such large sectors as communications, finance and retail trade and might expand to areas such as education and health services. It implies the seamless application of information and communication technology along the entire value chain of a business that is conducted electronically.

The impacts of information technology and electronic commerce on business models, commerce, market structure, workplace, labour market, education, private life and society as a whole.

1. Business Models, Commerce and Market Structure

One important way in which information technology is affecting work is by reducing the importance of distance. In many industries, the geographic distribution of work is changing significantly. For instance, some software firms have found that they can overcome the tight local market for software engineers by sending projects to India or other nations where the wages are much lower. Furthermore, such arrangements can take advantage of the time differences so that critical projects can be worked on nearly around the clock. Firms can outsource their manufacturing to other nations and rely on telecommunications to keep marketing, R&D, and distribution teams in close contact with the manufacturing groups. Thus the technology can enable a finer division of labour among countries, which in turn affects the relative demand for various skills in each nation. The technology enables various types of work and employment to be decoupled from one another. Firms have greater freedom to locate their economic activities, creating greater competition among regions in infrastructure, labour, capital, and other resource markets. It also opens the door for regulatory arbitrage: firms can increasingly choose which tax authority and other regulations apply.

Computers and communication technologies also promote more market-like forms of production and distribution. An infrastructure of computing and communication technology, providing 24-hour access at low cost to almost any kind of price and product information desired by buyers, will reduce the informational barriers to efficient market operation. This infrastructure might also provide the means for effecting real-time transactions and make intermediaries such as sales clerks, stock brokers and travel agents, whose function is to provide an essential information link between buyers and sellers, redundant. Removal of intermediaries would reduce the costs in the production and distribution value chain. The information technologies have facilitated the evolution of enhanced mail order retailing, in which goods can be ordered quickly by using telephones or computer networks and then dispatched by suppliers through integrated transport companies that rely extensively on computers and communication technologies to control their operations. Nonphysical goods, such as software, can be shipped electronically, eliminating the entire transport channel. Payments can be done in new ways. The result is disintermediation throughout the distribution channel, with cost reduction, lower end-consumer prices, and higher profit margins.

The impact of information technology on the firms’ cost structure can be best illustrated on the electronic commerce example. The key areas of cost reduction when carrying out a sale via electronic commerce rather than in a traditional store involve physical establishment, order placement and execution, customer support, strong, inventory carrying, and distribution. Although setting up and maintaining an e-commerce web site might be expensive, it is certainly less expensive to maintain such a storefront than a physical one because it is always open, can be accessed by millions around the globe, and has few variable costs, so that it can scale up to meet the demand. By maintaining one ‘store’ instead of several, duplicate inventory costs are eliminated. In addition, e-commerce is very effective at reducing the costs of attracting new customers, because advertising is typically cheaper than for other media and more targeted. Moreover, the electronic interface allows e-commerce merchants to check that an order is internally consistent and that the order, receipt, and invoice match. Through e-commerce, firms are able to move much of their customer support on line so that customers can access databases or manuals directly. This significantly cuts costs while generally improving the quality of service. E-commerce shops require far fewer, but high-skilled, employees. E-commerce also permits savings in inventory carrying costs. The faster the input can be ordered and delivered, the less the need for a large inventory. The impact on costs associated with decreased inventories is most pronounced in industries where the product has a limited shelf life (e.g. bananas), is subject to fast technological obsolescence or price declines (e.g. computers), or where there is a rapid flow of new products (e.g. books, music). Although shipping costs can increase the cost of many products purchased via electronic commerce and add substantially to the final price, distribution costs are significantly reduced for digital products such as financial services, software, and travel, which are important e-commerce segments.

Although electronic commerce causes the disintermediation of some intermediaries, it creates greater dependency on others and also some entirely new intermediary functions. Among the intermediary services that could add costs to e-commerce transactions are advertising, secure online payment, and delivery. The relative ease of becoming an e-commerce merchant and setting up stores results in such a huge number of offerings that consumers can easily be overwhelmed. This increases the importance of using advertising to establish a brand name and thus generate consumer familiarity and trust. For new e-commerce start-ups, this process can be expensive and represents a significant transaction cost. The openness, global reach, and lack of physical clues that are inherent characteristics of e-commerce also make it vulnerable to fraud and thus increase certain costs for e-commerce merchants as compared to traditional stores. New techniques are being developed to protect the use of credit cards in e-commerce transactions, but the need for greater security and user verification leads to increased costs. A key feature of e-commerce is the convenience of having purchases delivered directly. In the case of tangibles, such as books, this incurs delivery costs, which cause prices to rise in most cases, thereby negating many of the savings associated with e-commerce and substantially adding to transaction costs.

With the Internet, e-commerce is rapidly expanding into a fast-moving, open global market with an ever-increasing number of participants. The open and global nature of e-commerce is likely to increase market size and change market structure, both in terms of the number and size of players and the way in which players compete on international markets. Digitized products can cross the border in real time, consumers can shop 24 hours a day, seven days a week, and firms are increasingly faced with international online competition. The Internet is helping to enlarge existing markets by cutting through many of the distribution and marketing barriers that can prevent firms from gaining access to foreign markets. E-commerce lowers information and transaction costs for operating on overseas markets and provides a cheap and efficient way to strengthen customer-supplier relations. It also encourages companies to develop innovative ways of advertising, delivering and supporting their product and services. While e-commerce on the Internet offers the potential for global markets, certain factors, such as language, transport costs, local reputation, as well as differences in the cost and ease of access to networks, attenuate this potential to a greater or lesser extent.

2. Workplace and Labour Market

Computers and communication technologies allow individuals to communicate with one another in ways complementary to traditional face-to-face, telephonic, and written modes. They enable collaborative work involving distributed communities of actors who seldom, if ever, meet physically. These technologies utilize communication infrastructures that are both global and always up, thus enabling 24-hour activity and asynchronous as well as synchronous interactions among individuals, groups, and organizations. Social interaction in organizations will be affected by use of computers and communication technologies. Peer-to-peer relations across department lines will be enhanced through sharing of information and coordination of activities. Interaction between superiors and subordinates will become more tense because of social control issues raised by the use of computerized monitoring systems, but on the other hand, the use of e-mail will lower the barriers to communications across different status levels, resulting in more uninhibited communications between supervisor and subordinates.

That the importance of distance will be reduced by computers and communication technology also favours telecommuting, and thus, has implications for the residence patterns of the citizens. As workers find that they can do most of their work at home rather than in a centralized workplace, the demand for homes in climatically and physically attractive regions would increase. The consequences of such a shift in employment from the suburbs to more remote areas would be profound. Property values would rise in the favoured destinations and fall in the suburbs. Rural, historical, or charming aspects of life and the environment in the newly attractive areas would be threatened. Since most telecommuters would be among the better educated and higher paid, the demand in these areas for high-income and high-status services like gourmet restaurants and clothing boutiques would increase. Also would there be an expansion of services of all types, creating and expanding job opportunities for the local population.

By reducing the fixed cost of employment, widespread telecommuting should make it easier for individuals to work on flexible schedules, to work part time, to share jobs, or to hold two or more jobs simultaneously. Since changing employers would not necessarily require changing one’s place of residence, telecommuting should increase job mobility and speed career advancement. This increased flexibility might also reduce job stress and increase job satisfaction. Since job stress is a major factor governing health there may be additional benefits in the form of reduced health costs and mortality rates. On the other hand one might also argue that technologies, by expanding the number of different tasks that are expected of workers and the array of skills needed to perform these tasks, might speed up work and increase the level of stress and time pressure on workers.

A question that is more difficult to be answered is about the impacts that computers and communications might have on employment. The ability of computers and communications to perform routine tasks such as bookkeeping more rapidly than humans leads to concern that people will be replaced by computers and communications. The response to this argument is that even if computers and communications lead to the elimination of some workers, other jobs will be created, particularly for computer professionals, and that growth in output will increase overall employment. It is more likely that computers and communications will lead to changes in the types of workers needed for different occupations rather than to changes in total employment.

A number of industries are affected by electronic commerce. The distribution sector is directly affected, as e-commerce is a way of supplying and delivering goods and services. Other industries, indirectly affected, are those related to information and communication technology (the infrastructure that enables e-commerce), content-related industries (entertainment, software), transactions-related industries (financial sector, advertising, travel, transport). eCommerce might also create new markets or extend market reach beyond traditional borders. Enlarging the market will have a positive effect on jobs. Another important issue relates to inter linkages among activities affected by e-commerce. Expenditure for e-commerce-related intermediate goods and services will create jobs indirectly, on the basis of the volume of electronic transactions and their effect on prices, costs and productivity. The convergence of media, telecommunication and computing technologies is creating a new integrated supply chain for the production and delivery of multimedia and information content. Most of the employment related to e-commerce around the content industries and communication infrastructure such as the Internet.

Jobs are both created and destroyed by technology, trade, and organizational change. These processes also underlie changes in the skill composition of employment. Beyond the net employment gains or losses brought about by these factors, it is apparent that workers with different skill levels will be affected differently. E-commerce is certainly driving the demand for IT professionals but it also requires IT expertise to be coupled with strong business application skills, thereby generating demand for a flexible, multi-skilled work force. There is a growing need for increased integration of Internet front-end applications with enterprise operations, applications and back-end databases. Many of the IT skill requirements needed for Internet support can be met by low-paid IT workers who can deal with the organizational services needed for basic web page programming. However, wide area networks, competitive web sites, and complex network applications require much more skill than a platform-specific IT job. Since the skills required for e-commerce are rare and in high demand, e-commerce might accelerate the up skilling trend in many countries by requiring high-skilled computer scientists to replace low-skilled information clerks, cashiers and market salespersons.

3. Education

Advances in information technology will affect the craft of teaching by complementing rather than eliminating traditional classroom instruction. Indeed the effective instructor acts in a mixture of roles. In one role the instructor is a supplier of services to the students, who might be regarded as its customers. But the effective instructor occupies another role as well, as a supervisor of students, and plays a role in motivating, encouraging, evaluating, and developing students. For any topic there will always be a small percentage of students with the necessary background, motivation, and self-discipline to learn from self-paced workbooks or computer assisted instruction. For the majority of students, however, the presence of a live instructor will continue to be far more effective than a computer assisted counterpart in facilitating positive educational outcomes. The greatest potential for new information technology lies in improving the productivity of time spent outside the classroom. Making solutions to problem sets and assigned reading materials available on the Internet offers a lot of convenience. E-mail vastly simplifies communication between students and faculty and among students who may be engaged in group projects. Advances in information technology will affect the craft of teaching by complementing rather than eliminating traditional classroom instruction. Indeed the effective instructor acts in a mixture of roles. In one role the instructor is a supplier of services to the students, who might be regarded as its customers. But the effective instructor occupies another role as well, as a supervisor of students, and plays a role in motivating, encouraging, evaluating, and developing students. For any topic there will always be a small percentage of students with the necessary background, motivation, and self-discipline to learn from self-paced workbooks or computer assisted instruction. For the majority of students, however, the presence of a live instructor will continue to be far more effective than a computer assisted counterpart in facilitating positive educational outcomes. The greatest potential for new information technology lies in improving the productivity of time spent outside the classroom. Making solutions to problem sets and assigned reading materials available on the Internet offers a lot of convenience. E-mail vastly simplifies communication between students and faculty and among students who may be engaged in group projects.

Although distance learning has existed for some time, the Internet makes possible a large expansion in coverage and better delivery of instruction. Text can be combined with audio/ video, and students can interact in real time via e-mail and discussion groups. Such technical improvements coincide with a general demand for retraining by those who, due to work and family demands, cannot attend traditional courses. Distance learning via the Internet is likely to complement existing schools for children and university students, but it could have more of a substitution effect for continuing education programmes. For some degree programmes, high-prestige institutions could use their reputation to attract students who would otherwise attend a local facility. Owing to the Internet’s ease of access and convenience for distance learning, overall demand for such programmes will probably expand, leading to growth in this segment of e-commerce.

As shown in the previous section, high level skills are vital in a technology-based and knowledge intensive economy. Changes associated with rapid technological advances in industry have made continual upgrading of professional skills an economic necessity. The goal of lifelong learning can only be accomplished by reinforcing and adapting existing systems of learning, both in public and private sectors. The demand for education and training concerns the full range of modern technology. Information technologies are uniquely capable of providing ways to meet this demand. Online training via the Internet ranges from accessing self-study courses to complete electronic classrooms. These computer-based training programmes provide flexibility in skills acquisition and are more affordable and relevant than more traditional seminars and courses.

4. Private Life and Society

Increasing representation of a wide variety of content in digital form results in easier and cheaper duplication and distribution of information. This has a mixed effect on the provision of content. On the one hand, content can be distributed at a lower unit cost. On the other hand, distribution of content outside of channels that respect intellectual property rights can reduce the incentives of creators and distributors to produce and make content available in the first place. Information technology raises a host of questions about intellectual property protection and new tools and regulations have to be developed in order to solve this problem.

Many issues also surround free speech and regulation of content on the Internet, and there continue to be calls for mechanisms to control objectionable content. However it is very difficult to find a sensible solution. Dealing with indecent material involves understanding not only the views on such topics but also their evolution over time. Furthermore, the same technology that allows for content altering with respect to decency can be used to filter political speech and to restrict access to political material. Thus, if censorship does not appear to be an option, a possible solution might be labelling. The idea is that consumers will be better informed in their decisions to avoid objectionable content.

The rapid increase in computing and communications power has raised considerable concern about privacy both in the public and private sector. Decreases in the cost of data storage and information processing make it likely that it will become practicable for both government and private data-mining enterprises to collect detailed dossiers on all citizens. Nobody knows who currently collects data about individuals, how this data is used and shared or how this data might be misused. These concerns lower the consumers’ trust in online institutions and communication and, thus, inhibit the development of electronic commerce. A technological approach to protecting privacy might by cryptography although it might be claimed that cryptography presents a serious barrier to criminal investigations.

It is popular wisdom that people today suffer information overload. A lot of the information available on the Internet is incomplete and even incorrect. People spend more and more of their time absorbing irrelevant information just because it is available and they think they should know about it. Therefore, it must be studied how people assign credibility to the information they collect in order to invent and develop new credibility systems to help consumers to manage the information overload.

Technological progress inevitably creates dependence on technology. Indeed the creation of vital infrastructure ensures dependence on that infrastructure. As surely as the world is now dependent on its transport, telephone, and other infrastructures, it will be dependent on the emerging information infrastructure. Dependence on technology can bring risks. Failures in the technological infrastructure can cause the collapse of economic and social functionality. Blackouts of long-distance telephone service, credit data systems, and electronic funds transfer systems, and other such vital communications and information processing services would undoubtedly cause widespread economic disruption. However, it is probably impossible to avoid technological dependence. Therefore, what must be considered is the exposure brought from dependence on technologies with a recognizable probability of failure, no workable substitute at hand, and high costs as a result of failure.

The ongoing computing and communications revolution has numerous economic and social impacts on modern society and requires serious social science investigation in order to manage its risks and dangers. Such work would be valuable for both social policy and technology design. Decisions have to be taken carefully. Many choices being made now will be costly or difficult to modify in the future.

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With the smaller spaces that can be found in homes and condominiums, many home owners are thinking of creative ways on how they can have efficient solutions for small areas by using corner sofa bed with storage which have many uses and which they can also decorate. There are many kinds of corner sofa bed that are being sold in the market and this kind of furniture has a double feature that can function well in a bedroom or in a guest room as well.

There are corner sofa bed that has storages which can be placed in your living room and there are also other guides that you can follow in order for you to decorate properly your corner sofa bed and this will be a big help for you. You have to first measure up the size of the room so that you would know the size of the corner sofa bed sale that you are going to purchase for your room and the dimensions of the room should also be defined.

The use of the corner sofa bed is a great solution for maximizing or optimizing the space of the room and you must also learn on how you can rearrange the other furniture that can be found inside the room. There are many kinds of materials for a corner sofa bed and if you want to buy one, you may choose a sofa bed made up of a genuine leather because this is more classy as compared to other kinds of materials.

Fabric material for corner sofa bed is available in the market if you fine the genuine leather material quite expensive and this fabric can also blend in with other designs and colors of furniture that you would want to place in your room together with the corner sofa bed and this would be very helpful for you. You can always buy additional storage with fabric textiles as its cover so that it will be more decorative and colorful when you place it under the cheap corner sofa bed and this is very functional for small space in your room along with other furniture.

If you will buy a corner sofa bed make sure that the base material of your sofa bed is very durable so that it can last for a long time whether the material is a genuine leather of a fabric. Bright colored pillows or cushions can be added to your corner sofa bed if you want to decorate it with something lively and with something that is not that expensive and with this, the decorations will also be pleasing to the eyes.

Direct TV and HD – What’s The Story?

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So, you want to get into the HD scene and don’t know where to start? First, you’ll need to make sure you have an “HD-ready” television set to go with the service, that way you’ll actually be able to see the beautiful views and awesome sounds that HDTV will provide you with. You’ll most likely have to check your TV’s manual to find out if it supports 720p, 1080i, or 1080p, 720p and 1080i are the same, but most TV makers put 1080i to attempt to fool you, so watch out for that.

Now, you’ll need to decide which TV service you would like, Direct TV, Dish TV, or cable. With cable, you’ll get about 55 HD channels depending on which cable provider, with satellite TV, you’ll get 73 HD channels, and with Direct TV, you’ll receive 92 of your favorite HD channels, whereas with cable and Dish TV, nearly half of the HD channels you’ll be getting will be ones you’ve probably never heard of and if you have they are ones that you want and feel you need for the total HD experience.

For example, have you ever heard of Treasure HD, or Equator HD? No, no one has, and no one watches those channels either, so in fact, many people are paying extra for tons of channels that they have never heard of and will never watch. With Direct TV, you’ll be getting all the HD movies you could ever want with channels like Universal HD, Sony, Warner Brothers, and the traditional movie channels in HD, such as HBO and Starz. Direct TV also offers local High-Def channels, unlike what the cable companies would like to tell you on their commercials and DirecTV adds more HD programs all the time so there is little worry of tiring of these movie stations. Direct TV offers as many local HD channels as cable does, such as ABC, NBC, CBS, and Fox. Of course, like cable, the availability depends on the region.

As with cable, you will also have to get a separate receiver for your HD channels with HDTV Direct TV. The basic HD Receiver for Direct TV will give you 1080i (720p) picture, while the Plus version will give you the full 1080p picture that is truly worth showing off on your new flatscreen. You’ll only pay a one-time fee, though, for most Direct TV boxes, while with Cable ones, you have to pay so much per month.

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Media Influence – The Effects Media Has on Each of Us – Without Us Being Aware of That

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Many people do not realise how much media affects us in our daily lives. We are literally controlled by media: it determines the way we dress, what we eat and what lifestyle we pursue. Many people spend hours just flicking through channels till their bedtime.

Although we may not realise, it is media that makes us feel the way we feel, which is usually depressed, having no purpose in life and just feeling sad. The more you watch TV or listen to radio news, the more disasters you will hear, e.g. that someone was killed in your neighbourhood or that times are hard. Media forms the way we think and we let the media do this.

From my personal experience I can tell you that I have not watched TV for two years now. As soon as I stopped watching it, I instantly became happier. Instead of watching TV or flicking through newspapers I spent my time reading about how to acquire wealth, how to be healthy and positive. The absence of the influential media changed my life. I became a different person – I stopped gossiping, judging people, I became much more positive and happy. To tell you the truth, I did not have a bad day since I stopped being involved in the media.

But then many would argue that it is impossible to disengage from media as we would be not updated on current situation etc. But I would rather CHOOSE what I wish to be updated on by using on-line search engines, rather than just turn on the TV only to be bombarded by the depressing information.

Why do we always hear more negative than positive information on TV? Why do we feel sad, angry and insecure after watching news? Sometimes I think that society is kept in fear by such ways. Then common people are discouraged to achieve more, to start their own business because the media tells them that now the economic situation is disastrous and many businesses fail. I think it is ridiculous when people take everything that is told for granted.

The way many people live can be summed up in a few sentences: they work for someone else, they go home, eat, watch TV and sleep. Then on weekends they go shopping for cheap stuff to spend all their money in useless ways only to find themselves in debt after a few days of getting salaries. Then they go on vacation for a week or two once a year.

That is not life. That is a horrible loop they are stuck in. To break away from such life means to change habits. Change the habit of listening to media to doing something useful in that time. Reading is always good. Reading how to acquire wealth was my favourite pastime.

If yo do not like to read, buy educational tapes or DVDs, attend seminars. These are interactive and very useful ways to acquire knowledge and change your life. When you stop listening to the media, you will find yourself happier, healthier and wealthier. You will travel much more often, meet interesting people, maybe even start a new relationship. Things will change – I will guarantee you this. Get rid of this negative influence and you will change your life for good.

Do not hesitate to email me with your feedback on my articles! Thank you for taking time to read this post.

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I Watch TV on My PC For All the Best Movies

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I am so happy I just discovered I can watch TV on my PC. Before television on my computer I was paying over $75 a month for cable. Canceling your cable service is a very pleasurable experience. The customer service representatives there sometimes say that getting tv on your PC isn’t possible. One only has to try the service for a minute to know this isn’t true.

There are several options out there. To get tv on your pc used to require additional equipment. This is no longer the case. If you have a PC and are online, then you are ready to go. All you need is a simply downloaded program. Some companies attempt to charge a monthly license fee for this software in an attempt to mimic the cable companies.

A few allow you to break the monthly payment cycle forever. Charging a one time fee only, you are perpetually able to receive satellite tv channels with no ongoing cost. Many think it sounds to good to be true. I admit I was one of them. However, seeing is believing. Not only does it work, but you would be astounded at the selection of programming.

Some programs offer up to 3000 channels. Yes, three thousand. That puts my old cable line up to shame. It is possible to receive channels from all over the globe. Watching live coverage from Rio one minute then Iraq the next is wild. It is as if a window has opened up to the world. Whether it be news, sports or movies the best of all countries becomes available right on your PC.

Friends who are rabid soccer fans are rushing to get this service now. Whatever the sport, many fans can not access their favorite games and team on regular cable television. Satellite TV on your computer allows for an incredible choice between events from all over the world. Never again will you utter that there is nothing good on to watch.

As I mentioned, the best part is that there is nothing left to pay after purchasing the initial software. Never. No ongoing monthly bills like all normal cable and satellite services entail. I read this software used to cost several hundred dollars. Some companies would charge comparable amounts to cable bills for its use each month. However, recently that has changed.

My timing was perfect because the most cutting edge package has now hit the market, and I can’t believe what a bargain it was. After confirming with the seller that it was 100% legal, the plunge was made. Download was as simple as downloading and installing any other software program.

Within minutes, I was able to watch TV on my PC. The best part is that home computers are now easily connected to televisions. Viewed this way, the amazing high def picture is fully experienced along with all sound effects. Nothing is missing except the bill. Added were several thousand channels. I wonder why anyone has cable anymore.

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Media-Ocrity: Why Impartiality Is Not Their Concern

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The late Terence McKenna, the American ethnobotanist and mystic, once exclaimed, “We have to create culture, don’t watch TV, don’t read magazines, don’t even listen to NPR. Create your own roadshow. The nexus of space and time where you are now is the most immediate sector of your universe, and if you’re worrying about Michael Jackson or Bill Clinton or somebody else, then you are dis-empowered, you’re giving it all away to icons, icons which are maintained by an electronic media so that you want to dress like X or have lips like Y. This is shit-brained, this kind of thinking. That is all cultural diversion, and what is real is you and your friends and your associations, your highs, your orgasms, your hopes, your plans, your fears. And we are told ‘no’, we’re unimportant, we’re peripheral. ‘Get a degree, get a job, get a this, get a that.’ And then you’re a player, you don’t want to even play in that game. You want to reclaim your mind and get it out of the hands of the cultural engineers who want to turn you into a half-baked moron consuming all this trash that’s being manufactured out of the bones of a dying world.”

Indeed, the media has been responsible for propagating the widespread misinformation we see today. This insidious plot of social engineering, whether we acknowledge this or not, can be found in tailored TV, radio and newspapers, that are filled with celebrity tittle-tattle and government propaganda, (ISIS, Syria, et al.), essentially giving their recommendations on what to wear, who you should aspire to be, and what to believe. Most of it bile with endless fear-mongering and lacking any semblance of truth.

Impartiality is not their concern, and control and obedience is, and remains their sole aim as they continue to churn out half-truths and innuendos that line a popular political narrative that stick like barnacles on a whale, to nudge and cajole a susceptible viewing public to align with one commonly held point of view.

Most people are aware of this of course, however, as social conditioning is part of the fabric of our media culture this can go unnoticed, and is transferred as if by osmosis, and we are affected regardless, unless are concerted effort is made on our part not to react in the negative. The general populace can seem so burdened by the very act of daily living, they can feel almost powerless to mount a rebellion. However, a sea of change is afoot and those among the elite know this, and the movement is now gathering pace.

What we can do now is to resist this element of mind control by refusing to listen and to explore other sources of information to keep up to date and well-informed. Turning off the TV and radio in the first instance, and in so doing taking some of our power back. Effectively shutting the hatch on the rising tide of excrement that you may hear lapping against the shutter door, but just enough to prevent it seeping through. Expunged of government and media brainwashing tactics, we will hopefully develop a clearer mind and become instinctively aware of the many injustices around the world, and by refusing to accept the status quo, potentially enable everyone to live more empowered and fulfilling lives and finally usher in the long-awaited collapse of the controlling elite.

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Fanning the Flames of “Media Created” Anxiety – A Break From Unnecessary Drama

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Tips for gaining control of your life…

The news media is more than a source for information and current events. It has become a “roller coaster ride” of drama and self-aggrandizement. We consumers of these presentations are swept up and our visceral anxiety responses are fanned into a frenzy. But why are swept up in this media blitz of emotion?

Since the dawning of the “Information Age” in the 1970’s, we have been steadily drawn into an escalating 24/7 need for worldwide news and the media has provided us with anxiety producing excitement from every corner of the world. Technology allows this instant communication and seems to encourage our “need to know” mentality. We “need to know” because we have a very primitive survival mechanism that stimulates our external focus on any threats, even perceived threats that may exist thousands of miles away, so our unconscious minds can protect us by preparing to fight or to flee from “danger.” When the Flight/Fight Response is triggered, our reactive, survival mechanisms take priority. We can react with “knee jerk” habitual patterns that are unique to our learned responses, but are born from the survival reaction. One major reaction that occurs for many people under threat is a reduced ability to creatively problem solve and communicate effectively. We react and often do not really think things through. When this occurs, mistakes can be made. Accidents can happen. People or projects can get hurt. Relationships can be harmed. Our world can suffer by becoming a victim to poor rational thought in cases of fear or media driven anxiety. It is an extra “heaping, helping” of annoying distractions that take us away from self-care, focus on priorities, and creative pursuits that promote productivity and well-being.

Just before 9/11/2001 our news media changed. Do you remember? About 3 months prior to the terrorist attacks on New York, Washington, DC, and Pennsylvania, the television news media upgraded their reporting to include, not just a “talking head” (reporter) giving us the “news” but also text messages flying by on the bottom of the screen, and often a graphic on the left of the “talking head.” Now we have to deal with 3 sources of information simultaneously. This multi-tasking creates added frenetic anxiety in coping with this increased input. Have humans evolved to keep pace with this new use of technology? When we are threatened, we have a response that NEEDS to know what is going on around us so that we can take action and survive any threat. We are often overwhelmed. We have learned to cope by becoming unconscious regarding this media craziness. The media fights to keep our attention. The media has evolved their approach to sensationalize their coverage, to yell at us even louder, with more graphic events that “demand” our attention. Even the weather news whips us with “STORM” coverage that makes weather events major news, even when it occurs hundreds of miles away!

To combat this media blitz on our senses we must do three things. First, we must become aware that we can become victims to sensationalism that may not necessarily be an immediate threat, and filter the news so that we can respond more appropriately. Secondly, as my friend Rodger Ruge suggests, we should consider a media “Fast,” where we reduce and limit the amount of media news that we subject ourselves to. For many of us, turning off the news, especially before bedtime, would be a very good option. The third necessary step is to practice self-care and strengthen our emotional foundations by eating better, avoiding caffeine, getting regular exercise, and practicing daily relaxation.

Awareness of the media frenzy can help protect us and our children from the “overwhelm.” Since the mid 1980’s, we have been deluged by new technologies that force us to react to news and information that is swirling around us. We have experienced: pagers, fax machines, cable TV with 500 channels, Cell phones, text messaging, e-mail, internet information, changes in media coverage of world “disasters,” “robo-calls” at dinner time, and huge expectations that we are plugged in 24/7 and can respond instantaneously even when we are driving our cars…. This is crazy making! Some people can handle this gracefully, in fact, some people can thrive in this environment. But most of us are just victims to our technology and can benefit from setting some limits on the ways that we use, and react to, our technologies… We need to evolve and to create survival strategies that meet our unique, individual requirements.

Please be smart and figure out how to “not become a VICTIM” to the media and our newest technologies!

When we see natural disasters on the TV, we think that we filter the visceral effects on our survival systems, but our unconscious often reacts to the possible threats that are perceive through our visual and auditory senses. When we witness “coverage” of war zones, murders, attacks, rapes, fires, or vehicular accidents, we may believe that this does not affect us at a “conscious level,” but we are still triggering the flight/fight response in some systems at an unconscious level. Have you ever noticed your heart race or your gut tighten when confronted by news or movies? Does your neck, jaw, or back react to accidents or disasters that you witness in person or on TV? Do thoughts of “media images” ever pop into your conscious mind as you try to sleep? We are bombarded by negative media attacks almost everyday.

Do media pundits ever whip you up with their “news coverage” or editorials so that anger or fear seem to rise to the surface of you or your loved ones? This can be emotionally and physically hard on our systems…. Be aware and do not get caught up in the media circus, if at all possible.

Final note. Many people are studying and applying the principles of the “Law of Attraction” believing that goal setting and positive attitudes toward achieving these goals is essential to success. World class competitive athletes have been using these “Sports Psychology” techniques in their training regimen for decades to achieve advantages in mental preparation in their events. When we get caught in the sensationalized, negative reporting by the various media we are sapped of our positive thoughts and energy. We lose our focus on attracting success and positive outcomes. In fact, we can be overwhelmed by negativity. This can strip you of your ability to problem solve in positive and creative ways. Negative thoughts can attract negative outcomes, mistakes, and ill health. Avoiding negativity (and negative thoughts) can be a path to better health and lead to positive outcomes. “Dwell in the Light” and when you feel overwhelmed, consider turning off the negative newscasts and immerse yourself in a book or audio program, or a video that will inspire you with positive; thoughts, actions, and emotions.

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How MTV Got Started and How it Has Influenced Television Today

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For many young adults, they can never imagine life without computers, music video production and reality television. Many of these things got it’s start in the 1970’s or even later. This article will discuss the history of MTV, or the music television channel that has become a staple of cable television for many households with teens or young adults. Today’s youth are much more tuned into various types of media outlets using their computers or phones to see videos on Facebook, vimby preditor, Twitter and YouTube. It all started in 1977 with a small cable TV network that had a show called Sight On Sound in Columbus Ohio.

This show was a new concept as a music channel that featured concerts as well as music oriented TV programs. It was the first two way cable TV program where viewers could call in and vote for their favorite song or artist that was being shown on the program. This cable network also had other programs like a children’s show but the one that really became popular was the music channel. Viewers had never been able to see a concert or see a band interviewed on TV before unless they went to a concert themselves so it was a great new concept. With this increasing popularity, the network changed their format in 1981 to be called MTV-music television.

The original idea of MTV was to model it after the top 40 radio shows, putting on the best pop rock bands at the time. Instead of having a disc jockey like they did on the radio, they hired several young hip hosts to introduce the videos and called them VJ’s as in video jockeys. Some of these original VJ’s on MTV ended up being celebrities in their own right from the enormous amount of exposure that they got from being on MTV at the start.

Because music videos started out as just someone recording the band playing music, many film directors got involved and started creating a much more elaborate concept for the videos. They took a song and made almost a small movie type of clip that told the story of the song. This is how many of these film directors that went on to be quite famous got their first start, making music videos. With the increasing popularity of this channel and the new wave of music videos playing in the early 1980’s, the network created the MTV Music Video Awards in 1984. This was a way for the music industry to showcase some bands in a more hip and alternative way than the Grammy’s offered.

MTV soon started adding other types of shows on the channel like animated cartoons for the adolescent and young adult crowd, and they were the first ones to have a reality show creating the concept of the Real World where they had several young adults live together and have their lives filmed while adjusting to each other and a new city. MTV pioneered many of the popular shows that young adults continue to watch today.

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