International Business Assignment Example | Topics and Well Written Essays - 500 words - 2

International Business - Assignment Example The strategy that keeps IKEA to its position is through refreshing and renewing their service model. IKEA has a unique approach to deal with its customers as it employs a self-serving method. Customers make choices on the product, picks them from the shelves and assembles them at their at home on their own. Self-service is a rare approach in the furniture businesses, but the customers choose to apply the approach due the low prices offered. IKEA is a corporation often described as the prototypical Teflon multinational. Some describes the company as quintessential global cult brand which has a democratic culture. For instance, at a company dinner employees take dinner first, followed by the managers, directors and lastly Ingvar Kamprad. Kamprad emphasized on a matrix form of organization which is an informal, nonhierarchical and team-based organization. This kind of an organization has an open flow of information and knowledge within all stages of management. The current organizational structure can be described as highly functional, with an international market strategy. Therefore, IKEA maintains a centralized control over functional activities as well as taking advantage of low cost and good quality furniture from the international suppliers. In addition, control over strategic direction has been developed, and functional layoffs are minimized. To ensure the effectiveness of the logistics process, IKEA has integrated distribution and purchasing process under one umbrella function. The significance of centralized strategic direction will rise as IKEA continue to expand overseas (Capell, 2005). IKEA has found its strength in providing highly functional and quality products at a low price. Moreover, the company has been able to establish a market brand name and a goodwill that is essentially instrumental to the performance of the organization. On top of that, the company has an efficient value

Drew Sterling to replace Josh Newly In upcoming concerts Essay Example for Free

Drew Sterling to replace Josh Newly In upcoming concerts Essay The City Symphony will be showcasing the upcoming talents of Drew Sterling in the next two concerts. Mr. Sterling replaces the internationally renowned singer, Josh Newly. While Mr. Newly’s talents have been greatly appreciated in past concerts, the City Symphony has decided to utilize this opportunity to allow Drew Sterling to shine in both concerts as the baritone soloist. Mr. Newly has graced many orchestras around-the-world with his genuine gift as a soloist. Consequently, his talents are both known and respected internationally. Thus, it is understandable that Josh Newly is a very popular artist who is able to sell out concerts. Sadly, Mr. Newly will not be able to perform at this year’s concerts due to prior engagements. The City Symphony wishes that the media respects its desires to not discuss this topic. If Mr. Newly desires to address the media concerning this matter, then he will do so in his own time. On another note, we are happy to announce Mr. Drew Sterling as the baritone soloist. We feel that Mr. Sterling has earned the opportunity to shine in the spotlight. The City Symphony further believes that Mr. Sterling is a fresh and upcoming talent that will have fans on the edge of their seats. In addition, Mr. Sterling is a professional who has given the City Symphony the privilege of showcasing his talent in the next two concerts. Thus, Mr. Sterling will be available for questions and answers (QA) on Friday morning. We are hoping that you can feature this Press Release in your afternoon column as it requires the most urgent attention.

World War II Essay -- World War II, World War Two

World War II was one of the most deadly wars we know in history, having as many as sixty million casualties, most of whom were civilians. It impacted a lot of countries, almost all the world, which is why the name is given. This war impacted many countries in the world, and damaged almost all of the countries involved greatly. It also led to the downfall of Western European countries as world powers, leaving it to the Soviet Union, and the United States. The war started in 1939 and ended in 1945, with the invasion of Poland and the Axis surrender, respectively. It changed the economy and the growth of big countries, including Germany, Great Britain, United States, Japan, Russia and France. Aside from this, Jews were greatly influenced too. They were damaged, but then gifted. The war started in September 1, 1939 when Germany invaded the territory of Poland, which was allied with Great Britain and France. German officials signed a peace treaty in August 24-25 with the Soviet Union to prevent them from acting in the invasion and to stay in peace between both countries. So Great Britain, France, Australia and New Zealand declared war on Germany the day of September 3, 1939. After this event, Canada also declared war on Germany at September 10, 1939. Germany rapidly crushed Poland, since it had an incredible army with 100 infantry divisions and six armored divisions. Due to the peace treaty between Germans and Soviets, in September 17th the Soviet also invaded and took eastern Poland. Later in the year, on November 30th, the USSR invaded Finland while Great Britain and France where occupied with Germany. At this time, Japan was in the Far East, and had Asia in turmoil. Imperial Japan invaded china and various other territories ... ...ther atomic bomb, leaving Japan helpless. Japan surrendered in several places from September 7th to September 16th. Works Cited O’Neill, William L. World War II A Student Companion. 1 ed. William H. Chafe. New York, New York: Oxford University Press, 1999. Britannica Online, Encyclopedia. "3." http://www.school.eb.com.proxygsu-scob.galileo.usg.edu/eb/article-53533 (accessed March, 2011). Stokes, Phil. "1." 1999. http://www.secondworldwar.co.uk/dates.html (accessed March, 2011). Stokesbury, James L. http://www.worldbookonline.com/student/article?id=ar610460&st=world+war (accessed march, 2011). Robinson, Bruce. April 23, 2004.http://www.bbc.co.uk/history/worldwars/wwtwo/ww2_summary_01.shtml (accessed march 30, 2011). worldwar-2.net, "War in Europe." 2006.http://www.worldwar-2.net/timelines/war-in-europe/war-in-europe-index.htm (accessed march, 2011).

Commercial company Essay

Select a major industrial or commercial company based in the United States and listed on one of the major stock exchanges in the United States. Each student should select a different company. Avoid selecting an insurance company or a bank, because the financial ratios for these financial businesses are different. Write a seven-to-eight-page double-spaced paper answering and demonstrating with calculations and financial data the following questions. 1. What is the name of the company? What is the industry sector? Starbucks Corporation is in the Food and Beverage industry 2. What are the operating risks of the company? Economic conditions in the US and certain international markets could adversely affect Starbucks’ business and financial results. – as a retailer Starbucks is dependent upon the customer’s discretionary spending. Customers may have less money for discretionary purchases as a result of job losses, foreclosures, bankruptcies, increased fuel and energy costs, higher interest rates and taxes. Decreases in customer traffic will negatively impact financial performance. Starbucks may not be successful in implementing important strategic initiatives or effectively managing growth, which may have an adverse impact on our business and financial results. – there is no assurance that Starbucks will be able to implement strategic initiatives and achieve the results that are within management’s expectations. These initiatives are designed to create growth, improve operations and drive long-term shareholder value. Starbucks face intense competition in each of our channels and markets, which could lead to reduced profitability. Starbucks is highly dependent on the financial performance of the America’s operating segment – the Americas operating segment contributes 74% of the total net revenues in fiscal 2013. Starbucks is relying on the success in the European/ Middle East, China/Asia Pacific operating segments to achieve overall growth targets. Other international operations are also subject to additional inherent risk when conducting business abroad. Of which, include: Forex rate fluctuations. Changes or uncertainties in economic, legal, regulatory, social and political conditions in international markets. Restrictive actions of foreign or US governments affecting trade. Enforceability of intellectual and contract rights. Local laws Disruption in energy supplies. Delays in store opening beyond the control of management. Increases in the cost of high-quality Arabica coffee beans or other commodities. Disruption in the supply chain, which will impact the ability to deliver Starbucks’ products. The loss if key personnel or difficulties in recruiting and retaining qualified personnel Adverse public or medical opinions about the health effects of consuming Starbucks’s products, as well as reports of incidents involving food-borne illnesses, food tampering or food contamination. Starbucks relies heavily on information technology in operations, and any material failure, inadequacy, interruption or security failure of that technology could harm Starbucks’ ability to effectively operate the business. Failure to comply with local laws and regulations. 3. What is the financial risk of the company (the debt to total capitalization ratio)? Market Cap: 56.69 BN Debt: 2.05BN Debt/total cap ratio = 0.036 (yahoo.com, 2014) 4. Does the company have any preferred stock? The company does not have preferred stock. 5. What is the capital structure of the company: short-term portion of long-term debt, long-term debt, preferred stock (if any), and market value of common stock issued and outstanding? short-term portion of long-term debt 357.7 Million Long-term debt 1,299 Million Preferred Stock 0 Market value of common stock 56.69 Billion 6. What is the company’s current actual beta? 0.95 7. What would the beta of this company be if it had no long-term debt in its capital structure? Unlevered Beta using Hamada equation = Beta /[1+(1-T) x (D/E)] Beta : 0.95 Marginal Tax Rate, T: 32.8% D/E: 0.036 Unlevered Beta = 0.96 / [1+(1 -0.328)*0.036] =0.937 8. What is the company’s current marginal tax rate? Income taxes for the fiscal year ended 2012 resulted in an effective tax rate of 32.8% compared to 31.1% for fiscal year 2011. (Starbucks Coffee Company, 2013) 9. What is the price earnings multiple of the company? Price to earnings ration. This ratio is used in conjunction with other metrics to give analyst and investors are quick initial impression of whether a company would make a good investment. (investopedia, 2014) Starbucks P/E ratio is 385.05 10. How has the company’s stock been performing in the last 5 years? Starbucks share price 282.32% in the last 5 yrs. 11. Would you invest in this company? Why or why not? I would invest in Starbucks. SBUX has the highest P/E ratio among its competitors. Their cost of debt is low compared to their cost of equity. That is why they are relying on debt for their expansion. Their dividends per share have been increasing yearly. 18. The last page of your paper should be a Bibliography of the sources you used to prepare this paper. Bibliography investopedia. (2011, feb). Cost of Equity. (investopedia) Retrieved septmeber 2014, from Investopedia: www.investopedia.com/terms/c/costofeqquity.asp investopedia. (2014). Definition of â€Å"Prince Multiple’. Retrieved from www.investopedia.com: www.investopedia.com/terms/p/princemultiles.asp Starbucks Coffee Company. (2013). Fiscal 2013 Annual Report. Investor Relations. Seattle: Starbucks Coffee Company. yahoo.com. (2014, september). Yahoo Finance. (Yahoo.com, Producer) Retrieved september 2014, from Yahoo finance: finance.yahoo.com/q/ks?s=SBUX+Key+Statistics

“North and South” depends on contrasts for its momentum Essay

Gaskell is a very capable writer; she uses many skills to create atmosphere, tension and emotion in her book. However, to create the energy in her stories that makes her stand out as a writer, she uses contrast in many different forms The locations in the story contrast with each other, reflecting different stages in life of Margaret. In London, where she first starts off, it is polite, reserved and superficial. Her life there is complacently indolent. When she moves back to Helstone, we see it is still very leisurely and languid, but there is a solid and healthy feel to it. She then goes to Milton, which is in complete contrast. Here it is a very functional town; everyone is preoccupied and determined. There is more a feeling of energy about the people, it is a centre for new ideas, but it is also very dirty, smoggy and cold compared to the green of Helstone. In chapter 8 we see a clear contrast in Edith’s letter from Corfu, describing a hot, clean atmosphere of idleness and happiness compared to Margaret’s depressed north. Social values are another important factor in the story that gives it momentum Views on Religion help to distinguish the characters. Bessy believes very strongly in God while Mr. Higgins does not. This is mirrored in Margaret’s different attitudes to her father about questioning the church. There is also the importance of the employer and employee relationship. Margaret disagrees with the strong feeling of a parent and child relationship that exists between the masters and men, that often creates tension. There are differences not only between those that are rich and those that are not, but also gain and use of that wealth. There is an obvious contrast between Bessy, Margaret and Fanny. They are all the same age but live completely different lives according to their wealth. Bessy is poor and suffers greatly from the poverty. Margaret is comfortable while Fanny benefits from her brother’s wealth and like Edith enjoys an idle lifestyle. The Mr. Hales position is not as respected in the North as it is in the south, as reflected in the family’s trouble in getting a servant. There is also a difference in their route to wealth, Mr. Thornton’s is by being dynamic, working hard and seizing opportunities, while Mr. Hale’s was by doing dull, tedious work for many years. But it is their attitudes to wealth that are so different. The south prefer simple decoration, they have a secure knowledge of their wealth, while in the north, their need to heavily ornate and decorate themselves and surroundings is emphasised, showing a clear insecurity, and need to â€Å"show off†. This is best summed up at the dinner party, where Margaret shows distaste at the gross amount of food laid out before her, which is particularly shown up against her previous visit to Bessy’s house. The characters have to be both the easiest and strongest way of showing contrasts, and creating energy. The first contrast we see is at the beginning of chapter 1, where the differences between Edith and Margaret are made clear. Edith is superficial; she acts childishly, showing off her husband. Margaret on the other hand is full of intense reactions, nostalgia and basic sincerity. The next clear difference we see is of that between Margaret and her parents. Unlike both her parents, Margaret is strong and independent. Her father even has to rely on her to break news of the move to her mother. However, the best example of contrast is the first meeting of Margaret and Mr. Thornton. Here we see a strong sense of masculinity and femininity, the sexual tension is strong, and adds an electrifying air to the confrontation. Mr. Thornton’s masculinity is also contrasted with that of Margaret’s only other suitor, Mr. Lennox, who like her father is very feminine. Then there are the contrasts between and in the families. Mr. Thornton and Mrs. Thornton are both very strong characters, bullish almost, compared to the personality of Fanny, who is similar to Edith. However, Mrs. Thornton is more perceptive than her son, and sees that he has fallen in love with Margaret, even though Mr. Thornton cannot admit it to himself or anyone else. The two mothers are in deep contrast to each other. They are the personifications of the feeling of north and south. The north being strong and uncompromising, while the south is soft and snobbish. Another contrast that is picked out in the book is between the two males. One is described as soft, weak and tired even â€Å"almost feminine† the other is distinctly masculine, hardened, defined, astute and energetic. The final contrast in characters is between Bessy and Margaret. This is a clear contrast, as they are both girls, and are both the same age. They differ in wealth and attitudes and it is a clear indication of what is considered important when discussing what Margaret is going to wear to the dinner party. Interestingly, there is a feeling of contrast that, while Mr. Thornton is not academically learned, which Margaret is, he is much more socially and emotionally developed than her, while she is tormented by the sights of Bessy in her state. The first important example of contrasting dialogue is in chapter 9, between the Hales. Here, it helps to clearly show the different positions of each character. Mr. Hale is anxious, Mrs. Hale is querulous and Margaret is overworked. There is also a contrast between the Hales argument at the beginning of this chapter and the Thorntons, at the end, to emphasise how different they are. Other contrasts in dialogue include the way in which Mr. Thornton and then Mrs. Thornton talk to Margaret in chapter 15, and then in Margaret’s talk with Bessy where the contrasts between North and South are highlighted. Finally, another clear contrast is the discussion between Mr. Thornton and Margaret at the dinner party over the meaning of the word â€Å"gentleman†. Here, Gaskell skilfully uses the dialogue to create a sense of sexual tension between them. One major point in how the structure of the novel helps to create a contrast is in the titles. Significant titles like â€Å"haste to the wedding† are followed â€Å"roses and thorns† a juxtaposition of two images that heighten the point that Gaskell is trying to put across. The other is in Mr. Lennox proposing. Here we see a sudden crisis that Margaret faces which is mirrored by a deeply poignant crisis of having to move from Helstone. Similarities help to stress the contrasts in the novel. The easiest similarity is between Margaret and Mr. Thornton, most importantly in their pride. Another is the illness shared by the Higginses and the Hales. This can almost be seen as a reflection of social illnesses within the society. All these contrasts help to move the story along and create energy, particularly among the characters. One clear example of how Gaskell uses contrasts is in Mr. Thornton and Margaret’s first meeting where the sexual tension helps to create a strong atmosphere and well-written piece.

The Odyssey Study Guide

The Odyssey Study Guide The Odyssey is an epic poem attributed to the ancient Greek poet Homer. Most likely composed in the late 8th century B.C.E., it is the second-oldest-known work in Western literature. (The oldest-known work is Homers Iliad, for which The Odyssey is considered a sequel.) The Odyssey first appeared in English in the 17th century and has been translated more than sixty times. Many of the words and phrases employed by Homer are open to a wide range of interpretation, causing not-insignificant differences between translations. Fast Facts: The Odyssey Title: The OdysseyAuthor: HomerDate Published: Composed during the 8th century B.C.E.Type of Work: PoemGenre: Epic Original Language: Ancient GreekThemes: Spiritual growth, cunning vs. strength, order vs. disorderMajor Characters: Odysseus, Penelope, Telemachus, Athena, Zeus, Poseidon, CalypsoNotable Adaptations: Ulysses by Lord Tennyson (1833), Ithaka by C.P. Cavafy (1911), Ulysses by James Joyce (1922) Plot Summary At the start of The Odyssey, the author addresses the Muse, asking her to tell him about Odysseus, the hero who spent more time traveling back to his Greek home than any other Greek hero at the Trojan War. Odysseus has been kept captive by the goddess Calypso. The other gods, except Poseidon (god of the sea) fell sympathy for Odysseus. Poseidon hates him because he blinded his son, Polyphemus. The goddess Athena, Odysseus’ protector, convinces her father, Zeus, that Odysseus needs assistance. She disguises herself and travels to Greece to meet with Odysseus’ son, Telemachus. Telemachus is unhappy because his home is beset by suitors who want to marry his mother, Penelope, and take over Odysseus throne. With Athenas help, Telemachus sets out to search for his father. He visits other veterans of the Trojan War, and one of his father’s old comrades, Menelaus, tells him that Odysseus is being held by Calypso. Meanwhile, Calypso finally releases Odysseus. Odysseus sets out on a boat, but the vessel is soon destroyed by Poseidon, who harbors a grudge against Odysseus. Odysseus swims to a nearby island where he is warmly greeted by King Alcinous and Queen Arete of the Phaeacians. There, Odysseus recounts the story of his journey. Odysseus explains that he and his companions left Troy on twelve ships. They visited the island of the lotus-eaters and were captured by the cyclops Polyphemus, son of Poseidon. When making an escape, Odysseus blinded Polyphemus, inspiring Poseidons wrath as a result. Next, the men nearly made it home, but were blown off course. They first encountered a cannibal, and then the witch Circe, who turned half of Odysseus men into pigs but spared Odysseus thanks to the protection provided to him by the sympathetic gods. After one year, Odysseus and his men left Circe and reached the edge of the world, where Odysseus summoned spirits for advice and learned of the suitors living in his home. Odysseus and his men made their way past more threats, including the Sirens, a many-headed sea monster, and an enormous whirlpool. Hungry, they ignored warnings and hunted the sacred cattle of the god Helios; as a result, they were punished with yet another shipwreck, stranding Odysseus on Calypsoâ€℠¢s island. After Odysseus tells his story, the Phaeacians help Odysseus disguise himself and travel home at last. Upon returning to Ithaca, Odysseus meets his son Telemachus, and the two men agree that the suitors must be killed. Odysseus wife Penelope arranges for an archery competition, which she has rigged to guarantee Odysseus win. After winning the competition, Odysseus slaughters the suitors and reveals his true identity, which Penelope accepts after putting him through one final trial. Finally, Athena saves Odysseus from the vengeance of the dead suitors families. Major Characters Odysseus. Odysseus, a Greek warrior, is the protagonist of the poem. His journey home to Ithaca after the Trojan War is the primary narrative of the poem. He is a somewhat non-traditional hero, as he is known more for his cleverness and cunning than his physical strength. Telemachus. Telemachus, the son of Odysseus, was an infant when his father left Ithaca. In the poem, Telemachus goes on a quest to figure out his fathers whereabouts. He ultimately reunites with his father and helps him kill Penelopes suitors. Penelope. Penelope is the loyal wife of Odysseus and mother of Telemachus. Her cleverness equals that of her husband. During Odysseus 20-year absence, she devises numerous tricks to stave off the suitors who seek to marry her and gain power over Ithaca. Poseidon. Poseidon is the god of the sea. He is angry with Odysseus for blinding his son, the cyclops Polyphemus, and makes various attempts to hinder Odysseus journey home. He can be considered Odysseus primary antagonist. Athena. Athena is the goddess of cunning and intelligent warfare, as well as the crafts (e.g. weaving). She favors Odysseus and his family, and she actively helps Telemachus and advises Penelope. Literary Style As an epic poem written in the 8th century B.C.E., The Odyssey was almost certainly intended to be spoken, not read. It was composed in an ancient form of Greek known as Homeric Greek, a poetic dialect specific to poetic compositions. The poem is composed in dactylic hexameter (sometimes referred to as epic meter). The Odyssey begins in media res, starting off in the middle of the action and providing expository details later. The non-linear plot leaps back and forth in time. The poem employs flashbacks and poems-within-a-poem to fill in these gaps. Another key feature of the poems style is the use of epithets: fixed phrases and adjectives that are often repeated when a characters name is mentioned- e.g. bright-eyed Athena. These epithets serve to remind the reader about the characters most important essential traits. The poem is also notable for its sexual politics in that the plot is driven as much by the decisions made by women as it is by male warriors. In fact, many of the men in the story, like Odysseus and his son Telemachus, are passive and frustrated through much of the story. By contrast, Penelope and Athena take numerous active steps to protect Ithaca and assist Odysseus and his family. About the Author There is some disagreement about Homer’s authorship of The Odysseyï » ¿. Most ancient accounts refer to Homer as a blind poet from Ionia, but todays scholars believe more than one poet worked on what we know today as The Odyssey. Indeed, there is evidence that the final section of the poem was added much later than the previous books. Today, most scholars accept that The Odyssey is the product of several sources that were worked on by several different contributors. Sources â€Å"The Odyssey - Homer - Ancient Greece - Classical Literature.† Oedipus the King - Sophocles - Ancient Greece - Classical Literature, www.ancient-literature.com/greece_homer_odyssey.html.Mason, Wyatt. â€Å"The First Woman to Translate the Odyssey Into English.† The New York Times, The New York Times, 2 Nov. 2017, www.nytimes.com/2017/11/02/magazine/the-first-woman-to-translate-the-odyssey-into-english.html.Athens, AFP in. â€Å"Ancient Find May Be Earliest Extract of Epic Homer Poem Odyssey.† The Guardian, Guardian News and Media, 10 July 2018, www.theguardian.com/books/2018/jul/10/earliest-extract-of-homers-epic-poem-odyssey-unearthed.Mackie, Chris. â€Å"Guide to the Classics: Homers Odyssey.† The Conversation, The Conversation, 15 July 2018, theconversation.com/guide-to-the-classics-homers-odyssey-82911.â€Å"Odyssey.† Wikipedia, Wikimedia Foundation, 13 July 2018, en.wikipedia.org/wiki/Odyssey#Structure.

Public Health Information Systems Essay Example

Public Health Information Systems Essay Example Public Health Information Systems Paper Public Health Information Systems Paper Executive Summary The development of this White Paper has been facilitated by the Public Health Data Standards Consortium (PHDSC) 1 and the Integrating the Healthcare Enterprise (IHE). 2 The White Paper was developed by the participants of the PHDSC-IHE Task Force. The information in this document represents the views of the individual Task Force participants and may not represent the views of their organizations. The overall goal of this effort is to facilitate standardization of health information exchanges between clinical care and public health. The objective is to engage the public health community in a dialogue with health information technology (HIT) vendors to assure that the work processes and data needs of public health stakeholders in health information exchanges are 1) well understood and agreed upon by stakeholders themselves, and then (2) communicated clearly to the developers of the interoperable clinical Electronic Health Record (EHR) systems and Public Health information systems (EHR-PH Systems). The White Paper consists of three sections. The first section describes public health and population health practices of public health agencies that require health information exchanges with clinical care. The second and third sections describe Immunization and Cancer Surveillance domains in the IHE Technical Tasks for Information Exchanges outline. The Appendix section contains the description of examples of other public health domains (research, chronic care, personal health record, surveys, obesity, cancer, etc. ). The PHDSC-IHE Task Force participants believe that this effort will result in the formation of a Public Health Domain at IHE to begin collaboration between public health and HIT vendor communities to guide the development of the IHE Integration Profiles for the Electronic Health Record Systems to enable electronic information exchanges between clinical and public health settings. So, this White Paper serves as a framing document for the creation of the Public Health Domain at IHE. PHDSC and IHE invite public health experts to review the White Paper. During the review period, we would like to invite representatives of public health domains/programs to submit a description of their domains/programs using the IHE Technical Tasks for Information Exchange outline, so the final White Paper can include other examples of public health domains in addition to the immunization and cancer surveillance domains. This will help to identify potential public health domains/programs for the development of the IHE Integration Profiles in the upcoming year(s). We also would like to invite the reviewers to join our Task Force to participate in the formation of a Public Health Domain at IHE to begin collaboration between public health and HIT vendor communities to guide the development of the IHE Integration Profiles for the Electronic Health Record Systems, to enable electronic information exchange between clinical and public health settings. 1 2 Public Health Data Standards Consortium (PHDSC). URL: phdsc. org Integrating the Healthcare Enterprise (IHE). URL: himss. org/ASP/topics_ihe.asp 6. What is Public Health Mission The mission of public health is to protect the public from health threatening diseases, assure disease prevention by providing access to care for individual patients, promote and restore wellness, and â€Å"to assure the conditions in which people may be healthy. † 3 The patient-centric mission of public health is carried out using publicly-funded healthcare services. Vulnerable or at-risk patients may receive patient care services directly in their homes or at a health clinic funded by a public health agency. There are community health centers funded in the US by the Health Resources and Services Administration (HRSA) that provide a safety net for low income families. Public health funds may also be used to pay for and provide laboratory, pharmacy and other services for eligible populations. In this role, public health care is similar to private health care. The population-based mission of public health is carried out on various levels of government. The public health infrastructure includes agencies that operate on a local, state and/or federal level. In the US, there are 3000 local health departments, 50 state health departments and several federal health agencies, including the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Indian Health Service (IHS), and many others. In some states, the state health agency plays the key role in delivering services to communities; in other states, local health departments take the leading role. In some jurisdictions, public/private partnerships or other organizational entities may be involved in delivering public health services (e.g. , immunization coalitions – community-based groups that include parents). Stakeholders To fulfill its population-based and patient-centric mission, public health is represented by at least the following stakeholders: 3 Population at large Public health practitioners (including epidemiologists, environmental health specialists, health educators, public health nurses, administrators) Health care providers (including, but not limited to, publicly-delivered healthcare providers, e. g. , safety net clinic) Laboratories Payers Healthcare purchasers Pharmacies Other governmental agencies (e. g. , environmental, law enforcement) Professional Associations Research institutions Individual consumers, particularly vulnerable populations. Institute of Medicine. Future of Public Health. Report. 2002. 2nd edition. URL: iom. edu/? id=15251 7 Public Health Organization During the past 40 years, the population-based services of public health have been delivered using a categorical disease-specialized and services-specific domain approach. For example, public health agencies usually include the following programmatic areas and services: communicable disease control, lead poisoning prevention, vital registration, injury control, mental health services, substance abuse prevention and treatment, chronic disease prevention, newborn screening, immunizations, etc. (Tables 1 and 2). 4 This domain-specific organization of public health is supported by funding allocations that in turn shape the disease/domain-specific organizational structure of public health agencies, public health research activities, and workforce training. 5 Table 1. Personal Health, Population Level Assurance and Environmental Health Services Provided by Local Health Departments (LHD) 6 , 7 Personal Health Services Adult immunization Childhood immunization Tuberculosis treatment Sexually transmitted disease (STD) treatment Women, Infant Children (WIC) Family Planning Services Outreach and enrollment for medical insurance EPSDT LHDs Population Level LHDs Providing. Assurance Services Providing Service, Service, % % 91% Communicable 89% Disease surveillance 90% Tuberculosis 85% screening 85% Environmental Health 75% surveillance 61% High blood pressure 72% screening 67% 69% 58% Tobacco use  prevention HIV/AIDS screening 42% Blood lead screening 46%. Prenatal care Oral health care 4 40% Sexually transmitted disease screening Obesity prevention 31% Vector control Environmental Health Services Food service regulation Public swimming pool regulation Septic tank installation Schools/daycare centers LHDs Providing Service, % 76% 67% 66% 65% Private drinking water protection Lead inspections 57% 66% Hotels/motels regulation 49% 64% 39% 54% Campgrounds/ RVs regulation Smoke-free ordinances Groundwater / surface water protection 67% 56% 53% 38% 40% / 33% Lasker RD, editor. Medicine and public heath: the power of collaboration. 1997. New York, NY. Burke TA, Shalauta NM, Tran NL, Stern BS. The environmental Web: a national profile of the state infrastructure for environmental health and protection. J Public Health Manag Pract; 3(2):1-12. 6 Scutchfield, F. D. , Keck, C. W. Principles of public health practice, 2nd ed. 2003. Thomson/Delmar Learning: Clifton Park, NY. 7 2005 National Profile of Local Health Departments, National Association of County City Health Officials, July 2006. www. naccho. org 5 8 Personal Health Services Obstetrical care LHDs Population Level Providing Assurance Services Service, % 32% Diabetes screening Laboratory services 32%. Home health care School-based clinics 28% 25% HIV/AIDS treatment 26% Correctional health 20% Comprehensive primary care Behavioral/mental health services Substance abuse services Emergency medical services 14% 13% 11% 7% Unintended pregnancy prevention Cancer screening School health activities Chronic disease surveillance Injury control Cardiovascular disease screening Behavioral risk factors surveillance Syndromic surveillance Substance abuse prevention Violence prevention Injury surveillance Mental illness prevention LHDs Environmental Providing Health Services Service, % 51% Public drinking water protection 51% Health-related facilities regulation 46% Food processing 41% Mobile homes / housing inspections 41% Indoor air quality activities 40% Solid waste disposal regulation 36% Tobacco retailers LHDs Providing Service, % 30% 30% 30% 29% 29% 28% 21% 36% Animal Control 21% 33% Hazardous material response Hazardous waste disposal Land use planning Noise pollution Occupational safety health activities Radiation control 19% 26% 25% 24% 14% 18% 16% 14% 12% 10% 9 Table 2. Examples of Healthcare and Public health Responsibilities of State Health Departments (SHD) 8 Responsibilities SHDs Responsibilities SHDs Providing Providing Service,% Service,%. Healthcare Responsibilities Public health laboratory 79 Medical examiner 21 Rural health 79 State mental health authority 19 Children with special healthcare 77 State public health licensing agency 17 needs Minority health 72 State mental institution or hospital 17 Institutional licensing agency 60 Partial/split responsibility for 17 Medicaid State health planning 53 Medicaid state agency 15 development agency Partial/split leadership of 51 Lead environmental agency 15 environmental agency Public health pharmacy 34 State tuberculosis hospital 15 State nursing home 28 Health insurance regulation 15 Public Health Responsibilities. State public health authority 97 Disaster Preparedness 77 Newborn Screening 100 Perinatal Epidemiology 77 Immunizations 87 Violence Prevention 68 Bioterrorism 89 Emergency Medical Services 64 Regulation and Service Provision Injury Control Epidemiology 87 Quality Improvement or 62 Performance Measurement Injury Control Prevention 87 Toxicology 57 Breast and Cervical Cancer 87 Breast and Cervical Cancer 45 Screening Treatment Chronic Disease Epidemiology 85 Radon Control 55 Tobacco Control and Prevention 83 Institutional Review Board 45 State Title XXI Children’s health 28 Cancer Epidemiology 83 Insurance Initiative Environmental Epidemiology 79 8 Beitsch LM et al. Structure and functions of state public health agencies. APHA. 2006:96(1):167-72 10 Public Health Functions As a health care provider, public health clinics carry out all functions of a health care delivery system. As a governmental agency, public health is mandated to protect and improve the health of all people within a legal jurisdiction. It regulates healthcare services and coordinates healthcare delivery and resources allocation. The activities of public health agencies are focused on the following three core functions and ten essential services 9 , 10 : Assessment Monitor health status to identify community health problems; Diagnose and investigate health problems and health hazards in the community; Evaluate effectiveness, accessibility, and quality of personal and population-based health services; Research for new insights and innovative solutions to health problems Policy development and implementation Develop policies and plans that support individual and community health efforts Inform, educate, and empower people about health issues Mobilize community partnerships to identify and solve health problems Assurance Enforce laws and regulations that protect health and ensure safety Assure a competent public health and personal health care workforce. Link people to needed personal health services and assure the provision of health care when otherwise unavailable Public Health Data Sources Individual-patient clinical data comprises a large portion of data used to conduct communicable disease surveillance, case investigation, case management, and care coordination. Aggregated clinical data are used to perform surveillance to detect public health threat events and monitor the population’s health status. To fulfill the goal of protecting the public’s health, health care providers and public health agencies need the capability to exchange pertinent health information about individuals and communities. In addition to clinical data, other data sources are needed for public health decision making. For example, public health practitioners use environmental data, housing data, socio-economic data, geographic data, as well as information generated from surveys and research activities to meet the goals of public health programs. 11 9 Institute of Medicine. Committee for the Study of the Future of Public Health, 1988. Public Health Foundation. URL: www. health. gov/phfunctions/public. htm 11 Yasnof W, Overhage J, Humphrey B, LaVenture M. A national agenda for public health informatics. J Am Med Inf Ass 2001;8(6):535s of Domains, Stakeholders, Functions, Services Interventions, Data Sources Public Health Domains Stakeholders Infectious diseases Injury/Trauma Sexually transmitted diseases Consumer product safety Environmental health Occupational health Substance abuse. Mental health Chronic diseases Bioterrorism Disability Elected official Policy maker Health Department Researcher Private sector Clinician Educator Citizen Community Population Communitybased organizations Core Public Health Functions Assessment Policy development and implementation Assurance Essential Services Interventions Data Sources Data Types Monitoring Surveillance Screening Survey Risk assessment Policy research Policy development and implementation Regulation Outreach Case management Advocacy Social Marketing Education Evaluation Physician’s office patient medical record Registries Patient hospital records Emergency. Medical Services records Governmental regulations and guidelines Research databases Peers of Public Health Domains/Programs. 1 Research 6 Trauma Registries 2 Personal Health Record (PHR) 7 Chronic Diseases 3 Cancer Surveillance 8 Birth and Death Registries 4 Patient Safety and Population Health Perspectives 9 Obesity 5 Surveys 12 Orlova AO and Lehmann HR. A UML-based meta-framework for system design in public health informatics. AMIA 2002 Symposium Proceedings, November 9-13, San-Antonio, TX: 582-586. 12 Health Information Technology in Public Health For many decades, public health agencies and research institutions have been utilizing information technology (IT) to facilitate data management activities (data gathering, analysis, reporting, etc.). Public health information systems are created to support specific needs of disease-specific program areas within health departments, i. e. , newborn screening, birth defects, vital registration, immunization, communicable disease surveillance, chronic disease surveillance, school health, injury prevention, preparedness, etc. (Tables 1 2). These systems deploy various software products that are often custom-made and are not interoperable. Many of these systems contain redundant data; however, the varying data formats and standards preclude data integration across systems for public health decision support and research. These sytems lack the ability to provide real-time data back to providers for care coordination and disease prevention. The sections below describe the public health data gathering activities of clinical data that represent the major portion of public health data of interest. Current Practices on Data Reporting from Clinical Settings to Health Department Programs Most public health information systems are populated with data reported by health care providers. There is mandatory data reporting to CDC on 62 notifiable infectious diseases across all 50 states in the US 13 . This data is reported by clinicians to their local health departments. The latter reports this data to the state health department that in turn reports this data to CDC. In addition, various jurisdictions require clinicians to also report data on the conditions that are of interest for a specific jurisdiction (reportable conditions). Besides infectious disease reporting, various other public health programs receive data from clinician, e. g. , immunization registries, chronic disease registries, etc. In some jurisdictions, clinicians are expected to report data to both their local health department programs and their state health department programs. In many jurisdictions, data is currently reported using paper forms sent by fax or mail. For example in one state, providers (primary and emergency physicians) need to report data on 62 notifiable (mandatory) conditions and 32 reportable (state-specific) conditions using (a) over 50 various disease-specific Adobe Acrobat-generated paper forms required by the state communicable diseases surveillance system. This is in addition to providing data to other numerous programs maintained by the state health department. Lack of integration and interoperability across public health systems leads to the duplication of efforts and frustration among providers and consumers asked to provide the same information on multiple forms of varying formats to various programs. None of these activities are reimbursed by health insurance. According to the national data, public health data systems currently suffer from limitations such as underreporting (only 49% of cases are getting reported to public health agencies), 14 , 15 lack of 13 Centers for Disease Control and Prevention (CDC). Nationally Notifiable Infectious Diseases. URL: cdc. gov/EPO/DPHSI/phs/infdis. htm 14 Campos-Outcalt D, England R, Porter B. Reporting of communicable diseases by university physicians. Public Health Rep 1991;106:579-583. 15 Marier R. The reporting of communicable diseases. Am J Epidemiol 1977;105:587-590. 13 representativeness, lack of timeliness, inconsistency of case definitions across systems, inability to integrate data across the systems, etc. 16 , 17 Figures. 1a-d present schematic views of paper-based data reporting by healthcare providers to various public health data systems at the State and local levels. These views may also be applicable to any web-based data reporting to individual public health data systems maintained by the programs. EHR-based Health Information Exchanges between Clinical Care and Public Health Because of the automation of clinical data – inpatient and increasingly outpatient – via the Electronic Health Record Systems (EHRS), public health programs stand at the threshold of change in the way in which they gather programmatic data. Many of the information systems used by local health departments are not capable of exchanging data through RHIOs or with health care service delivery agencies. Many of them are not capable of sending/receiving HL7 messages and cannot or do not comply with other nationally accepted vocabularies and standards. In addition, many of the systems are not configured to serve as an electronic medical record to receive information from physicians; this restricts their ability to contribute to a longitudinal health care record for those clients for whom they serve as a primary care provider Nationally, electronic health record systems are beginning to be certified taking into account these considerations. The issue of compatibility/interoperability of these systems with public health systems to be able to send, receive and exchange relevant data for both public health and clinical practice needs to be addressed. 18 16 Centers for Disease Control and Prevention (CDC). Lesson Five: Public Health Surveillance. Principles of Epidemiology in Public Health Practice. Third Edition (Print-based). 336-409. Available at: cdc. gov/training/products/ss1000/ss1000-ol. pdf. Last accessed November 29, 2006. 17 Konowitz PM, Petrossian GA, Rose DN. The underreporting of disease and physicians’ knowledge of reporting requirements. Public Health Rep 1984;99:31-35. 18 Laverne Snow. Personal Communications. June 9, 2007. 14 Health Education/Risk Reduction Genetic Disorder Communicable Diseases Communicable Diseases Vital Statistics Provider 1 Provider 1 Immunization Provider 2 Immunization EPSDT Provider 3 Lead and Environmental Epidemiology Provider 2 Injury Control Injury Control Provider 3 School Health Provider 4 School Health Chronic Care Chronic Care Provider 4 Biosurveilance, BT, Preparedness Biosurveilance, BT, Preparedness WIC Provider X WIC Occupational Safety and Health Public Health Laboratory Provider X HEDIS Cancer a b Genetic Disorder Genetic Disorders Vital Statistics Health Education/Risk Reduction Provider 1 Communicable Diseases Provider 2 Immunization HRSA Communicable Diseases Provider 1 AHRQ Lead Registry Immunization Provider 2 Provider 3 Vital Records Injury Control Injury Control School Health School Health Chronic Care Chronic Care Biosurveilance, BT, Preparedness Biosurveilance, BT, Preparedness WIC WIC Public Health Laboratory Occupational Safety and Health HEDIS Provider 4. Provider X CDC Injury Control Immunization EPSDT Provider 3 Communicable Diseases Provider 4 School Health Chronic Care Biosurveilance, BT, Preparedness Provider X HEDIS Cancer c d Fig 1. Paper-Based Data Reporting by Health Care Provider to Various Public Health Data Systems: a Provider’s Data Reporting to Local Health Department Data Systems; b Provider’s Data Reporting to State Health Department Data Systems: c Provider’s Data Reporting to Local and State Health Department Data Systems; d Multiple Providers Data Reporting to State Health Department Data Systems. 15 â€Å"Many public health agencies are examining their existing information systems and seeking to improve their ability to support programmatic needs to detect, assess, and respond to a range of threats to the public, including infectious diseases, pandemics, such as avian flu, bioterrorism, and chronic diseases such as obesity, diabetes and asthma. The challenges of transitioning from a paper environment to an electronic environment involve rethinking the workflow, staff skills, resources, habits, and culture of an organization†. 19 Electronic transmission of data from the clinical care settings to public health agencies via EHRS is essential to (1) support key public health functions and services and (2) supply public health data repositories, e. g. , registries, research databases, etc. , for aggregated analysis of the health status of populations. 20 Provision of real-time aggregated community-level information back to providers bi-directional EHRS-based data exchanges between public health practitioners and clinicians will inform clinical decision support, improve care coordination and response capabilities to a public’s health threat event. The integrated Electronic Health Record-Public Health (EHR-PH) systems will become the backbone of a NHIN and regional HIEs. Fig. 2 represents a schematic view of the difference between the current public health data reporting mechanism (Fig. 2a) and the future standardized EHR-PH health information exchange (Fig. 2b). When the EHR-PH connectivity is completed, various public health data systems will be able to electronically receive data from clinical EHRS, so when an authorized provider enters patient data into his/her EHRS, various public health programs as authorized users can receive/retrieve/view/access their data of interest. 21 To facilitate the development of interoperable EHR-PH systems there is a need for standardization of health information exchanges across the clinical and public health enterprise. The US Health Information Technology Standards Panel (HITSP) 22 identified the following categories of standards for system interoperability: 1. Data content standards, i. e. , vocabularies and terminology standards (CDA2, SNOMED, ICD, X12, NCPDP, Omaha, etc. ) 2. Information content standards (Reference Information Models (RIMs) standards) 3. Information exchange standards, e. g. , messaging standards (HL7) 4. Identifier standards, e. g. , National Provider Identifier (NPI) standard 5. Privacy and security standards the US Health Insurance Portability and Accountability Act (HIPAA) privacy regulations provide a framework to protect privacy 19 Common Grounds: Transforming Public Health Information Systems. Robert Wood Johnson Foundation. 2006 Call for Proposals. URL: rwjf. org 20 Public Health Data Standards Consortium. Electronic health record-public health perspectives. White Paper. PHDSC Ad Hoc Task Force on the Electronic Health Record-Public Health. March 9, 2004. : 27p. plus 9 Attachments. URL: phdsc. org/knowresources/papers/docsandpdfs/PHDSC_EHRPH_WhitePaper2004. pdf 21 Orlova AO, Dunnagan M, Finitzo T, Higgins M, Watkins T, Tien A, Beales S. An electroninc health recordpublic health (EHR-PH) system prototype for interoperability in 21st century health care systems. Am Med Inform Assoc. (AMIA), Annual Symposium, Proc. , 2005. 22 Health Information Technology Standards Panel (HITSP). American National Standards Institute (ANSI). URL: amsi/org/hitsp 16 confidentiality of personal information; however, they do not cover all potential actors in health data exchanges. 23 6. Functional standards, i. e. , workflow/dataflow standards 24 7. Other, i. e. , information technology infrastructure standards, interoperability standards (IHE). HIE Genetic Disorders Communicable Diseases Provider 1 Immunization Provider 3 Communicable Diseases CDA2 Provider 2 Vital Records Provider 1 Genetic Disorders HL7 Provider 2 Immunization Vital Records Provider 3 Injury Control Provider 4 X12 Injury Control Provider 4 School Health School Health NCPDP Chronic Diseases Chronic Diseases Provider X Biosurveilance, BT, Preparedness Provider X Biosurveilance, BT, Preparedness, Syndromic Surveillance LAB IHE HEDIS HEDIS a b Fig. 2. Health information exchanges between clinical care and public health agency: a – current paper form – based information exchange; b – standardized EHR-PH –based information exchange. Fig. 2b presents examples of standards (CDA2, HL7, X12, NCPDP, IHE) that the EHR-PH HIEs will have to support. To help facilitate the development of the standardized EHR-PH health information exchanges, it is critical to start a dialogue between the public health community and EHRS developers to assure that the work processes and data needs of public health stakeholders are well understood and agreed upon by stakeholders themselves and then communicated clearly to the developers of the interoperable EHR-PH systems. The section that follows presents two examples of the beginning of this dialogue by describing one of the public health domains in the IHE suggested framework for the technical tasks for information exchanges. 23 See ncvhs. hhs. gov/060622lt. htm Developing a Vision for Functional Requirements Specification for Electronic Data Exchange between Clinical and Public Health Settings: Examples of School Health and Syndromic Surveillance in New York City. Public health Data Standards Consortium. 2006, 40p plus attachments. 24 17 Technical Tasks for Information Exchanges: Examples of Public Health Domains IHE provided a list of Technical Tasks for the description of the information exchanges related to a domain as follows: 1. What is ? 2. Who are Stakeholders? Technical Tasks for Information Exchanges 3. Expressing the criteria 4. Selecting a site 5. Identifying a patient meeting certain criteria 6. Retrieving additional data elements (queries) 7. Reporting data elements (notifications) 8. Data review/feedback (filters) 9. Analysis/evaluation 10. Mapping 11. Aggregation/Reporting 12. Communication We used Immunization and Cancer Surveillance as examples of public health domains (Tables 1 2) and have attempted to describe them in terms of the IHE proposed technical tasks for information exchanges between clinical and public health EHR-PH systems. The section below includes the descriptions of the existing use cases and standards identified by the immunization domain and cancer surveillance experts to date as well as the existing IHE profiles applicable to these domains. It also includes the list of existing and emerging standards and possible future IHE profiles needed to meet the EHR of Immunization Domain 1) What is the Immunization Domain? Immunization is critical to control many infectious diseases including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles),