Wildlife Art – Its History and Development
SummarySome of the earliest of all known art (pre-historic cave and rock art) features wildlife. However, it might be more properly regarded as art about food, rather than art about wildlife as such.Then for a lot of the rest of the history of art in the western world, art depicting wildlife was mostly absent, due to the fact that art during this period was mostly dominated by narrow perspectives on reality, such as religions. It is only more recently, as society, and the art it produces, frees itself from such narrow world-views, that wildlife art flourishes.Wildlife is also a difficult subject for the artist, as it is difficult to find and even more difficult to find keeping still in a pose, long enough to even sketch, let alone paint. Recent advances such as photography have made this far easier, as well as being artforms in their own right. Wildlife art is thus now far easier to accomplish both accurately and aesthetically.In art from outside the western world, wild animals and birds have been portrayed much more frequently throughout history.Art about wild animals began as a depiction of vital food-sources, in pre-history. At the beginnings of history the western world seems to have shut itself off from the natural world for long periods, and this is reflected in the lack of wildlife art throughout most of art history. More recently, societies, and the art it produces, have become much more broad-minded. Wildlife has become something to marvel at as new areas of the world were explored for the first time, something to hunt for pleasure, to admire aesthetically, and to conserve. These interests are reflected in the wildlife art produced.The History and development of Wildlife Art…Wildlife art in Pre-history.Animal and bird art appears in some of the earliest known examples of artistic creation, such as cave paintings and rock artThe earliest known cave paintings were made around 40,000 years ago, the Upper Paleolithic period. These art works might be more than decoration of living areas as they are often in caves which are difficult to access and don’t show any signs of human habitation. Wildlife was a significant part of the daily life of humans at this time, particularly in terms of hunting for food, and this is reflected in their art. Religious interpretation of the natural world is also assumed to be a significant factor in the depiction of animals and birds at this time.Probably the most famous of all cave painting, in Lascaux (France), includes the image of a wild horse, which is one of the earliest known examples of wildlife art. Another example of wildlife cave painting is that of reindeer in the Spanish cave of Cueva de las Monedas, probably painted at around the time of the last ice-age. The oldest known cave paintings (maybe around 32,000 years old) are also found in France, at the Grotte Chauvet, and depict horses, rhinoceros, lions, buffalo, mammoth and humans, often hunting.Wildlife painting is one of the commonest forms of cave art. Subjects are often of large wild animals, including bison, horses, aurochs, lions, bears and deer. The people of this time were probably relating to the natural world mostly in terms of their own survival, rather than separating themselves from it.Cave paintings found in Africa often include animals. Cave paintings from America include animal species such as rabbit, puma, lynx, deer, wild goat and sheep, whale, turtle, tuna, sardine, octopus, eagle, and pelican, and is noted for its high quality and remarkable color. Rock paintings made by Australian Aborigines include so-called “X-ray” paintings which show the bones and organs of the animals they depict. Paintings on caves/rocks in Australia include local species of animals, fish and turtles.Animal carvings were also made during the Upper Paleolithic period… which constitute the earliest examples of wildlife sculpture.In Africa, bushman rock paintings, at around 8000 BC, clearly depict antelope and other animals.The advent of the Bronze age in Europe, from the 3rd Millennium BC, led to a dedicated artisan class, due to the beginnings of specialization resulting from the surpluses available in these advancing societies. During the Iron age, mythical and natural animals were a common subject of artworks, often involving decoration of objects such as plates, knives and cups. Celtic influences affected the art and architecture of local Roman colonies, and outlasted them, surviving into the historic period.Wildlife Art in the Ancient world (Classical art).History is considered to begin at the time writing is invented. The earliest examples of ancient art originate from Egypt and Mesopotamia.The great art traditions have their origins in the art of one of the six great ancient “classical” civilizations: Ancient Egypt, Mesopotamia, Greece, Rome, India, or China. Each of these great civilizations developed their own unique style of art.Animals were commonly depicted in Chinese art, including some examples from the 4th Century which depict stylized mythological creatures and thus are rather a departure from pure wildlife art. Ming dynasty Chinese art features pure wildlife art, including ducks, swans, sparrows, tigers, and other animals and birds, with increasing realism and detail.In the 7th Century, Elephants, monkeys and other animals were depicted in stone carvings in Ellora, India. These carvings were religious in nature, yet depicted real animals rather than more mythological creatures.Ancient Egyptian art includes many animals, used within the symbolic and highly religious nature of Egyptian art at the time, yet showing considerable anatomical knowledge and attention to detail. Animal symbols are used within the famous Egyptian hieroglyphic symbolic language.Early South American art often depicts representations of a divine jaguar.The Minoans, the greatest civilization of the Bronze Age, created naturalistic designs including fish, squid and birds in their middle period. By the late Minoan period, wildlife was still the most characteristic subject of their art, with increasing variety of species.The art of the nomadic people of the Mongolian steppes is primarily animal art, such as gold stags, and is typically small in size as befits their traveling lifestyle.Aristotle (384-322 BC) suggested the concept of photography, but this wasn’t put into practice until 1826.The Medieval period, AD 200 to 1430This period includes early Christian and Byzantine art, as well as Romanesque and Gothic art (1200 to 1430). Most of the art which survives from this period is religious, rather than realistic, in nature. Animals in art at this time were used as symbols rather than representations of anything in the real world. So very little wildlife art as such could be said to exist at all during this period.Renaissance wildlife art, 1300 to 1602.This arts movement began from ideas which initially emerged in Florence. After centuries of religious domination of the arts, Renaissance artists began to move more towards ancient mystical themes and depicting the world around them, away from purely Christian subject matter. New techniques, such as oil painting and portable paintings, as well as new ways of looking such as use of perspective and realistic depiction of textures and lighting, led to great changes in artistic expression.The two major schools of Renaissance art were the Italian school who were heavily influenced by the art of ancient Greece and Rome, and the northern Europeans… Flemish, Dutch and Germans, who were generally more realistic and less idealized in their work. The art of the Renaissance reflects the revolutions in ideas and science which occurred in this Reformation period.The early Renaissance features artists such as Botticelli, and Donatello. Animals are still being used symbolically and in mythological context at this time, for example “Pegasus” by Jacopo de’Barbari.The best-known artist of the high Renaissance is Leonardo-Da-Vinci. Although most of his artworks depict people and technology, he occasionally incorporates wildlife into his images, such as the swan in “Leda and the swan”, and the animals portrayed in his “lady with an ermine”, and “studies of cat movements and positions”.Durer is regarded as the greatest artist of the Northern European Renaissance. Albrecht Durer was particularly well-known for his wildlife art, including pictures of hare, rhinoceros, bullfinch, little owl, squirrels, the wing of a blue roller, monkey, and blue crow.Baroque wildlife art, 1600 to 1730.This important artistic age, encouraged by the Roman Catholic Church and the aristocracy of the time, features such well-known great artists as Caravaggio, Rembrandt, Rubens, Velazquez, Poussin, and Vermeer. Paintings of this period often use lighting effects to increase the dramatic effect.Wildlife art of this period includes a lion, and “goldfinch” by Carel Fabrituis.Melchior de Hondecoeter was a specialist animal and bird artist in the baroque period with paintings including “revolt in the poultry coup”, “cocks fighting” and “palace of Amsterdam with exotic birds”.The Rococo art period was a later (1720 to 1780) decadent sub-genre of the Baroque period, and includes such famous painters as Canaletto, Gainsborough and Goya. Wildlife art of the time includes “Dromedary study” by Jean Antoine Watteau, and “folly of beasts” by Goya.Jean-Baptiste Oudry was a Rococo wildlife specialist, who often painted commissions for royalty.Some of the earliest scientific wildlife illustration was also created at around this time, for example from artist William Lewin who published a book illustrating British birds, painted entirely by hand.Wildlife art in the 18th to 19th C.In 1743, Mark Catesby published his documentation of the flora and fauna of the explored areas of the New World, which helped encourage both business investment and interest in the natural history of the continent.In response to the decadence of the Rococo period, neo-classicism arose in the late 18th Century (1750-1830 ). This genre is more ascetic, and contains much sensuality, but none of the spontaneity which characterizes the later Romantic period. This movement focused on the supremacy of natural order over man’s will, a concept which culminated in the romantic art depiction of disasters and madness.Francois Le Vaillant (1769-1832) was a bird illustrator (and ornithologist) around this time.Georges Cuvier, (1769-1832), painted accurate images of more than 5000 fish, relating to his studies of comparative organismal biology.Edward Hicks is an example of an American wildlife painter of this period, who’s art was dominated by his religious context.Sir Edwin Henry Landseer was also painting wildlife at this time, in a style strongly influenced by dramatic emotional judgments of the animals involved.This focus towards nature led the painters of the Romantic era (1790 – 1880) to transform landscape painting, which had previously been a minor art form, into an art-form of major importance. The romantics rejected the ascetic ideals of Neo-Classicalism.The practical use of photography began in around 1826, although it was a while before wildlife became a common subject for its use. The first color photograph was taken in 1861, but easy-to-use color plates only became available in 1907.In 1853 Bisson and Mante created some of the first known wildlife photography.In France, Gaspar-Felix Tournacho, “Nadar” (1820-1910) applied the same aesthetic principles used in painting, to photography, thus beginning the artistic discipline of fine art photography. Fine Art photography Prints were also reproduced in Limited Editions, making them more valuable.Jaques-Laurent Agasse was one of the foremost painters of animals in Europe around the end of the 18th C and the beginning of the 19th. His animal art was unusually realistic for the time, and he painted some wild animals including giraffe and leopards.Romantic wildlife art includes “zebra”, “cheetah, stag and two Indians”, at least two monkey paintings, a leopard and “portrait of a royal tiger” by George Stubbs who also did many paintings of horses.One of the great wildlife sculptors of the Romantic period was Antoine-Louis Barye. Barye was also a wildlife painter, who demonstrated the typical dramatic concepts and lighting of the romantic movement.Delacroix painted a tiger attacking a horse, which as is common with Romantic paintings, paints subject matter on the border between human (a domesticated horse) and the natural world (a wild tiger).In America, the landscape painting movement of the Romantic era was known as the Hudson River School (1850s – c. 1880). These landscapes occasionally include wildlife, such as the deer in “Dogwood” and “valley of the Yosemite” by Albert Bierstadt, and more obviously in his “buffalo trail”, but the focus is on the landscape rather than the wildlife in it.Wildlife artist Ivan Ivanovitch Shishkin demonstrates beautiful use of light in his landscape-oriented wildlife art.Although Romantic painting focused on nature, it rarely portrayed wild animals, tending much more towards the borders between man and nature, such as domesticated animals and people in landscapes rather than the landscapes themselves. Romantic art seems in a way to be about nature, but usually only shows nature from a human perspective.Audubon was perhaps the most famous painter of wild birds at around this time, with a distinctive American style, yet painting the birds realistically and in context, although in somewhat over-dramatic poses. As well as birds, he also painted the mammals of America, although these works of his are somewhat less well known. At around the same time In Europe, Rosa Bonheur was finding fame as a wildlife artist.Amongst Realist art, “the raven” by Manet and “stags at rest” by Rosa Bonheur are genuine wildlife art. However in this artistic movement animals are much more usually depicted obviously as part of a human context.The wildlife art of the impressionist movement includes “angler’s prize” by Theodore Clement Steele, and the artist Joseph Crawhall was a specialist wildlife artist strongly influenced by impressionism.At this time, accurate scientific wildlife illustration was also being created. One name known for this kind of work in Europe is John Gould although his wife Elizabeth was the one who actually did most of the illustrations for his books on birds.Post-impressionism (1886 – 1905, France) includes a water-bird in Rousseau’s “snake charmer”, and Rousseau’s paintings, which include wildlife, are sometimes considered Post-impressionist (as well as Fauvist, see below).Fauvism (1904 – 1909, France) often considered the first “modern” art movement, re-thought use of color in art. The most famous fauvist is Matisse, who depicts birds and fish in is “polynesie la Mer” and birds in his “Renaissance”. Other wildlife art in this movement includes a tiger in “Surprised! Storm in the Forest” by Rousseau, a lion in his “sleeping Gypsy” and a jungle animal in his “exotic landscape”. Georges Braque depicts a bird in many of his artworks, including “L’Oiseaux Bleu et Gris”, and his “Astre et l’Oiseau”.Ukiyo-e-printmaking (Japanese wood-block prints, originating from 17th C) was becoming known in the West, during the 19th C, and had a great influence on Western painters, particularly in France.Wildlife art in this genre includes several untitled prints (owl, bird, eagle) by Ando Hiroshige, and “crane”, “cat and butterfly”, “wagtail and wisteria” by Hokusai Katsushika.Wildlife art in the 20th Century, Contemporary art, postmodern art, etc.Changing from the relatively stable views of a mechanical universe held in the 19th-century, the 20th-century shatters these views with such advances as Einstein’s Relativity and Freuds sub-conscious psychological influence.The greater degree of contact with the rest of the world had a significant influence on Western arts, such as the influence of African and Japanese art on Pablo Picasso, for example.American Wildlife artist Carl Runguis spans the end of the 19th and the beginnings of the 20th Century. His style evolved from tightly rendered scientific-influenced style, through impressionist influence, to a more painterly approach.The golden age of illustration includes mythical wildlife “The firebird” by Edmund Dulac, and “tile design of Heron and Fish” by Walter Crane.George Braque’s birds can be defined as Analytical Cubist (this genre was jointly developed by Braque and Picasso from 1908 to 1912), (as well as Fauvist). Fernand Leger also depicts birds in his “Les Oiseaux”.There was also accurate scientific wildlife illustration being done at around this time, such as those done by America illustrator Louis Agassiz Fuertes who painted birds in America as well as other countries.Expressionism (1905 – 1930, Germany). “Fox”, “monkey Frieze, “red deer”, and “tiger”, etc by Franz Marc qualify as wildlife art, although to contemporary viewers seem more about the style than the wildlife.Postmodernism as an art genre, which has developed since the 1960′s, looks to the whole range of art history for its inspiration, as contrasted with Modernism which focuses on its own limited context. A different yet related view of these genres is that Modernism attempts to search for an idealized truth, where as post-modernism accepts the impossibility of such an ideal. This is reflected, for example, in the rise of abstract art, which is an art of the indefinable, after about a thousand years of art mostly depicting definable objects.Magic realism (1960′s Germany) often included animals and birds, but usually as a minor feature among human elements, for example, swans and occasionally other animals in many paintings by Michael Parkes.In 1963, Ray Harm is a significant bird artist.Robert Rauschenberg’s “American eagle”, a Pop Art (mid 1950′s onwards) piece, uses the image of an eagle as a symbol rather than as something in its own right, and thus is not really wildlife art. The same applies to Any Warhol’s “Butterflys”.Salvador Dali, the best known of Surrealist (1920′s France, onwards) artists, uses wild animals in some of his paintings, for example “Landscape with Butterflys”, but within the context of surrealism, depictions of wildlife become conceptually something other than what they might appear to be visually, so they might not really be wildlife at all. Other examples of wildlife in Surrealist art are Rene Magritte’s “La Promesse” and “L’entre ed Scene”.Op art (1964 onwards) such as M. C. Escher’s “Sky and Water” shows ducks and fish, and “mosaic II” shows many animals and birds, but they are used as image design elements rather than the art being about the animals.Roger Tory Peterson created fine wildlife art, which although being clear illustrations for use in his book which was the first real field guide to birds, are also aesthetically worthy bird paintings.Young British Artists (1988 onwards). Damien Hirst uses a shark in a tank as one of his artworks. It is debatable whether this piece could be considered as wildlife art, because even though the shark is the focus of the piece, the piece is not really about the shark itself, but probably more about the shark’s effect on the people viewing it. It could be said to be more a use of wildlife in/as art, than a work of wildlife art.Wildlife art continues to be popular today, with such artists as Robert Bateman being very highly regarded, although in his case somewhat controversial for his release of Limited-Edition prints which certain fine-art critics deplore.
Rebuilding the Tower of Babel – A CEO’s Perspective on Health Information Exchanges
Defining a Health Information ExchangeThe United States is facing the largest shortage of healthcare practitioners in our country’s history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati based HIE and one of the largest community based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases communication can be achieved but the process is cumbersome and often ineffective.”United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.History of Health Information ExchangesMajor urban centers in Canada and Australia were the first to successfully implement HIE’s. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it’s third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.In the United States one of the earliest HIE’s started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.In Tennessee Regional Health Information Organizations (RHIO’s) initiated in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri Cities region was considered a direct project where clinicians interact directly with each other using Carespark’s HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the midsouth eHealth Alliance is a RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.Seventeen US communities have been designated as Beacon Communities across the United States based on their development of HIE’s. These communities’ health focus varies based on the patient population and prevalence of chronic disease states i.e. cvd, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety and efficiency due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mississippi, just south of Memphis, was granted a $100,000 grant by the department of Health and Human Services in September 2011.A healthcare model for Nashville to emulate is located in Indianapolis, IN based on geographic proximity, city size and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center and Shalom Health Care Center Inc. In addition, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange 2) Improving long term and post acute care transitions 3) Consumer mediated information exchange 4) Enabling enhanced query for patient care 5) Fostering distributed population-level analytics.Regulatory Aspects of Health Information Exchanges and Healthcare ReformThe department of Health and Human Services (HHS) is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions and Tennessee is part of Region IV headquartered out of Atlanta. The Regional Director, Anton J. Gunn is the first African American elected to serve as regional director and brings a wealth of experience to his role based on his public service specifically regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast area.The National Health Information Network (NHIN) is a division of HHS that guides the standards of exchange and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities and state HIE’s (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to care programs for chronic patients leading to continuity and finally timely public health alerts through agencies like the CDC based on this information.12 The Health Information Technology for Economic and Clinical Health (HITECH) Act is funded by dollars from the American Reinvestment and Recovery Act of 2009. HITECH’s goals are to invest dollars in community, regional and state health information exchanges to build effective networks which are connected nationally. Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. To date 56 states have received grant awards through these programs totaling 548 million dollars.History of Health Information Partnership TN (HIPTN)In Tennessee the Health Information Exchange has been slower to progress than places like Maine and Indiana based in part on the diversity of our state. The delta has a vastly different patient population and health network than that of middle Tennessee, which differs from eastern Tennessee’s Appalachian region. In August of 2009 the first steps were taken to build a statewide HIE consisting of a non-profit named HIP TN. A board was established at this time with an operations council formed in December. HIP TN’s first initiatives involved connecting the work through Carespark in northeast Tennessee’s s tri-cities region to the Midsouth ehealth Alliance in Memphis. State officials estimated a cost of over 200 million dollars from 2010-2015. The venture involves stakeholders from medical, technical, legal and business backgrounds. The governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing the office of eHealth initiatives with oversight by the Office of Administration and Finance and sixteen board members. By March 2010 four workgroups were established to focus on areas like technology, clinical, privacy and security and sustainability.By May of 2010 data sharing agreements were in place and a production pilot for the statewide HIE was initiated in June 2011 along with a Request for Proposal (RFP) which was sent out to over forty vendors. In July 2010 a fifth workgroup,the consumer advisory group, was added and in September 2010 Tennessee was notified that they were one of the first states to have their plans approved after a release of Program Information Notice (PIN). Over fifty stakeholders came together to evaluate the vendor demonstrations and a contract was signed with the chosen vendor Axolotl on September 30th, 2010. At that time a production goal of July 15th, 2011 was agreed upon and in January 2011 Keith Cox was hired as HIP TN’s CEO. Keith brings twenty six years of tenure in healthcare IT to the collaborative. His previous endeavors include Microsoft, Bellsouth and several entrepreneurial efforts. HIP TN’s mission is to improve access to health information through a statewide collaborative process and provide the infrastructure for security in that exchange. The vision for HIP TN is to be recognized as a state and national leader who support measurable improvements in clinical quality and efficiency to patients, providers and payors with secure HIE. Robert S. Gordon, the board chair for HIPTN states the vision well, “We share the view that while technology is a critical tool, the primary focus is not technology itself, but improving health”. HIP TN is a non profit, 501(c)3, that is solely reliant on state government funding. It is a combination of centralized and decentralized architecture. The key vendors are Axolotl, which acts as the umbrella network, ICA for Memphis and Nashville, with CGI as the vendor in northeast Tennessee.15 Future HIP TN goals include a gateway to the National Health Institute planned for late 2011 and a clinician index in early 2012. Carespark, one of the original regional health exchange networks voted to cease operations on July 11, 2011 based on lack of financial support for it’s new infrastructure. The data sharing agreements included 38 health organizations, nine communities and 250 volunteers.16 Carespark’s closure clarifies the need to build a network that is not solely reliant on public grants to fund it’s efforts, which we will discuss in the final section of this paper.Current Status of Healthcare Information Exchange and HIPTNTen grants were awarded in 2011 by the HIE challenge grant supplement. These included initiatives in eight states and serve as communities we can look to for guidance as HIP TN evolves. As previously mentioned one of the most awarded communities lies less than five hours away in Indianapolis, IN. Based on the similarities in our health communities, patient populations and demographics, Indianapolis would provide an excellent mentor for Nashville and the hospital systems who serve patients in TN. The Indiana Health Information Exchange has been recognized nationally for it’s Docs for Docs program and the manner in which collaboration has taken place since it’s conception in 2004. Kathleen Sebelius, Secretary of HHS commented, “The Central Indiana Beacon Community has a level of collaboration and the ability to organize quality efforts in an effective manner from its history of building long standing relationships. We are thrilled to be working with a community that is far ahead in the use of health information to bring positive change to patient care.” Beacon communities that could act as guides for our community include the Health and Hospital Corporation of Marion County and the Indiana Health Centers based on their recent awards of $100,000 each by HHS.A local model of excellence in practice EMR conversion is Old Harding Pediatric Associates (OHPA) which has two clinics and fourteen physicians who handle a patient population of 23,000 and over 72,000 patient encounters per year. OHPA’s conversion to electronic records in early 2000 occurred as a result of the pursuit of excellence in patient care and the desire to use technology in a way that benefitted their patient population. OHPA established a cross functional work team to improve their practices in the areas of facilities, personnel, communication, technology and external influences. Noteworthy was chosen as the EMR vendor based on user friendliness and the similarity to a standard patient chart with tabs for files. The software was customized to the pediatric environment complete with patient growth charts. Windows was used as the operating system based on provider familiarity. Within four days OHPA had 100% compliance and use of their EMR system.The Future of HIP TN and HIE in TennesseeTennessee has received close to twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIO) need to be full scalable to allow hospitals to grow their systems without compromising integrity as they grow.21and the systems located in Nashville will play an integral role in this nationwide scaling with companies like HCA, CHS, Iasis, Lifepoint and Vanguard. The HIE will act as a data repository for all patients information that can be accessed from anywhere and contains a full history of the patients medical record, lab tests, physician network and medicine list. To entice providers to enroll in the statewide HIE tangible value to their practice has to be shown with better safer care. In a 2011 HIMSS editor’s report Richard Lang states that instead of a top down approach “A more practical idea may be for states to support local community HIE development first. Once established, these local networks can feed regional HIE’s and then connect to a central HIE/data repository backbone. States should use a portion of the stimulus funds to support local HIE development.”22 Mr. Lang also believes the primary care physician has to be the foundation for the entire system since they are the main point of contact for the patient.One piece of the puzzle often overlooked is the patient investment in a functional EHR. In order to bring together all the pieces of the HIE puzzle patients will need to play a more active role in their healthcare. Many patients do not know what medicines they take every day or whether they have a living will. Several versions of patient EHR’s like Memitech’s 911medical id card exist, but very few patients know or carry them.23 One way to combat this lack of awareness is to use the hospital as a catch-all and discharge each patient with a fully loaded USB card via case managers. This strategy also might lead to better compliance with post in patient therapies to reduce readmissions.The implementation of connecting qualified organizations began earlier this year. To fully support organizations to move toward qualification the Office of National Coordinator for HIE (ONC) has designated regional education centers (TN rec) who assist providers with educational initiatives in areas like HIT, ICD9 to ICD10 training and EMR transition. Qsource, a non-profit health consulting firm, has been chosen to oversee TNrec. To ensure sustainability it is critical that Tennessee build a network of private funding so that what happened with Carespark won’t happen to HIP TN. The eHealth Initiatives 2011Survey Report states that of the 196 HIE initiatives, 115 act independently of federal funding and of those independent HIE’s, break even through operational revenue. Some of these exchanges were in existence well before the American Recovery and Reinvestment Act in 2009. Startup funding from grants is only meant to get the car going so to speak, the sustainable fuel, as observed in the case of Carespark, has to come from value that can be monetized. KLAS research reports that 54% of public HIE’s were concerned about future sustainability while only 35% of private HIE’s shared this concern.Hospital Implications of HIP TN (A Call to Action)From a Financial perspective, taking our hospital into the future with EMR and an integrated statewide network has profound implications. In the short term the cost to find a vendor, establish EMR in and outpatient will be an expensive proposition. The transition will not be easy or finite and will involve constant evolution as HIP TN integrates with other state HIE’s. To get a realistic idea of the benefits and costs associated with health information integration. we can look to HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in productivity reduction. Specific areas of savings include paper or fax costs $5 versus $0.25 electronically, virtual health record savings of $50 per referral, $26 saved per ED visit and $17.41 per patient/year due to redundant lab tests which amounts to $52 million for a population of 3 million patients. In Grand Junction Colorado Quality Health Network lowered their per capita Medicare spending to 24% below the national average, gaining recognition by President Obama in 2009. The Santa Cruz Health Information Exchange (SCHIE) with 600 doctors and two hospitals achieved sustainability in the first year of operation and uses a subscription fee for all the organizations who interact with them. In terms of government dollars available, meaningful use incentives exist to encourage hospitals to meet twenty of twenty five objectives in the first phase (2011-2012) and adopting and implement an approved EHR vendor. ARRA specified three ways for EHR to be utilized to obtain Medicare reimbursement. These include e-prescribing, health information exchange and submission of clinical quality measures. The objectives for phase two in 2013 will expand on this baseline. Implementation of EHR and Hospital HIE costs are usually charged by bed or by the number of physicians. Fees can range from $1500 for a smaller hospital up to $12,000 per month for a larger hospital.Perhaps the most compelling argument to building a functional Health Information Exchange is patient and community safety. The Healthbridge reduction in disease outbreak detection of 3-5 days is a perfect example of this safety benefit. Imagine the implications in the case of a rampant virus like avian or swine flu. The goal is to avoid a repeat of the 1918 influenza outbreak and ultimately save the lives of our most at risk. Rick Krohn of Healthsense makes the case for a socially responsible HIE that serves those who are chronically ill, uninsured and homeless. As the taxpayers ultimately bear the societal burden for our country’s healthcare coverage, the need to reduce redundancies, increase efficiency and provide healthcare worthy of the United States is imperative. Right now our healthcare is in the Critical Care Unit it’s time to stabilize it through operational excellence starting with our hospital. Let’s rebuild the Tower of Babel and enhance communication to provide our patients the healthcare they deserve!