Win Big in Baccarat with These Easy Tips

Baccarat is a traditional favorite within the global of on line casino card games. But before you lay down your bets and channel your James Bond sport actions, test out those smooth tips on a way to win this interesting game.

Learn the Game’s Rules by Heart
The maximum important step to win baccarat is to recognize how the sport works. You do not get to hold the playing cards whilst you play this game. Instead, you are to guess on who holds the better baccarat hand among the banker and the participant. Many สูตรเล่นบาคาร่า casinos allow players to play games in Free Play mode. This will help you master baccarat’s rules and average gameplay with out placing real money bets.

Understand the Good and the Bad in Each Bet
There are only three options to bet on when you play baccarat – the Player, Banker, or Tie. Before placing your bet, recognize the blessings and disadvantages of each bet. Ranked from the lowest to maximum residence part, underneath are the bets you may use while gambling baccarat.

Banker Bets
House facet determines the common go back a casino can get out of your bets as you play. A recreation with higher house part incurs a better unit loss for you. This is why having a bet within the banker’s hand is the most secure while playing baccarat. With a low residence fringe of 1.06%, you may get again almost two times your wager whilst you location your guess at the banker’s hand.

Player Bets
The Player bet holds 1.24% in-residence gain. Although this house edge is a touch higher than that of the Banker guess, betting at the Player hand remains a possible option while playing baccarat.

Tie Bets
Tie bets come with a median house fringe of 14%, which is appreciably better than that of Player bets and Banker bets. A Tie wager does no longer come out too frequently, however many punters nevertheless wager on this selection as it gives a huge payout of eight to at least one. Meaning, if you guess US$10, you may upload US$eighty minus the residence part on your bankroll.

Each bet has its professionals and cons. Pick the maximum appropriate wager in step with your preference and bankroll. If you want to assignment into a extra lucrative baccarat sport, opt for high-restriction baccarat. It is in particular designed for excessive rollers as the game allows the bettors to play with higher amounts of bet. If you’re new to this recreation, you can check out tutorials for High-Limit Bacarrat to study smooth pointers that will help you ace the game.

Skip Looking for Baccarat “Patterns”
No patterns will decide the subsequent card to be drawn or which of the hands will preserve the higher cards in Baccarat. Do not positioned your bets in the palms of non-existent styles and just enjoy the game.

Set a Time Limit for Each Game Session
Baccarat is an entertaining sport, but keep in mind to preserve your playtime brief and candy. You have many probabilities to get rewarding prizes or winning streaks but bet most effective inside your way. Take gain of your prevailing upswings, but recognise whilst to stop.

With the assist of those suggestions, you may make the maximum out of your baccarat gaming revel in. Do now not miss out in this interesting game and win big rewards these days.

What Are The Top Challenges Facing The Top Outdoor Clothing Brands?

Outdoor clothing and system manufacturers north face logo have turn out to be increasingly more stylish among the younger era. Walk down any avenue now and you’ll see North Face waterproofs, Rab down jackets, or even Berghaus… Walk into excessive street style chains extra typically related to streetwear like Size and Urban Outfitters and also you’ll see North Face & Patagonia on the cabinets. Clearly, the target audience has grown. It’s not just the uniform of the nearby BBC news reporter reporting from Cumbria in some sideways rain.

Some human beings confer with this group as millennials, that’s a word I simply detest, but it’s miles proper that the ones people born between the mid-80s and mid-90s were raised on a food plan of Red Bull and Monster subsidized excessive sports activities occasions, gap years, web sites like Mpora and Outside Online filling our social feeds with (admittedly, quite epic) content and the GoPro advertising and marketing their present day Hero5 variety with videos like this…

(Full display screen and flip it as much as 4K if you can – you received’t regret it)


You can argue any variety of reasons at the back of the increase in recognition some of the young. Perhaps a rejection of the contemporary, smart cellphone pushed lifestyles (even though it’s incredibly ironic that you’re going to want that very aspect if you need to Instagram your modern-day #VanLife journey), a less inflexible 9-5 work agenda allowing such hobbies, or without a doubt our more linked international allowing us to look a lifestyles that became always there, just less visible? Perhaps it’s sincerely seeing celebrities carrying outdoor tools as a fashion assertion? See Drake underneath sporting each Patagonia and North Face:


drake2https://fashionbombdaily.Com/mens-fashion-flash-drakes-the-motto-video-ideally suited-x-north-face-leopard-nupste-down-jacket/

Either manner, it’s a marketplace that’s presently booming. For instance, in 2013 the daylight hours outdoor undertaking enterprise become worth £21billion to the UK economic system. If you take into account related overnight stays (i.E motels, b&b’s etc.), it jumps to £27billion. If you look throughout the pond there may be over $120bn according to year in sales alone (clothes, system etc.)

Like any retail quarter it will face demanding situations and on this put up I’ll be looking on the top three challenges that I feel they are presently dealing with. It turns out I have one important factor to make and numerous smaller ones.

How do out of doors clothing manufacturers end up & remain relevant to the younger era?
Young humans outdoors
A main problem to the outside garb enterprise (although not completely) is the truth there is a lot competition. I noted in a previous retail blog put up I wrote that opposition and relevance are vital to any logo. The out of doors garb enterprise isn’t any exception and they need so that it will preserve customers sold into their philosophy for when fashion unavoidably actions on. Whilst all people knows the big players consisting of North Face, Berghaus, Rab, Jack Wolfskin and so forth., how do the smaller manufacturers even get a glance in? Well, it may be considered one of two approaches. I’ve already proven you the GoPro video above (feel unfastened to watch it once more… I could) and one of the motives I feel GoPro is so a success isn’t always simply because it makes incredible products, but that it hit the nail squarely on the pinnacle whilst it got here to person generated content material. It become so a success at getting human beings to movie and percentage their adventures and exploits whilst using their cameras that nowadays, movement cameras are frequently noted really as a GoPro. This is despite the fact that the likes of Sony, Garmin, Nikon and Olympus all make possible alternatives.

For manufacturers to remain relevant they’ve to show that their products are relevant to the humans of these days. One way of doing this is to undertake an technique just like those big businesses and encourage consumer generated content. But… it’s going to be difficult to outperform the large boys. You’re not likely to outdo the likes of Red Bull and Go Pro on their content & social media advertising.

There can be a manner though… This article from Outside Online hits the nail on the head:

(Pre-caution: it carries connection with that ‘Millennial’ word again)

In my opinion, it’s not just the price that would be the cause why some of these manufacturers are struggling to attraction and appear applicable. Young clients nowadays frequently have a social moral sense and out of doors clothing and system brands will need to illustrate that they do too. Can brands show that their products are environmentally friendly as an instance?

One example of this in practice comes simply this 12 months, and it’s a large organisation doing it… In short, conventional wetsuits are crafted from neoprene that’s petroleum primarily based, strength intensive to manufacture and is non-renewable (FYI, a number of boards themselves may be simply as terrible for the surroundings) and Patagonia have these days introduced a number of herbal rubber wetsuits. For a sport which normally prides itself on being at least environmentally conscious, this will be a big manner for Patagonia to garner long term emblem loyalty.

Other moral factors also can be taken into consideration; are your merchandise ethically produced? At a corporation-huge stage do you do your quality to minimise your environmental impact? Do some of your profits cross into charitable or network initiatives? These matters will be the way for outside brands to certainly resonate with young those who are so vital to their futures.

It’s now not just the manufacturers even though, what about the outside shops? They can adopt this technique too. If you watched of the main outdoor outlets you probably consider Blacks, Millets (equal enterprise), Cotswold and Go Outdoors and the fact is that we are able to probable go to whichever is closest or has a suggestion on. We experience no loyalty to either. In this industry, really having the best prices, although virtually useful, might not be enough.

The technique of mixing your products and your marketing to attraction without delay on your key demographic is the way ahead.

The Price of Outdoor Equipment
The elephant within the room is that outdoor garb and equipment is effing expensive! I touched on it in my closing point with the article I referenced however if the big outdoor manufacturers (we’re looking at you North Face, Patagonia, Rab) want to get the younger technology on board then in reality there has to be a concerted attempt to introduce more fee powerful ways for people to buy into your imaginative and prescient.

I’m absolutely a believer in ‘you get what you pay for’, and I get that a variety of the outside equipment available should take you to the north pole, however for a generation that has been squeezed by the worldwide recession, rising lease and arguably poorer job potentialities, many can be really priced out.

But (there’s always a but), the danger of this is potentially cheapening and in the end destroying the emblem. Burberry is probably my favourite instance of this, what become as soon as a classic, iconic and high-stop British fashion employer became broadly derided inside the space of a few years.

Changing Marketing for Outdoor Clothing Brands
We cited on the begin of the yr that shops and brands have been going to must exchange how they did matters in 2016 with the intention to live applicable and a success. As we’ve protected, the out of doors industry is no different and I could argue may also actually be less difficult…

The outside is frequently inherently lovely, it’s a manner of life that many aspire to and therefore shouldn’t be hard to marketplace but once I take a look at the advertising and marketing campaigns of those huge businesses we don’t see so much the ‘life-style’ brand that younger human beings want, we see people on an journey. We see people summiting Everest, mountaineering El Capitan and browsing waves larger than my residence. All very brilliant, but only a few resonate.

External Timber Cladding: An Attractive and Green Way of Protecting Your Home

Is it accurate to say that you are searching for a simple to introduce harmless to the ecosystem method of shielding your home from the components? Obviously you are. One alternative is outer wood cladding. By introducing outer wood cladding on your home you can make an appealing outside which will forestall the disintegration and rot that steady openness to climate and contamination. In opposition to vinyl siding which has issues of catching dampness and shape into the dividers and can require a decent arrangement of support, utilizing cladding made of wood empowers security like the ones normally made by trees. The common permeable nature of the wood empowers the house to “inhale” better, diminishing these dangers. Another benefit to lumber cladding is the production of acoustical divider boards. The additional layer among you and the external will help hose any unwanted commotions from the street outside.

natural wood siding

To begin, you can begin on only one wood cladding divider. Picking the material will affect the existence of this siding. On the off chance that you use woods like Douglas Fir, it will last from 10 to 15 years, nonetheless on the off chance that you utilize a wood that is delegated “tough” like red cedar, it should last from 15 to 25 years. Cedar siding additionally can give an appealing look. Preferably, in the event that you are searching for the best harmless to the ecosystem approach, research what kind of wood is locally accessible, and which doesn’t need being transported over significant distances. This will likewise help lessen any future expenses for minor fixes.

Video Poker Slot Machines – Jokers Wild a Perfect Game For Novices

If you are playing video poker slot machines or looking to play them, then consider Jokers Wild – its the perfect introduction for novice players.

Video poker slot machines, unlike standard slot machines allow you to get an edge over the casino by playing correctly, you can therefore increase your chances of winning if you play correctly.

If all the video poker slot machine games Jokers Wild is arguably one of the most fun. Below we will look at the rules and how you can win.

An easy and fun introduction

Jokers Wild is a hot new video poker slot game   okerwho  that is easy, has lots of winning hands, and with the wild Joker (good for any card you wish it to be), you can more often than other video poker slot machine game.

You can play as fast or as slow as you wish, and most machines accept small bets (even $0.01) to $10.

The Rules

Jokers wild on the video slot uses a 53 pack of cards.These are all the normal cards, plus one Joker. If the Joker appears in any hand, it can used as any card you wish it to be.

You begin by making a bet. Then five cards are dealt. Now you can discard as many of the 5 cards as you wish, or keep them all. After your decision on what to keep and what to discard new cards are dealt to replace the discarded ones.

The game at this point is essentially over, it only needs to see if you won or not.

Below is a list of the winning hands, from the lowest to the highest rank.

The Winning Hands (from the lowest ranking to the highest)

Two Pair / Pair of Kings or Aces – This is any 2 cards of the same values

Three of a Kind – This is any 3 cards of the same value.

Straight – This is any 5 consecutive cards, such as J, 10, 9, 8 and 7, but not in the same suit..

Flush – This is any 5 cards of the same suit, in no particular order.

Full House – This is 3 cards of one value, and 2 cards of another value.

Four of a Kind – This is a hand with 4 cards of the same value.

Straight Flush – This is 5 consecutive cards in the same suit, for instance 8, 9, 10, J and Q. Remember the A count as a 1 or after the K.

Joker Royal Flush – This is a royal flush where one of the five cards is the poker

Five of a Kind – This is four same-value cards plus the joker.

The Natural Royal Flush (without the joker) – A, K, Q, J, and 10 of the same suit.

How to Win

Firstly, in any Video poker slot machine game like joker poker, play a machine with the highest payouts i.e. a 7 / 5 machine.

Keep in mind you want to win the royal flush and you only get this by playing max coins so make sure you do.

Now here are some tips below to help you win that are statistically proven to help you win at Jokers Wild.

They are tried and tested rules of what to keep and what to discard, and each depending what in your hand. Follow these tips, and you will see yourself

If you cant memorize them then pre printed cards are available free on the net.

Here they are:

If you find a joker in your hand then keep all cards that are three-of-a-kind or higher, except hold four cards to the royal flush.

Keep any 4 card straight flush and a 4-card flush if it includes K, A or both.

Keep 3 cards to a royal flush

Keep any paying pair of high cards (K , A).

Keep any 3 cards to a straight flush.

Keep any 4-card flush without K or A.

If none of the above applies, keep the Joker only.

If there is no Joker in your hand, then,

Keep all paying hands, except hold a 4-card royal flush.

Keep any 4 cards to a straight flush and any 3 cards to a royal flush.

Keep 4 cards to any flush.

Keep any pair of 2’s to Queens.

Keep any 3 cards to a straight flush.

Keep any 4-card consecutive straight.

Keep 2 cards to a royal flush if one of the cards is a A or K.

Keep unsuited K and A.

Keep K or A alone.

Keep 2 suited royal flush cards lower than K or A.

If you have no joker and no potential cards, its better to ask for 5 new ones. The odds are much better than keeping even one card – if you have junk throw the cards away.

An involving gaming experience fun and great odds

Video poker bridges the gap between games of pure chance such as other online slots and games of skill such as blackjack. Add in the fact that the graphics are normally fantastic and you have an involving slot game, that is great fun and good odds of success – if you play the right way.

Jokers Wild is a great intro to online video poker games but if you enjoy this one try Jacks or Better or Deuces Wild as well.

If you have never played video poker before you will find it great fun and with good odds of winning as well, its no wonder video poker slot machines such as Jokers Wild are so popular.

What is the Role of Dropship Suppliers and SaleHoo in Your Online Business?

If you are into wholesale business, it is highly important that you are dealing with individuals that are greatly competitive and reliable. When you say “partners” in a wholesale business concept, it represents either dropshipping company or wholesale lists. However, these    Dropshipping Supplier UK two can be combined together to have extremely effective online business. So, how do these two factors works and what they can do for your business?

Let’s start with wholesale dropshipping company. Dropshipping Company that is also known as dropshippers or dropship suppliers are the people or group of individuals that provide online sellers a certain product niche at wholesale price. They are also responsible for shouldering the task of packaging and distributing of purchased items. Until the products have been purchased by clients, they will keep the product and take care of the inventory. Where are your probable profits? Deduct the retail price from wholesale price. The result is your profit margin. With the role played by dropship supplier, it clearly show how significant having reliable partner is.

It is now SaleHoo’s turn. SaleHoo is an innovative web tool wherein listings of dropship supplier and products are listed. If you are looking for updated and complete information about wholesale business, SaleHoo can provide you. You just have to be a member in order to access their updated database. Moreover, since they are very strict in accepting membership (only those high quality and legitimate dropship supplier and seller are accepted), the risk of encountering fraudsters is decreased. SaleHoo is regularly performing necessary background check to their member to guarantee that illegitimate dropship suppliers are eliminated.

So, when you engage yourself into dropshipping business, it’s up to you whether to utilize these factors or not. But remember, it is your business that is at stake therefore you should do your best and try all possibilities to be successful. Good luck!

Managed Service Providers and Virtualization

I’ll begin this article by creating a fake company, BadDesign Inc. This company has 85 users and currently run 8 servers. The mix includes Microsoft OS, Mac OS X and some Unix boxes. Altogether there are six servers running in a poorly ventilated room. The small owner of BadDesign is from the old school of networking and has no interest in Managed Services. He once heard about it and sarcastically replied “and I own the Brooklyn Bridge!” Mr. Russell believes in the break/fix model. “Why must I pay for something that works all month? he asks with a feral growl. “I’ll pay if it’s broken”. What Mr. Russell ignores is the amount of downtime whenever that happens. Plus, most of the time he can’t locate the Mac guy. “I should have never used that silicon brain!” And “the Unix guy acts like he’s the President”. “I’m going crazy with these computer guys, it’s like they own my company!” Unfortunately this scenario is played out everyday, somewhere in the world.

My question is, how do you possibly sell Mr. Russell on virtualization? Do you educate him on the benefits of managed services first and then gradually introduce virtualization? The MSP has an undaunting task of converting the small business owner to paying for what is really intangibles. Education to me is the key to success. In my Security + classes one of the major tenets of network security is executive buy-in. The average SMB owner cannot be approached with technologies, he has to be placed in his comfort zone, profitability. Deposit a little, withdraw a lot.

Virtualization is the MSPs golden child. Knowledge of the technology will go a long way in winning over the client. The very first thing that needs to be addressed is the misconception that virtualization is new. Technologies that closely resemble virtualization was common in the 60s an 70s. I could picture Mr. Russel smiling and stressing “I knew it, all these new things and we go right back to the correct way!”. When processing power increased it became less expensive to move to PC servers as  Cyber Security Strategy opposed to mainframe computing. Today’s network are victims of computer sprawl, some enterprise networks have hundreds of servers. The cost of housing, powering, cooling and maintaining these devices keep rising and rising. Virtualization gives the client the ability to run multiple servers and apps on one physical box. Due to the fact that there is a decrease in physical devices management becomes easier. The large developers have thrown money behind virtualization. Citrix buying ZenSource ($500m), Sun buying Innotek, Microsoft buying Softricity and Kidaro and VMWare. It is reported that VMWare has the majority of the market with their VMWare ESX Server. With Windows Server 2008, Microsoft is offering a new Windows Server Virtualization option. Windows 2008 Hyper-V allows you to run multiple servers inside one physical box resulting in more efficient use of hardware and administrative services. One major requirement is an x64 based processor.

I believe that if the MSP at first educates him/herself on the basic workings of virtualization it will require very little convincing. Just the demonstration of having multiple operating systems functioning independently on one physical machine is a great sales pitch. What is outstanding is that you can actually remove the physical server and yet have the same service. Mr. Russell can be converted. Like Miss Lanowitz, I totally agree that virtualization is the technology of the 21st century. Maybe by the next 25 years we will see virtualized community servers running movies, radio stations, complete classrooms, the potential is limitless.

Mechanical gaming machines and their coin acceptors were a portion of the time defenseless

Mechanical gaming machines and their coin acceptors were a portion of the time defenseless against misleading devices and various stunts. One legitimate model included turning a coin with a short length of plastic wire. The ทดลองรวยกับการเล่นเกมสล็อต weight and size of the coin would be recognized by the machine and credits would be yielded. In any case, the curve made by the plastic wire would make the coin exit through the crackpot chute into the payout plate.

This particular stunt has gotten old due to overhauls in additional cutting-edge betting machines. Another obsolete method for beating gaming machines was to use a light source to overwhelm the optical sensor used to count coins during payout.

Present day betting machines are compelled by EPROM CPUs and, in huge club, coin acceptors have escaped date for charge acceptors. These machines and their bill acceptors are arranged with forefront against cheating and threatening to distorting measures and are difficult to cheat. Early automated gaming machines were now and again hoodwinked utilizing deceiving contraptions, for instance, the “slider”, “monkey paw”, “lightwand” and “the tongue”.

Countless these old deceiving devices were made by the late Tommy Glenn Carmichael, a betting machine fraudster who probably took more than $5 million.[30] In the current day, electronic gaming machines are totally deterministic and as such outcomes can be now and again adequately expected.

For example, discover the stowaway in a school building contrasts from a comparative game in an entertainment place; an auto race can be significantly special depending upon the track or street course, even with comparative vehicles.

How Essay Writing Can Benefit Your Intellectual Development

To write method to put mind on paper. It makes all people writers, even if we do now not professionally do this. Bloggers write my essay are not exaggerating once they talk approximately the blessings of being capable of materialize their thoughts on paper. Many successful writers confirm it.

The question is: must writing an essay to be a addiction of people who are not skilled writers? In reality, this career can be important for lots of us.

There is a massive amount of literature describing the blessings of expressing your thoughts and emotions in the shape of an essay. The experts of custom essay writing carrier additionally proportion their reviews and reflections.

The method of the writing of the essay, structures your wondering. Thoughts, sensations, emotions flash in us spontaneously and once in a while slowly for us, but thanks to writing we crystallize these mind and construct them in a logical collection.

Writing an essay improves your skill with the phrase, syllable, fashion, that is so important for ordinary existence.

Writing for an target audience (even if it consists of one person) helps you suspect from their point of view. And then the magic starts offevolved, because in case you once stuck the “wave” of the reader, then you definately begin to understand the people round you, colleagues and friends higher. You increase an knowledge of the world and those.

The ability of writing a convincing essay teaches you to steer different people’s questioning. If you attack the factor of view of someone – he is even more entrenched, but in writing it’s miles rarely contested. You can convince the rationality in their judgments, and then they may observe your opinion.

Everyday writing an essay makes you look for new thoughts (you don’t plan to write about the same issue usually?). And this pushes you to 1 important query: “Where do you get these ideas?” Ideas are everywhere! In humans with whom you communicate, at the Internet, newspapers, magazines, movies, music, books. When you begin writing the essay regularly, your eyes end up open to them.

If you post essays at the Internet, then quickly you will have an target market interested in what you need to percentage with them. It helps in business, in profession increase, and brings new friends.

Whatever you write your essay, you gradually enhance your fashion. Let not right away, however there are new techniques, a metaphor or comparison is born.

At a few point, you unexpectedly find intonation – sincere and honest, and it’s far yours. And in case you write for a long time, you can even see some of them, growth your variety. It is invaluable for the author, because it’s miles by means of his voice that they apprehend him, all of sudden grabbing a paragraph of text from a person else’s e-book within the subway. It is the voice that fascinates us in poetry and from time to time settles in our head for the complete day, irrespective of what we do.

When you write, you’re on the intersection of spheres: written and private speech. Inner speech is the manner you communicate to yourself, adjusting your feelings and will, evaluating actions. Before being spoken, the word is born internal you – inside the inner speech. The greater advanced the emotional expression of someone, the higher his psychological culture. Writing essays provides you with an invaluable provider – it develops your internal speech.

The potential to jot down an essay is the method of mirrored image, upkeep, and self-expression of innovative properties in tone. Writing texts, consisting of an essay, as a shape of self-expression has a selected therapeutic impact. The statement of mind in writing facilitates to enhance temper, nicely-being and increase pressure resistance, in case you do it systematically.

Writing essay enables to preserve intellectual performance. The composition is gymnastics for the thoughts, respectively, in addition to bodily exertion, and it’s going to assist you maintain yourself in excellent form at any age.

Based on the textual content of the thing, it’s miles possible to securely say that writing an essay is of fantastic importance for the psycho-emotional state and the highbrow development of someone.

If you have got already decided to begin writing an essay for yourself, first we will come up with a few tips. Find records on your selected essay topic. Study it, seeking to spend on studying as little time as viable and focusing on the maximum crucial points. Briefly nation the essence, cautiously pick the words.

Professional Development Training

Professional development training refers to the development of skills related to a person’s current occupation. It is very useful for beginners and professionals. It helps staff to become diligent and assiduous in their work. There are many companies that help organizations to build outstanding relationships and a sound culture, through leadership style training, management skill and team building seminars. They provide leadership training for managers and training in specific techniques or equipment for technicians, metal workers, medical practitioners and engineers.

There are various professional  Director of staff development job development centers that provide efficient training to fresh graduates and professionals. Professional development training coursers provide efficient training and resources, essential to integrate the potential of beginners and working staff. There are conferences, exhibitions, workshops, web seminars and video presentations that help in the training program. The managerial students learn organizational development by training in leadership and management skills.

There are professional development training staff, who are trained specialists dedicated to meeting the current and future technical education and training of the staff. They provide traditional training programs and are committed to implement and effective use of teaching strategies, in conjunction with conventional methods. This helps to improve the quality of the training and educational services.

There are distance- learning professional training courses offered online.

The courses are designed to train people for a new career, progress within their current company and learn new skills, to stay competitive in the ever-changing job market. Students are offered staffed educational support and a student services department that provides solutions to their queries.

Some of the training programs also offer a career assistance center director, who personally offers advice on resumes, cover letter preparation, networking, interviewing skills. They are an important resource for professionals and people who wish to improve and become efficient and productive and enhance their vocation.

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   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 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    the manner in which the communication takes place.  , 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  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  & 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.     Depot or 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  of regional and state health information exchanges.

History of Health Information Exchanges

Major urban  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  systems already in place. Health Level  system in the United States, beginning with a meeting at the University of Pennsylvania in 1987.  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  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 sets the standards that foster this delivery of communication between health networks.   is now on it’s third version which was published in 2004. The goals of   are to increase interoperability, develop coherent standards, educate the industry on s 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.  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  Health Data) began their efforts in 2004.

In Tennessee Regional Health Information  initiated in Memphis and the  Cities region.  a 501(3)c, in the  Cities region was considered a direct project where clinicians interact directly with each other using compliant system as an intermediary to translate the data bi- Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the   Alliance is a  connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems,   Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical  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.   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 , 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   Inc, Raphael Health   and Shalom Health Care  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.  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  . This experience will serve him well as he encounters societal and demographic challenges for and chronically ill patients throughout the southeast area.