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There is widespread interest throughout the mental health system in routine quality assessment to facilitate quality improvement, oversight, purchasing, and consumer choice. In the absence of agreement on a limited number of meaningful and feasible quality measures, delivery systems, payers, managed care organizations, regulators, and accreditors have each implemented unique measures and specifications. The resulting heterogeneity among measures has increased the burden on providers, limited the comparability of results, and hindered efforts to focus limited resources on further development of the most promising measures. Policy makers have initiated efforts for stakeholders to reach consensus on a core set of measures for common use, but barriers to progress remain, including differences in stakeholder needs and trade-offs between prioritizing desirable attributes of measures and representing the mental health system broadly. The authors present a framework for the selection of a core set of measures, clarify divergent perspectives, and make recommendations for further development of core quality measures for mental health care.
In recent years, stakeholders in the mental health care system have moved to embrace routine assessment of the quality of care delivered. To a varying extent, health care facilities, delivery systems, and plans use data on quality to improve the care they provide (1,2,3). Government regulators, accreditors, and managed behavioral health care organizations provide care delivery organizations with comparative data on quality in efforts to drive improvement from above (4,5). More than 50 stakeholder groups have proposed more than 300 process measures for quality assessment (6,7). However, these measures vary widely in their evidence base, technical sophistication, and readiness for routine use. Moreover, the number and diversity of these measures increase the burden of data collection on providers and reduce the usefulness of the results.
Policy makers and other stakeholders have responded to the proliferation of measures by calling for the adoption of core measures (8,9,10,11,12), or "standardized performance measures that are selectively identified and limited in number … [and that] can be applied across programs … [with] precisely defined specifications … [and] standardized data collection protocols" (11). Core measures could reduce the burden on facilities and plans, which often must measure and report on different aspects of care for each agency, accreditor, and payer to which they are accountable. Common specifications would increase the comparability of data across facilities and plans. Core sets would also focus resources on the most promising measures for further development, testing, and case-mix adjustment. The concept of core measures is based on a number of assumptions: that quality measures meeting a broad range of criteria are available, that the same measures can be used for multiple purposes, and that diverse stakeholders can agree on a small number of measures.
Despite the advantages it would offer, a broad-based set of core measures for the U.S. mental health system has proved elusive. Individual stakeholder groups have produced measures for use with their membership. These groups include the National Committee for Quality Assurance (NCQA) (13), the American Managed Behavioral Healthcare Association (AMBHA) (14), and the National Association of State Mental Health Program Directors (NASMHPD) (15). The Washington Circle Group has developed and begun pilot testing measures for substance abuse (16). An initiative led by the American College of Mental Health Administration has made progress in identifying potential areas to measure (17). These efforts represent important steps toward convergence.
In March 2001, the Substance Abuse and Mental Health Services Administration (SAMHSA) hosted a summit at the Carter Center in Atlanta to pursue the development of systemwide core measures. Individuals from more than 75 mental health and substance abuse organizations attended, representing a wide range of perspectives. With this and other initiatives under way, a review of considerations underlying the development of a core set of measures is timely.
We present a framework, summarized in F1, that integrates considerations of the attributes of measures—in a sense, the qualities of quality measures—and dimensions of the mental health system. In doing so, we highlight two challenges to the development of a core set of measures. First, there are fundamental tensions between maximizing the quality of measures and broadly representing diverse features of the mental health system. Second, competing priorities among stakeholders become manifest in the process of selecting what to measure.
In presenting a framework, we seek to make more explicit these measure attributes and system dimensions—and trade-offs between them—in order to educate stakeholders and facilitate the process of developing a core set of measures. Our framework is built on the work of others. Most groups that have developed measures have based their initiatives on a framework, typically some variation of Donabedian's triad of structure, process, and outcome (18). For example, the American Psychiatric Association categorized measures into four groups: access, quality, perceptions of care, and outcomes (19). Several organizations have also described desirable attributes of measures, such as meaningfulness or basis in evidence (9).
We focus on process measures, which examine interactions between patients and the health care system. Many of the concepts we discuss could be applied to other methods of assessing quality of care, including measurement of outcomes, patients' perspectives, and the fidelity of treatment programs to evidence-based protocols. Our focus is not intended to imply that process measures are superior; we have previously written about the importance of varied approaches to quality assessment (20,21). Our focus here reflects the fact that process measures are already widely used in mental health care (6) and could be used more effectively.
An example of a simple process measure is the proportion of outpatients for whom an antidepressant is prescribed for major depression who remain on the medication for the 12-week acute treatment phase (an NCQA measure) (22). With adjustment for differences among patients—not a small matter—this measure could be applied to caseloads of individual providers, to clinics and group practices, and to facilities, health plans, or beneficiaries of public health insurance programs.
In the sections that follow we ask three questions related to principles of core measure selection. What characteristics of process measures are desirable? What features of the mental health system should these measures evaluate? What trade-offs are necessary to achieve balance between the attributes of high-quality measures and the diverse priorities of stakeholders?
Embedded in the construct of the meaningfulness of a quality measure are several concepts, some inherently subjective and others based on more objective information. The face validity of a measure is subjective. Individuals who are familiar with a process can be asked whether the process is clinically important to measure, whether there is a gap between optimal and actual practice, and whether closing the gap would improve patients' outcomes. An individual's response to these questions may vary with his or her stake in the health care system.
In some cases, empirical data are available to inform these judgments. Some measures have been derived from research evidence establishing the effectiveness of a clinical process. For instance, the previously described measure of antidepressant use is based on randomized controlled studies establishing that an acute episode of depression is more likely to remit if a patient takes an antidepressant medication for at least 12 weeks. In contrast, there is no evidence that a single outpatient visit within 30 days of inpatient care for depression has an impact on outcome—a continuity-of-care measurement from the same developer (22).
Research data may also address whether a measure reflects a potential quality problem by identifying gaps between actual and optimal practice. NCQA data for 2000 show that 55.6 to 62.6 percent of individuals enrolled in participating health plans who initiate antidepressant treatment for major depression discontinue the medication before 12 weeks (5).
After measurement of a particular process has been implemented, predictive validity can be assessed. Predictive validity characterizes the association within a treated sample between conformance to the measure and clinical outcome. In such a retrospective analysis, Melfi and colleagues (23) found that adherence to antidepressant treatment guidelines was associated with a lower probability of relapse or recurrence.
Other aspects of meaningfulness of measures are less well established, such as the threshold of quality assessed by a measure. Does a given measure reflect minimally acceptable care, average care, or best practice? The continuity measure—the proportion of patients who make an outpatient visit within 30 days of hospital discharge—seemingly reflects a minimal level of care. In contrast, the measure of the proportion of patients remaining on an antidepressant medication for 12 weeks or more is based on a guideline recommendation. An organization can further calibrate a measure's threshold to clinical circumstances by setting a performance standard—for example, that 80 percent of patients continue an antidepressant medication for 12 weeks.
Although the concept proposed for a measure may be simple, constructing the measure's specifications is often more complex. Each measurable component—clinical process, population, and data source—must be defined operationally. Inclusion criteria, procedure codes, and time frames must be precisely specified. Data collection protocols, abstraction forms, and programming specifications need to be developed. The measure should then be tested in a variety of settings and health systems, with particular attention given to the availability and accuracy of the data and the reliability of the collection process.
One of the most important challenges in selecting core measures is the affordability of data collection—another aspect of feasibility. Typically, use of administrative or claims data, which are collected routinely in the course of administering or billing for care, is the least burdensome. However, resources are required to access, link, and analyze these data. Abstracting data from medical records or collecting data directly from clinicians and patients is more labor-intensive. The collective burden of gathering data for a core set of measures must be balanced against the resources available for measurement. To date, there is no consensus among facilities, payers, and regulators about appropriate costs for measurement or who should pay them.
Other challenges to the feasibility of routine process measurement remain. An operational balance is needed between having access to data for measurement and safeguarding patient confidentiality. This issue is likely to receive greater attention as federal privacy regulations in the Health Insurance Portability and Accountability Act (HIPAA) are implemented.
Comparing results across clinicians, facilities, or plans may require adjustment for differences in patient populations that are unrelated to quality of care. Such case-mix adjustment is often said to be less necessary for process measures than for outcome measures, because a clinical process, such as the assessment of a patient's mental status, may be fully under the control of the clinician. However, many process measures rely on utilization data to determine whether the duration or intensity of treatment is appropriate. For psychiatric care, utilization data are problematic because they reflect the actions of both clinicians and patients. Clinicians can influence patients' compliance by providing education, scheduling follow-up visits, using outreach resources, and addressing medication nonresponse and side effects. Nonetheless, persons with severe mental illness have no-show rates for scheduled appointments as high as 50 percent (24). Differences in patient populations, such as the rate of comorbid illness and substance abuse, also influence compliance. Thus statistical adjustment for underlying differences in patient populations may be needed to provide fair comparisons among clinicians or facilities.
For other patient characteristics, such as race or ethnicity, adjustment would not serve the purpose of quality assessment. In this context, the goal would be to identify groups receiving substandard care and intervene to narrow these disparities. Case-mix adjustment methods can range from stratification to more complex multivariate analyses, but such methods are relatively underdeveloped for mental health measures.
Although a measure may be well defined and may address a quality problem, the results may not be "actionable"—that is, users of the measure may not be able to act on them to improve care. Highly technical specifications may yield a result not easily comprehensible to users. Results may reveal a serious problem whose solution is not under the user's control. For example, the nursing staff of an inpatient unit initiated a quality improvement project to reduce the high rate of medication errors detected on their unit, only to learn that labeling errors at the pharmacy—a process over which they had little authority—caused the problem. They were able to refocus the project to improve detection of errors; however, in many cases a solution is not so readily available.
More data are needed to facilitate interpretation of quality measurement results. For many measures, 100 percent conformance is not a reasonable expectation. Despite a clinicians' best efforts, some patients will discontinue an antidepressant prematurely. Consequently, a facility that receives a performance rate of 60 percent on this measure may wonder whether better results might have been attainable.
Several types of comparative data can enhance interpretability. Norms, such as those used in NCQA's Quality Compass (5), reflect average results for population-based samples. Benchmarks reflect the results attained by the best-performing plans and providers (25). Different points of comparison may have different effects. Using norms may reinforce a status quo, whereas using benchmarks may motivate participants to improve. Currently, few quality measures in mental health have established benchmarks (6). In the absence of benchmarks, some health care organizations prescribe standards, which are thresholds that they believe represent an acceptable and achievable level of care.
Selecting core measures to assess the quality of mental health care is an ambitious undertaking. The mental health care "system," which was described as a "de facto system" first by Regier and colleagues (26) and then more broadly by Fox and colleagues (27), includes a sprawling array of services, settings, populations, and modalities. Each of these dimensions, elaborated on below and depicted in F1, is a potential area for core measures. Which dimensions, and which areas within them, should be given priority? As with decisions about attributes of measures, these decisions can be informed by data but may also differ by stakeholder perspective.
Donabedian defined process as "a set of activities that go on within and between practitioners and patients" (18). Accordingly, process measurement is not limited to treatment but can also examine processes of care before treatment (such as detection, access, and assessment), after phases of treatment (such as continuity across levels of care), and across sources of treatment (such as coordination among treaters, including a patient's prescribing clinician and therapist). Process measurement can also assess primary prevention in healthy populations. A seventh domain, patient safety, has been subject to increasing attention in recent years as research on the impact of medication errors and other safety concerns has accumulated (28). Measures have been developed for each of these domains in behavioral health, and each domain is highly important to one or more stakeholder groups (6).
Some process measures can be applied broadly to populations, across diagnostic categories and demographic groups. Others are condition specific. In the selection of core measures, a wealth of data describing mental illness in populations is available for setting priorities among clinical disorders. National epidemiological studies have identified highly prevalent conditions, such as major depression, substance abuse, and several anxiety disorders (29). Bipolar disorder, schizophrenia, and obsessive-compulsive disorder are less prevalent but warrant consideration because of their impact on functioning—the three conditions rank among the ten leading causes of disability worldwide, as measured in years lived with a disability (30).
Although measurement often focuses on acute illness, Wagner and associates (31) have pointed out the need to assess and improve management of chronic conditions. The selection of measures should focus first on conditions that have clearly effective treatments and for which the quality of care can be decisive. Medical and substance use problems commonly co-occur with mental illness and should also be a priority for measurement and quality improvement. Comorbid illnesses among persons who have primary psychiatric conditions are frequently undetected, inadequately treated, and associated with poorer outcomes (32,33,34,35).
Diagnosis alone does not adequately capture population characteristics that are relevant in identifying what to measure. Research studies have highlighted quality-of-care problems experienced by groups who may have a limited ability to advocate for themselves and to navigate an increasingly complex health care system. These more vulnerable population groups include children (36), elderly persons (37,38), and persons with severe and persistent mental illness (39). Moreover, an expanding body of literature has documented disparities in health care among racial and ethnic minorities (40,41). Geographic variation in the concentration of mental health clinicians has also led to problems with access and quality in rural areas (42,43).
Amid the diverse array of interventions, a core set of measures should at a minimum include both biological and psychosocial treatments. Measures can be based on findings from research studies of overuse and underuse of treatments, from analyses of utilization patterns and expenditures (44), and from population-based needs assessment. In developing measures, one challenge is to advance beyond determining whether or not a patient received a treatment to assessing the adequacy of the treatment's content, intensity, and duration. To date, this limitation has been more effectively addressed for biological than for psychosocial interventions (6).
As the focus of clinical care shifts from the inpatient setting—where quality assurance efforts originated—to ambulatory, intermediate, and community levels of care, quality measures must assess care at a range of levels and in various settings. Research studies have documented problems with the quality of mental health care in the general medical sector (45) and in nontraditional clinical settings with high rates of mental illness, such as homeless shelters, prisons, and nursing homes.
Comparing quality of care across health plans can be thought of as assessment across horizontal components of the health care system. A more complete picture would include processes taking place within the various vertical strata of the system: patients, clinicians, facilities, delivery systems, managed behavioral health care organizations or plans, and populations. Methods of evaluating the treatment of individual patients, as opposed to aggregate groups, have become more systematic, building on traditional methods such as peer review and morbidity and mortality conferences to incorporate structured methods of assessment (46,47). Assessment at the level of the managed behavioral health care organization might compare organizations' denial and appeal rates in utilization management. A population-based measure might assess the rate of detection or appropriate treatment of depression on the basis of the prevalence of the disorder in communities.
Although process measurement in health care systems has been used primarily for internal and external quality improvement activities (6), it has other potential uses. As health care has become increasingly market driven, employer coalitions have sought measures of quality to inform purchasing decisions, which are otherwise based principally on cost. Similarly, consumer groups have sought measures that members and their families can use in the selection of providers and plans. Mental health services researchers also use measures of quality as one means of assessing the impact of organizational and financial changes in the delivery of care.
The challenges inherent in reaching consensus among stakeholders on core measures can be seen by viewing F1 not as a two-dimensional diagram but as a multidimensional matrix. Each cell in the matrix represents the intersection of measurement principles, potential subjects of measures, and conflicting stakeholder perspectives that must be prioritized internally and relative to other cells in the selection of measures for common use. Prioritizing and integrating these components was an implicit goal at policy-making forums such as the stakeholder meetings held by the American College of Mental Health Administration and the recent summit at the Carter Center. The prioritization process itself can also be made explicit, as it was in a consensus development process conducted by the Center for Quality Assessment and Improvement in Mental Health at Harvard Medical School. A diverse panel of stakeholders used a modified Delphi process to rate the attributes of measures; rating scores were then used to select a dimensionally balanced set of candidate core measures (Hermann R, Palmer R, Shwartz M, et al, unpublished manuscript, 2001).
Some fundamental tensions have emerged in both implicit and explicit processes. In many cases, assigning priority to one measure comes at the expense of another. Highly meaningful measures of evidence-based practices often require data from medical records and other sources rich in clinical information. However, these data are more costly to collect than more commonly used claims data, and therefore the measures may be less feasible. Detailed specifications produce an accurate and reliable measure that has high feasibility, but potential users may find results from complex measures difficult to comprehend, resulting in low actionability.
Fortunately, the attributes of measures can sometimes be improved. Upcoming federal standards under HIPAA may improve the accuracy and comparability of claims data by specifying data elements and definitions (48). Influential payers such as Medicare are beginning to add clinically important variables to the administrative data that providers submit for reimbursement, facilitating evidence-based quality measurement without chart review (49,50). Even chart review itself—opposed by some groups because of its cost—can become more efficient. Nearly every health care facility does some chart review in response to external requirements. Developing a consensus on the most important chart-based variables would improve the use of limited resources for chart review.
A basic tension arises in the development of a core set of measures between seeking to maximize the quality of measures, depicted by the vertical arrow in F1, and representing the breadth and diversity of the mental health care system, depicted by the horizontal arrow. For example, a principle of measure selection is a strong basis in research evidence. However, selecting measures that are supported by well-controlled research leads to a preponderance of medication measures that pertain to relatively few conditions (6)—hardly a broad representation of mental health care. Although some psychosocial interventions, including assertive community treatment, have a rigorous research foundation, the complexities of these interventions necessitate a more extensive evaluation of fidelity to the empirically tested model. A simple process measurement does not suffice. In contrast, the results of drug trials can be more easily assembled into simple measures of diagnosis, drug selection, dosage, and duration. Well-controlled trials exist for specific types of psychotherapy, such as interpersonal or cognitive-behavioral therapy, but neither administrative claims nor medical records typically document the type of therapy provided.
Understanding these tensions helps to bring into focus some of the trade-offs involved in the production of a set of core measures. Differences in priorities among stakeholders complicate the selection process. There has been little systematic study of the attitudes of mental health stakeholders toward quality measures. However, a review of stakeholders' published reports (6) and observations at national meetings suggests that differences are marked, rational, and deeply held.
Representatives of groups who carry out the data collection for quality measurement—managed behavioral health care organizations, delivery systems, and accreditors—have frequently expressed concern about measurement burden. AMBHA's Performance Measures for Managed Behavioral Healthcare Programs (PERMS 2.0) (14) contains a preponderance of utilization measures, appropriate for a trade association for managed behavioral health care organizations, which principally manage resource utilization. Physicians are trained intensively in technical clinical processes, such as diagnosis and treatment interventions. Thus it is not surprising that the American Psychiatric Association's set of measures emphasizes technical quality of care. Lacking such clinical training, consumers and families often rely on personal experience to identify problems with quality; the consumer-focused measures of the Mental Health Statistics Improvement Project (MHSIP) focus on interpersonal experiences (51). More subtle differences emerge even among groups allied in many areas. Family advocates have encouraged evidence-based measures of medication use and assertive community treatment outreach, while consumers have advocated for measures that promote autonomy, generally by emphasizing such topic areas as recovery, peer support, and housing assistance.
Several opportunities to identify preliminary core measures for mental health care will present themselves over the next few years. The multistakeholder process begun last year at the Carter Center continues to pursue common process and outcome measures for adults and children with mental health and substance use disorders. The American Medical Association's Physician Consortium for Performance Improvement plans to join with other organizations to produce a consensus set of measures for depression. The Agency for Healthcare Research and Quality has funded a National Quality Measure Clearinghouse to disseminate detailed information about selected measures in each area of medicine, including mental health.
The challenge to policy makers, stakeholder group leaders, and measurement methodologists is to work together to select a set of measures that reflects each of their priorities enough to warrant individual participation but that also covers enough common ground to justify broad use. There is widespread anxiety among stakeholder groups that, once selected, these measures—and the underlying treatment processes—will rapidly receive disproportionate attention. Policy leaders might gain stakeholder confidence by emphasizing gradual implementation of preliminary measures designed initially to provide individuals and institutions with confidential feedback for internal improvement activities. Experience with such measures will allow users to improve their feasibility and will generate data to evaluate validity and develop benchmarks. After iterative cycles of measure development, use of the measures for oversight activities and public disclosure may be better received. Fears of undue focus can be assuaged in part by rotating some of the measures in a core set over successive measurement cycles. However, continuous use of some measures allows for an examination of trends over time.
Process measures are most useful when combined with complementary methods of quality assessment. Clinicians can use outcome measures to compare the progress of their patients with that of patients treated at similar facilities. Adding process measures can then highlight areas for improvement when outcomes are lagging (20,21). Simple population-based process measures can indicate whether a patient is receiving an appropriate form of treatment. For example, such a measure will reveal whether an individual with unstable symptoms of schizophrenia and multiple hospitalizations is enrolled in an assertive community treatment program. More complex fidelity measures can be used to "drill down" to evaluate the quality of an individual assertive community treatment program in greater detail (52).
Assessment of patients' perceptions of care provides information about interpersonal process to complement the technical detail of process measurement (53). Another potential linkage is between measures that identify gaps in quality and the availability of effective models for improvement. For example, health plans that score poorly on the NCQA's evidence-based depression measures may be motivated to consider quality improvement models for depression such as those developed by Wells and associates (54) and Katon and colleagues (55).
Further experience with core measures will in turn allow for further refinement of the concept of a single core set from a societal—that is, a broadly based—perspective. It may be that a "core menu" of measures is a more useful vision, with subsets used for individual purposes (quality improvement versus purchasing), settings (specialty versus primary care), and populations (competitively employed versus psychiatrically disabled groups). Despite the obstacles inherent in selecting core measures, we should not lose sight of the advantages: lowering measurement burden, focusing resources for development and testing, and improving the interpretability of results. Each of these steps will advance the mission of identifying quality problems and improving care for mental and substance use disorders.
This work was supported by grant K08-MH001477 from the National Institute of Mental Health, by grant R01-HS-10303 from the Agency for Healthcare Research and Quality, and by the Substance Abuse and Mental Health Services Administration.
Dr. Hermann is assistant professor of psychiatry, health policy, and management at Harvard Medical School and School of Public Health and director of the Center for Quality Assessment and Improvement in Mental Health at the Cambridge Health Alliance. Dr. Palmer is professor of health policy and management and director of the Center for Quality of Care Research and Education at the Harvard School of Public Health. Send correspondence to Dr. Hermann at the Department of Psychiatry, Cambridge Hospital, 1493 Cambridge Street, Cambridge, Massachusetts 02139 (e-mail, firstname.lastname@example.com).
A framework for selecting core quality measures
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A bishop's first impression
PASSAU — Just inside the German border with Austria, Passau is a midsized university city of 50,000 where three rivers, the Danube, Inn and Ilz meet. At the confluence of the rivers, it appeared that the Inn, which has its headwaters deep in the Alps, provided more flow and stronger current than the Danube.
Passau has a long history of once being the largest Catholic bishoprics in Holy Roman Empire. It continues this tradition with 55 churches in the city. During a Sunday morning walking tour, we visited St. Stephen's Cathedral, where services were just concluding. It was the first Mass said by Passau's new bishop, Dr. Stefan Oster, who was just invested the day earlier. The 48-year-old native of Amberg, Germany, passed by us on exiting the cathedral and appeared to look more than a Hollywood leading man than a bishop.
In an appealing historical center, Passau has many Baroque buildings designed by Italian architects after fire destroyed most of city in 1600s.
Rowing on the river
VILSHOFEN — This is where Amacerto ended our Danube journey. A small town of 17,000 residents with winding streets beneath the twin spires of the Benedictine monastery of Schweikberg, Vilhosfen is where two rivers, the Vils and Wolfach, flow into the Danube.
On those rivers, we saw members of an active rowing club practicing their rowing techniques. One member was on the Olympic champion eight-man shell.
Next, we bused north to Regensburg to end our days on the Danube.
Big-box ubiquity
REGENSBURG — This midsize German city on the Danube has the reputation of having one of the best-preserved — and rebuilt — historical centers.
A smaller part of the old town is on an island between the Danube and a canal. The historical Stone Bridge, currently under reconstruction, leads to the main part of the old town with all kinds of shops and restaurants on the sometimes narrow streets.
The local cathedral, The Dom of St. Peter, is one of the architectural gems of the city. We had lunch in an outdoor café next to the cathedral. We were not alone; a Viking River Cruises ship was in port, and we encountered any number of tour groups along the way.
Although known the city is known for its picturesque city center, on entering and leaving Regensburg in our tour bus, I couldn't help but notice the cluster of big-box stores along the main thoroughfare. Even Regensburgers, staunchly proud of their historical center, want those kinds of shopping options.
Bavarian history
MUNICH — We started our visit to Munich — the capital of the Free State of Bavaria, which has some of the same state-pride attitude as Texas — with a walking tour as a light rain fell.
We made our way to the Marienplatz, where groups of tourists holding hundreds of cameras and cellphones waited until the Glockenspiel figures in the tower came to life in the new Rathaus (city hall).
Dinner in a traditional German restaurant with plenty of bratwurst and beer followed.
Later, historian Dr. Marcus Urban outlined the history of Bavaria as part of the Holy Roman Empire until Napoleon marched in early in the 19th century and ended reigns of prince-bishops. How state known for "Gemütlichkeit" could have been the birthplace of the Nazi party in the 1920s is hard to explain, he said, except to say that Bavarians are traditionalists who were frightened by the abortive takeover attempt by the communists after World War I and found Hitler and his Nazi Party the less threatening of two choices, especially in the wake of hyperinflation that made most German currency worthless.
Since World War II, Munich has grown from the home of farms and breweries into an economic powerhouse as home of BMW, Audi, Siemens and countless "mittelstand" — middle-sized — manufacturing firms. Unemployment is among the lowest in Germany.
But there is still beer poured down in Munich, and plenty of it, at numerous beer halls, restaurants and outdoor beer gardens. The Nazi Party is long gone, but "Gemütlichkeit" lives on. Prost!
• Sam Matthews, Tracy Press publisher emeritus, has returned from a trip in Europe. He can be reached at email@example.com or 830-4234.

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The NCH Healthcare System is a not-for-profit, multi-facility healthcare system located in Naples, Florida, United States. The System is more than just two hospitals (referred to as the NCH Downtown Naples Hospital, and NCH North Naples Hospital) with a total of 715 beds. The NCH Healthcare System is an alliance of 650 physicians and medical facilities in dozens of locations throughout Collier County and southwest Florida. The services offered by the NCH Healthcare System are extensive. Inpatient services include: medical, surgical, cardiac, orthopedic, obstetric, pediatric, rehabilitative, psychiatric, oncology, emergency treatment, and diagnostics. Outpatient services include: rehabilitation, home care, walk-in centers, wound healing, and more. This year the system had 37,284 admissions, 87,100 emergency room visits, 3,033 births, 416 open heart surgeries, 11,282 surgical procedures, and 3,000 employee colleagues. NCH is a member of the Mayo Clinic Care Network.
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Stay at one of our Edmonton hotels to be close to the city's frontier attractions and West Edmonton Mall. West Ed, as the locals call it, is not just the largest mall in North America; it's a multipurpose shopping and entertainment complex.
Explore Alberta's easygoing capital from the comfort of our hotels in Edmonton. Even if shopping is not on your agenda, West Edmonton Mall offers plenty of diversions for visitors. Kids will find hours of playtime in the mall's amusement rides, waterpark, ice rink and aquarium. Don't miss Fort Edmonton Park, Canada's largest living-history museum. From May through Labor Day, costumed guides, historical reenactments and old-fashioned steam-train rides bring to life the city's rough-and-tumble frontier past. From our Edmonton hotels it's easy to zip downtown on Edmonton's fast and economical light-rail transit. Budding naturalists can spend hours at the Royal Alberta Museum, just west of downtown, where the region's wild world is imaginatively highlighted in lifelike dioramas. Bugs get the star treatment at the museum, which holds one of Canada's largest collections of bees and wasps. Admission is half-price on Saturday and Sunday mornings.
From our hotels in Edmonton, you can take part in Edmonton's lively year-round calendar events. 'Festival City' has some 30 festivals annually, ranging from music and dance to theater and family fun. Many of the top events, including the acclaimed Fringe Theatre Festival, take place in and around the Old Strathcona and Whyte Avenue districts. It's a great place to dine year-round, where you can savor international cuisine at the latest ethnic hot spot or order a brew and burger at a friendly pub.
Book a room at our Holiday Inn® Edmonton hotels for year-round festivals and easy access to the city's exciting shopping, dining and entertainment opportunities.
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Point2Point Airways, the Grand Forks, N.D.-based on-demand "airline style" charter company, ceased operations recently and laid off all its employees. The company was formed in 2002 to respond to what it called a lack of connectivity in the Great Plains region.
A Notice of Proposed Rulemaking (NPRM) seeking to make major changes to Parts 61, 91 and 141 closes for comments today. Among the proposed changes is the addition of training standards for night vision goggles and the combination of simulator training regulations into one section.
Irish entrepreneur Dermot Desmond has acquired majority ownership of Zurich-based ExecuJet Aviation Group, the company announced today. Though the terms were not released, Desmond will hold more than 51 percent of ExecuJet and join the board as chairman.
Honeywell has gone on the record as saying that the transponders aboard the Embraer Legacy involved in September's fatal midair with a Gol Airlines Boeing 737 were working properly at the time of the accident.
Jet Aviation is here at EBACE'07 (Booth No. 776) with recent news of its launching a $35 million investment program at its Basel facility to add ramp space and a hangar large enough to accommodate an Airbus A380 and a Boeing B747 simultaneously.
March marked the 30th anniversary of the creation of the European Business Aviation Association (EBAA). Since 1977, the Brussels-based group has defended the concerns of an industry that is steadily expanding.
The European Business Aviation Association (EBAA) has never had more work on its plate and the industry has never had a greater need for the group's lobbying efforts on its behalf.
Avionics manufacturer Rockwell Collins announced that its Pro Line 21 Integrated Display System (IDS) has been certified for the Piaggio 180.
Snecma is progressing with its plans to develop a turbofan in the 10,000-pound-thrust class. Last October, the French manufacturer revealed plans to enter the business jet engine market. Design of the Silvercrest powerplant is well under way and the core should run later this year.
New regulations being developed by Europe's Joint Aviation Authorities (JAA) may soon enable operators of HUD-equipped aircraft to hand-fly Cat II and Cat IIIA precision approaches and conduct Cat I approaches with a reduced runway visual range (RVR) of 400 meters instead of 550.
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The Nike Rosherun is a new model by Nike Sportswear and combines a very breathable mesh upper with a Nike Free inspired Lunarloon Outsole. The Rosherun can be worn barefoot and features a removable inlaysole.
DHL Premium
Tax-Free:If you are living in an non-EU country your order is free of sales tax(which is 19%).


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All-C-USA First Team Honoree (2012, 2013)
2013 (SOPHOMORE): Finished sixth in the 8K at the C-USA Championships ... ran the 5K for the Miners at the Lobo Invitational and Kachina Classic, placing third at both meets ... finished in third place at the Lori Fitzgerald in the 5,500 meter run ... posted a 24:43.7 at the Notre Dame Invitational to finish 15th in the 8K and a 24:32.7 in the same event at the Pre-National Invitational ... ran a 10K personal best of 30:18.9 in the at the NCAA Mt. Region Championships ... concluded the season with four top-10 finishes.
2012 (FRESHMAN): Clocked in a personal-best time of 23:54.2 at the NCAA Pre-National meet in the men's 8K race ... earned All-Conference USA first team honors after registering a sixth-place finish with a time of 24:19.0 ... was the second Miner to cross the finish line at the NCAA Mt. Region Championships posting a time of 31:05.5 in the 10K ... opened the season with a second-place finish at the Lori Fitzgerald meet recording a time of 15:09.80 in the 5K ... wrapped up the season with four top-10 finishes.


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Friday, September 24, 2010
© Copyright 2014 Albany Herald
DAMASCUS -- Southwest Georgia Academy seniors Taylor Tabb and cousin Troupe Tabb combined for -- count 'em -- eight touchdowns Friday night in a 58-21 win against Harvesters Christian as the Warriors (3-1, 1-0 in Region 3-AA) opened region play with a win.
Taylor Tabb, The Herald's only preseason Dynamite Dozen selection from a GISA program, had 16 carries for 228 yards and three touchdowns -- one of them receiving from quarterback Dillon Driver, who threw two -- and also picked off two passes and returned one for a score. Troupe Tabb carried 10 times for 76 yards and three scores -- again, one of them receiving from Driver -- and, like his older brother, also picked off two passes and returned one for a TD.
SGA now gets set to host Valwood at home next week.
Nick Beaver rushed for three TDs -- of 19, 17 and 20 yards -- as the Eagles (1-2-1) got their first win of the season, as well as opening up Region 2-A play with a win.
The Eagles welcomed a new QB in Zach Hurst, who replaced starter Chris Rogers (torn ACL). Hurst commanded the offense to a 35-0 halftime lead on scores from Beaver, Levi Griffin (8 yards and 7 yards) and one from Brian Ambrose (2 yards). The Eagles ran for 284 yards on the night, including the longest score of the game from freshman Josh Brunswick from 45 yards out to cap TAE's scoring.
J.T. Edore scored the first three touchdowns for the GISA Class A No. 1-ranked Wildcats, then older brother Jake Edore scored twice to lift Westwood to a perfect 5-0 start overall and a 1-0 beginning in region play.
Westwood's other two TDs were scored by John Vereen and Brody Collins, both coming on the ground.
The Greenwave led, 8-6, at halftime, but a different Pirates team emerged from the locker room after intermission.
And when they did, Marvin Grant (two TDs, 68 yards on each), T.T. Barber (one TD, 1 yard out) and Jack Edwards (one TD, 18 yards) ran wild for Miller (3-1, 1-0), which opened Region 1-A play up with a win, while Terrell (1-4, 0-2) remained winless in region play.
"We hadn't played in 10 days, and we just didn't have the intensity and focus in the first half," Miller coach Frank Killingsworth said. "We got refocused at halftime and came out strong."
The Greenwave's lone score came from quarterback Jerkerious Scott from 1 yard out, while Tim Bennett added a safety. The Greenwave, however, were blanked in the second half.
"We have to learn how to finish games," Terrell coach William Huff said.
Miller's Marcus Bullard also picked off two passes, while Barber also had nine tackles and Grant finished with 168 yards rushing.
For a while, Bainbridge looked ready to pull off the biggest upset in Georgia, but the Bearcats couldn't stay with Northside, Warner Robins, the top-ranked Class AAAA team in the state which stayed unbeaten with a 35-14 win in the Region 1-AAAA opener for both teams Friday night.
Bainbridge got two touchdowns from Aaron Hall, who caught a 10-yard TD pass from Steven Bench and scored on a 62-yard run to keep things at 14-14, but Northside (4-0) scored with 24 seconds left before halftime, then shut out Bainbridge (2-2, 0-1 in Region 1-AAAA and 2-3 overall) in the second half.
Daylon Blanton, in place on injured starting quarterback Grant Kimbrel, rushed for 115 yards on 17 carries and scored twice as the Patriots (2-3, 1-0) picked up their first Region 2-A win. Matt Kendrick added Randolph's other TD on a five-yard rush.
Randolph travels to face Crisp Academy next week in another region game.
The Indians were in a "dogfight" early with the state power Purple Hurricanes and actually sat tied, 0-0, after the first quarter.
But Fitzgerald scored three times before halftime -- one of them coming with 18 seconds before intermission -- and all Albany could manage was two Daniel Castenada field goals after five trips inside the Purple Hurricanes' red zone.
"It was a dogfight at first, and we played well, but as everyone knows, if you make mistakes against Fitzgerald, they make you pay," Albany coach Felton Williams said. "We missed some tackles and the defense really took a step back (Friday night), but on offense, we also have to come away with more than field goals when you get inside their 20 five times."
Albany falls to 1-3 overall and 0-1 in Region 1-AA as the Indians travel to Berrien next week.
One week after the Bobcats' first victory, which came against Westover, they ran into the buzzsaw that is the state powerhouse Bulldogs, who racked up only 328 yards of total offense to Early's 331, but took advantage of three lost Bobcats fumbles in the win.
Ladonis Bryant, who passed for more than 100 yards Friday, tossed Early's first score of the night in the first quarter to Devontay Spencer from 16 yards out, then Bryant found Quayven Levatte from 65 yards out in the third quarter as Ricardo Castro converted both PATs.
Bryant capped off Early's scoring in the fourth quarter with a 46-yard TD run, but it was too late at that point as Early fell to 1-4 on the season and opened Region 1-AA play with a loss.
The Bobcats, who racked up 197 yards rushing on the night, are off next week, then travel to Fitzgerald.
Southland broke up a 14-14 tie with two fourth-quarter touchdown runs from Collin Holloway to knock off Tiftarea. The Raiders improved to 2-1 in GISA Region 1-AAA and are 3-2 for the year. Tiftarea dropped to 1-4 and 1-2 in the region.
Holloway scored three times. He had a 6-yard TD run in the first half, and then scored on a 10-yard TD run to lift Southland to a 21-14 lead, and finally scored on a 5-yard TD run late in the fourth quarter to put the game away. He finished with 73 yards on 15 carries.
Southland quarterback Jake Hood was the workhorse, gaining 165 yards on 22 carries. He scored on a 10-yard run.
More like this story
- FRIDAY NIGHT PREP FOOTBALL ROUNDUP: Terrell County knocks off previously unbeaten, Herald No. 3 Randolph-Clay ( October 8, 2010 )
- FRIDAY NIGHT PREP FOOTBALL ROUNDUP: Driver's big night lifts SGA past previously unbeaten Valwood; R-C's Curry scores four times as Red Devils stomp Stewart; Hardaway nips Bainbridge, 21-20 ( October 1, 2010 )
- FRIDAY NIGHT HIGH SCHOOL FOOTBALL ROUNDUP: Worth shakes up state rankings with stunner; Bainbridge wins thriller vs. Early in final seconds ( August 27, 2010 )
- FRIDAY NIGHT PREP FOOTBALL ROUNDUP: Bainbridge wallops Westover; DWS doubles up on Bethesda ( September 10, 2010 )
- FRIDAY NIGHT PREP FOOTBALL ROUNDUP: SGA wraps up first Region 2-AA title under Bell with win against Flint River ( October 29, 2010 )


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A Middle Tennessee family is starting off the new year with new hope, as their son makes a remarkable recovery after a brain lesion was removed from his head.
Each day, 17-year-old Nathanael Price is making progress.
"I'm doing good," he said.
He is recovering from brain surgery after suffering from seizures since he was a child.
"You know if you get cold and your body shivers? Like that, just more aggressive," he said.
Price recalls that his left side would shut down almost as if he had a stroke.
Then, when he was 13, doctors finally diagnosed him with an Arteriovenous malformation, or an AVM. The condition causes tangles in both arteries and veins in the brain. Those vessels weaken over time, which can lead to significant bleeding.
"He played soccer, basketball and football and then his world had to come to a halt because those were no longer allowed," said mother Cindy Price.
Doctors tried several treatment options, including two rounds of radiation, but Nathanael Price wasn't getting better.
His family says many doctors thought that removing it was too risky.
"They are the most difficult lesions we treat as brain surgeons," said Dr. Robert Spetzler, Barrow Neurological Institute.
Spetzler is the Arizona surgeon who eventually removed the lesion on his brain. It was a complex treatment, given where the AVM was located.
Following the surgery, Nathanael Price had to undergo weeks of physical and speech therapy.
He's also still recovering from a bleed that happened after surgery.
"To be able to take that life and put it on a path of normal life expectancy, that is incredibly gratifying," Spetzler said.
Now, Nathanael Price is focused on his recovery and is making great progress. He's looking forward to once again spending time outdoors and future mission trips - something he's passionate about.
Later this year, doctors will check on Nathanael Price's progress by doing a MRI scan. They think he'll be in good shape and expect he'll make a great recovery with time.
Copyright 2014 WSMV (Meredith Corporation). All rights reserved.


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Census Records | Vital Records | Family Trees & Communities | Immigration Records | Military Records Directories & Member Lists | Family & Local Histories | Newspapers & Periodicals | Court, Land & Probate | Finding Aids
Contact me at:
This website in dedicated to my grandfather Sergeant Leonard Patrick Murphy who was in the Veterinary Corp in WW 1. Leonard was with the Veterinary Hospital No. 18 assigned to Sougy France south of Paris. Leonard crossed the Atlantic Ocean bringing horses and supplies to the War effort in Europe in 1918. Leonard was borne to Patrick and Margaret Rogers Murphy who farmed in Polk County Wisconsin in the area of Milltown and grew up on the farm. Patrick's father William Murphy and wife Mary Clancy Murphy farmed in the Long Lake, Balsam Lake area.
Sgt. Leonard Patrick Murphy Veterinary Hospital No 18, Sougy, France 1919 WW1.
Leonard Patrick Murphy in WW1 website
Click on the below link:
Leonard Murphy in WW1
Click on the below link:
Veterinary Corps in WW1
Look-ups from the book POLK COUNTY WISCONSIN IN WW 1 published in the year 1919 are available for the men that served from Polk County Wisconsin during World War 1. This book lists those men with a brief description of their service record and many times with a picture. Please feel free to e-mail me. Just click on greg krenzelok at the top of the page.
107th Field Signal Battalion, 32nd Division, repair telephone lines in France WW1
Introduction page to Polk County Wisconsin in WW1
Example page from the book. The red dot in Leonard Murphy's listing
Those that died is Service
Those that Served names starting with A
Those that Served names starting with B
Those that Served names starting with C and D
Those that Served names starting with E and F
Those that Served names starting with G and H
Those that Served names starting with I and J
Those that Served names starting with K and L
Those that Served names starting with M
Those that Served names starting with N,O and P
Those that Served names starting with T and V
Those that Served names starting with W, Y and late add on's
Other Service Men
Polk County's Nurses and US Army Division Chart
This is a work in progress due to waves on the pages not all scans are clear. Please e-mail me if you need a clearer scan
I can also do look-ups from the book Wisconsin in the World War (WW1)
Important Notice to future Murphy family researchers: Byron and his wife Mary Doyle published a very limit amount of copies of books on the Murphy family history and also the ROGER Family. It is a very complete book of our Murphy and Roger's line from Ireland to America. The book was published in 1981 and Byron donated a copy to the Church of Jesus Christ of Latter-day Saints and this book is at their library in Salt Lake City. You can also go to their website
Click on the below link:
Church of Jesus Christ of Latter-day Saints Website
To confirm that they do have the book: Go to the FAMILY HISTORY LIBRARY SYSTEM and click on SEARCH THE FAMILY HISTORY LIBRARY CATALOG FOR RECORD AND RESOURCES. Now click on AUTHOR SEARCH put in DOYLE in the surname box and BYRON in the first name box. Click on search and click on DOYLE, BYRON, DANIEL, 1917 and you will find the listing for the Murphy Book and the Rogers book. Byron's mother Rose was Leonard's sister. Byron and his wife Mary worked very hard and did a wonderful job on tracing our Murphy family history in this book. Many of the families did buy this book at the time of publishing in 1981 but now copies are very rare. It is good to know that if the family did want to research this book it is available at the Church of Jesus Christ of Latter-day Saints in Salt Lake City
Microfilm copies of the MURPHY AND ROGERS BOOK are available by contacting the Church of Jesus Christ of Latter-day Saints(LDS)at their research centers in your area or at their library in Salt Lake City
I would be happy to do look-ups from the MURPHY BOOK if you can send me a list of 2 or 3 generations starting no later than 1981 of your family tree or you can for sure trace your family to the Polk County Wisconsin Murphys.
Leonard, Sylvester and Veronica at their parent's Patrick and Margaret Roger Murphy farm Milltown 1906
Click on the below link to go to the "Our Family the Murphys Website"
Murphy Family of Polk County Wisconsin
The Polk County Murphy's are descendants of James and Mary Anne O'Donnell Murphy who lived at the estate of Ardglass in Co. Cork Ireland. James and Mary were borne in 1790 according to the MURPHY BOOK. They had 8 children and 4 of their children Sarah, Bridget, Margaret and William came to America. William and his wife Mary move to Long Lake in around 1860 to start their farm. William is Leonard's grandfather. Leonard Murphy married Esther Hoppe Kulibert Murphy.There children were Emmett Murphy and Geraldine Murphy Krenzelok.
Click on the below links:
Veterinary Corps in WW1
Click on the below link to go to: WW1 Army Insignia Identification page
WW1 Army Insignia Identification.
Fort Ord Equestrian Center and Station Veterinary Hospital
Motto: "Illic est Vires in Numerus" There is Strength in Numbers
"Working Hard to Preserve Our Country's History wherever it is being lost"
U.S. Army Veterinary Corps Historical Preservation Group is a group of individuals that are concerned about the preservation of the History of the Veterinary Corps, Remount Service and Cavalry or wherever our country's history is being lost in conjunction with our beloved "Horse and Mule". There is no cost to join and membership is for life. We believe by uniting together in numbers we will be a more powerful force to be heard. Our membership list is private and only used to contact our members. Email us and become a member.
Greg Krenzelok
FACEBOOK: U.S. Army Veterinary Corps Historical Preservation Group
Click on the below link:
U.S. Army Veterinary Corps Historical Preservation Group


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Narrow your search
Dag Kittlaus, who co-founded Siri, the company that created the service that has become a cornerstone of the iPhone 4S, has left Apple.
Raptr has also raised an additional $15 million, led by DAG Ventures and Tenaya Capital. It now has $27 million in funding.
The Commission on the Theft of American Intellectual Property has submitted a report to the US Congress proposing anti-piracy measures and is considering the government-sanctioned use of ransomware.
The software giant posts several job openings to work with its speech recognition personal assistant that will "help build out new areas of expertise for Siri."
Apple's sassy voice assistant has a new boss who used to run Amazon's search technology, a new report claims.
Adam Cheyer, another co-founder of the sassy voice assistant found in Apple's iPhone and (soon) iPad, has left the company.
In one story, a girl tells a boy she will sleep with him if he gets 1 million Facebook Likes. In another, a dad tells his kids he will get them a puppy for the same "achievement." Is the world demented?
One True Media, which makes the small-business-focused SpotMixer ad creation software, has also been named an "authorized reseller" for the video arm of Google's AdWords service.
According to one of Siri's creators, late Apple co-founder Steve Jobs was not initially enamored with the name.
The new service means wireless carriers can sell customers a way to seamlessly make transactions at any credit card terminal with their phones, and no hardware has to be changed.


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- 13 total posts
- 1 review
- 12 comments
Reviews by PointLomaDave
Septoplasty / Rhinoplasty in Less Than a Week! - San Diego, CA
Cost is after insurance btw, my portion after deductible and 20%...in other words, my total out of pocket for the procedure. I had surgery for a deviated septum when I was 15 due to breathing troubles. Now at 37, it's become clear that my surgeon back then botched the job and failed to... READ MORE
Recent comments from PointLomaDave
What is difficult is from going from something that almost seemed good enough to being disfugured again. Time will tell as the swelling goes down as there is still more than a bit of swelling at the incision site that will take more... READ COMMENT
Good for you. And all your update pics look great! I'm feeling about the same as you. It's feeling more normal but wondering when it'll feel completely norm. Insurance finally paid, and not near as much as I had been expecting. =( ... READ COMMENT
I'll PM the doc's name after I get all the billing figured out. That will be part of my "worth it" rating as well. READ COMMENT
I dunno on the spreader grafts. I tried to not ask too many details. I think years ago I was watching a tv show where a doctor was getting ready to break someone's nose with a hammer and I had to look away. I decided I didn't want to... READ COMMENT
Mine was done "open." Thanks for the compliments =) READ COMMENT


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Two forces—the downturn in the current economic climate and server virtualization and consolidation—are placing IT into an even tighter pinch. Thomas Stockwell shows you how automated monitoring, alerts, and consoling on IBM Power Systems can put your organization on the path to success in this new world.
Everything you need to know about IBM i, you learned in kindergarten. In this webinar, learn how StandGuard Anti-Virus can help you ensure the data stored on your Power System is clean enough to make your mother proud.
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Discover the Bytware solution for your system monitoring and security needs.
Attend an upcoming webinar or review the great information in our resource library.
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Senior PGA Championship
Joe Durant leads Senior PGA Championship after first round
Durant birdied his final hole Thursday for a 6-under 65 and a one-stroke lead after the first round of the Senior PGA Championship . Making his third Champions Tour start after turning 50 in April 7, the four-time PGA Tour winner had seven
Trump courses to host a PGA, Senior PGA championship
partnership Thursday that will bring the 2022 PGA Championship to Trump National Golf Club in Bedminster, N.J. The Senior PGA Championship will go to Trump National Golf in Potomac Falls, Va., in 2017. Trump has 17 golf courses around the world
Colin Montgomerie wins for 2nd straight week on Euro Senior Tour
the fifth time in 10 career European Senior Tour starts. He has four victories this season, also winning the Senior PGA Championship in Michigan and the U.S. Senior Open in Oklahoma.
Colin Montgomerie wins Russian Senior Open
the fifth time in 10 career European Senior Tour starts. He has four victories this season, also winning the Senior PGA Championship in Michigan and the U.S. Senior Open in Oklahoma.
Bernhard Langer on dominant run heading into U.S. Senior Open
not the first significant event. Jeff Sluman won the 1988 PGA Championship at the course and Haas won the 2006 Senior PGA Championship . Langer said Oak Tree is a good and difficult course. "I would think it's the hardest course I have ever
Cleveland Rocks: 5 Places LeBron Can Work On His Golf Game
Amateur Championship (1968) and the U.S. Senior Open Championship (1986). In 2016, it'll host the Senior PGA Championship . Keeping LeBron's best interest in mind, there's an indoor practice facility that would allow him to keep
Golf Capsules
made a putt on No. 18 to par the hole and claim the win. Montgomerie became the fifth golfer to win both the Senior PGA Championship and U.S. Senior Open in the same year. He led at the end of the first and second days of the Senior Open
PGA Championship hole-by-hole course preview
has an impressive championship history – having thus far been home to PGA Championships in 1996 and 2000, the Senior PGA Championship in 2004, and the Ryder Cup in 2008. The PGA of America bought the club in 2000 for good reason. Valhalla's
PGA Championship: Stricker still hasn't ruled out Ryder Cup
weekend for the first time since the 2010 British Open at St. Andrews. Montgomerie qualified by winning the Senior PGA Championship (he also won the U.S. Senior Open this year). He had a 72 on Friday to make the cut with one shot to spare
Golf Capsules
bird kept flying before Walker made another par. SENIOR PGA CHAMPIONSHIP BENTON HARBOR, Mich. (AP) - Tom Watson shot a 3-under 68 for a share of the lead in the Senior PGA Championship with fellow Hall of Famer Bernhard Langer and


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Maryland health insurance exchange
Despite site snags, MD tops enrollment goals with 372,000 covered
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- By Carla Anderson
- healthinsurance.org contributor
- July 24, 2014
The open enrollment period for Obamacare in Maryland has ended for 2014. People who get married or divorced, change jobs, have a child or experience another qualifying event may be eligible for a special enrollment period. Enrollment for Medicaid and the Children's Health Insurance Program (CHIP) continues throughout the year. Individuals who don't have health insurance that provides minimum essential coverage may have to pay a penalty: $95 or one percent of income, whichever is greater. Some individuals, such as those who are uninsured less than three months of the year or who recently filed for bankruptcy, are exempt from the penalty. See HealthCare.gov for a full list of exemptions.
Open enrollment for 2015 coverage through the marketplace begins Nov. 15.
Maryland Health Connection, the state-run marketplace, has experienced numerous challenges including technical problems, legal disputes, the executive director's resignation, and more.
Severe technical problems have plagued the Maryland Health Connection website. Some consumers who were unable to sign up for private insurance were temporarily enrolled in the state's high-risk insurance program, at the state's expense. Problems with determining who qualifies for Medicaid means the state may make about $20 million in unnecessary payments over two years. Maryland fired its prime contractor, Noridian Healthcare Solutions, and hired Deloitte Consulting to adapt Connecticut's successful technology for use by Maryland. Consultants put the cost of rebuilding the Maryland Health Connection website at up to $60 million.
Maryland Health Connection has been criticized for its lack of transparency. News outlets have informally complained about inadequate disclosure of website problems, and the Kent County News filed a formal complaint with the state's Open Meetings Compliance Board. Industry experts, state and federal legislators, and the state comptroller have all questioned the mostly closed-door meetings during which exchange officials decided to rebuild the state's website rather than transition to the federal site.
In addition, the Maryland Health Benefit exchange, which oversees the marketplace, has repeatedly delayed the launch of the Small Business Health Options Program (SHOP). Work on the SHOP website was put on hold in February, and the launch date pushed back until Jan. 1, 2015. As of April, small businesses can purchase policies and receive tax credits by working directly with insurers or through brokers or third-party administrators (TPAs). Thirteen insurers are selling small-business plans.
Despite all of the problems, Maryland exceeded its enrollment goal of 260,000. As of May 31, 372,517 Marylanders obtained health insurance coverage: about 72,000 enrolled in qualified health plans (QHPs) and 300,000 qualified for Medicaid or the Children's Health Insurance Program (CHIP).
The vast majority of those enrolling in QHPs selected plans offered by CareFirst BlueCross BlueShield. CareFirst captured nearly 94 percent of enrollees, followed distantly by Kasier with about 5 percent, Evergreen Health Cooperative with 0.7 percent, and All Savers (part of United Healthcare) with 0.4 percent.
Insurers submitted rate proposals for 2015 in early June. CareFirst proposed much higher rates in 2015: an average of 26 percent more for individual policies and an average of 6 percent more for small businesses. Kaiser requested a 12.1 reduction, and Evergreen proposed a 10.3 percent reduction. All Savers requested a 4.8 percent increase. Two insurers who weren't part of Maryland's marketplace in 2014 submitted rate proposals for 2015: Cigna Health and Life Insurance and UnitedHealthcare of the Mid-Atlantic. The Maryland Insurance Administration is reviewing all proposals and will announce the final lineup of carriers and rates by late summer.
Maryland was an early adopter of the health insurance marketplace envisioned by the Affordable Care Act (ACA). While many other states waited to see the outcome of the Supreme Court challenge to the ACA, Maryland moved ahead. The Maryland Health Benefit Exchange (MHBE) was signed into law in April 2011, with additional legislation passed in May 2012. The MHBE was later rebranded as the Maryland Health Connection. In December 2012, the Maryland Health Connection was among the first six state-based exchanges to be approved by the federal government.
Maryland Health Connection is overseen by a nine-member board. On June 25, Carolyn Quattrocki was named to a one-year term as executive director of the board. She began serving in that role on an interim basis in December 2013 following the resignation of Rebecca Pearce.
Maryland Health Connection functions as a clearinghouse, meaning any QHP can sell policies on the exchange. Any health plan with significant market share in the state is required to participate in the marketplace. After two years of operation, the exchange has the option to adopt an active purchaser model. Health plans are limited to selling four benefit packages per metal level (platinum, gold, silver, and bronze).
Maryland health insurance exchange links
Maryland Health Connection
Maryland Health Benefit Exchange (MHBE)
Information about exchange planning and development
State Exchange Profile: Maryland
The Henry J. Kaiser Family Foundation overview of Maryland's progress toward creating a state health insurance exchange.
Health Education and Advocacy Unit, Office of the Attorney General
Serves residents and other consumers who receive health care from a Maryland health care provider or health insurance provider.
(877) 261-8807


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MT. PLEASANT, MI (WKZO) - About 50 Tea Party groups in Michigan will be sponsoring a debate between Republican U.S. Senate candidates this afternoon, but front runner Pete Hoekstra won't be there. The former Congressman from Holland reportedly fears it may be a set-up that favors another candidate, and has said he will skip it. Five of the 8 candidates will be at the lectern on the Central Michigan University campus in Mt. Pleasant for the political event that starts at 1PM. Hoekstra claims because the event is linked to a straw poll to be held next month, and because the poll won't reflect the views of all the Tea Party movement, he won't participate. The Tea Party says this is the process they have chosen to pick their candidate.
Roger Hedgecock Show 6:00 PM - 10:00 PM
On Air Now.


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Jeff Simmermon, a coffee drinker who knows how he likes his coffee, walked into Murky Coffee and ordered an iced espresso. The barista, David Flynn, who knows how to serve coffee by adhering to store policies, refused to serve the coffee this way. Apparently, this wasn't a Zen moment for either Jeff or David.
Jeff shared his side of the story and Murky Coffee shared theirs. The Washington Post had a few things to say about it. There's a heated discussion going on over at the coffeegeek forums and numerous blogs have made mention of this coffee controversy, taking one side or the other.
So I thought I'd add my voice to the chorus. Zen is the way of balance, of finding the middle road. Zen is the way of peace and harmony. Well, we all know that didn't happen.
The one thing that no one has considered is: What about the coffee? Coffee beans, by their very nature, are Zen-like and live in harmony. How do you think the coffee felt being pulled into this situation? The sole purpose of a coffee bean's life is to bring you the best cup of coffee it can, filled with its unique flavor. I'll bet the little coffee beans were trembling with fear at this confrontation, maybe wondering if they'd be devoured in an iced espresso or be held captive in the espresso machine. Poor little babies.
I'd like to hear what you have to say about this. Please keep in mind that this is a Zen site and we practice peacefulness here. Maybe we could all stir a little loving kindness into our coffee and take a peaceful Zen moment to meditate on our coffee before we say anything, both on this blog and in our everyday activities. Just a thought...
Welcome to Zen Coffee... A place for coffee and conversation, quiet contemplation and mindful meditation.
Wednesday, July 23, 2008
Coffee Controversy
Posted by Gloria Chadwick at 10:51 AM
Labels: iced espresso, Jeff Simmermon, loving kindness, Murky Coffee, zen, zen coffee
2 comments:
What ever happened to "the customer is always right?" Good lord, (and I mean no disrespect to the humble bean) but if you sell coffee and the cutomer wants his coffee drink over ice, give it to him. What's next? The great sugar controversy?
- July 23, 2008 at 1:51 PM
- Caroline said...
Nice site...thanks for stopping by mine this morning.
My thoughts on this is...give the guy his coffee the way he wants it. The customer should be happy. Maybe the barista needs to re-think his career...b/c if he's not happy in his job...no one will be happy around him.
- July 23, 2008 at 3:37 PM
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As of Thursday, July 26, 2012
© Copyright 2014 Newton Citizen
Throughout the school year, I order my life around the Christian calender. That calendar begins with Advent and ends with Holy Trinity Sunday. But in the summer, I order my life around the blockbuster movie schedule.With many movies to watch -- from "Battleship" to "Batman" -- I'm having a blast counting down from one movie to the next. But, popcorn aside, these kinds of blockbusters make me wonder about peace, war and violence in general.
Over the past two decades, we've seen a resurgence of superhero movies that follow a predictable story line. Superhero wrestles with self and world, doubts whole enterprise, turns vigilante, saves the world.
It's great stuff for summer, but I'm always left wondering where God is in all of this. Of course, God gets one line in "The Avengers." As two demigods fight, one Avenger warns another Avenger: "You don't want to interfere -- they are like gods, you know!" The other one responds, "I only know of one God, and he doesn't look like that." Cue applause in our local Conyers movie house.
He's is right: God doesn't look like that. According to the Bible, God calls us to love our enemies and be at peace with others. We are not avengers, but are to "leave room for God's wrath" (Romans 12:19).
In his letter to the Romans, Paul echoes Jesus' Sermon on the Mount (Matthew 5-7) when he encourages the churches in Rome -- those little communities filled with conflict -- to start acting like the Christians they were called to be.
To God, they are to give all of who they are as an act of worship (Romans 12:1-2). In church, they are to "let love be genuine" (Romans 12:9). In the world, they should "live in harmony" and "bless those who persecute you... and do not curse them" (Romans 12:14).
These are hard challenges because when someone is persecuting, annoying, harassing, or badmouthing us, our first instinct is not to bless. Cursing just comes too easily; blessings are for people who sneeze.
The Bible encourages us to walk a different path because, at the end of the day, we have much more in common with our enemy than we like to admit. "We still wage war," preached William Sloane Coffin, "because we are still at war with ourselves." The darkness we see in others is only but a mirror of the darkness that we still have in our own hearts.
I realized this not too long ago when I became impatient at a grocery store. The deli clerk was in a bad mood and was rude. I got annoyed. She got annoyed. When I left and was walking to my car, I saw a bumper sticker that read, "America can't fix stupid."
I laughed awkwardly because I realized how ironic the sticker was: We always think we're the smart ones! "Be not proud," Paul writes, "Do not repay evil for evil." Humbling words for sure.
If that wasn't hard enough, Paul writes that we are to meet the needs of our enemies (Romans 12:20) and make room for repentance. When we make room for God and repentance to work rather than seek revenge, we make room for God to work in us.
The best way to defeat an enemy is to make your enemy a friend. Besides, we all have something in common: we are human and imperfect. Better we celebrate that fact then end up killing each other in the long run.
This weekend "Batman" will likely become the next cash cow; so, we need to be reminded that, although movies may be fun to watch, in real life we are called to love others because God is love.
The Rev. Joe LaGuardia is the senior pastor of Trinity Baptist Church, 301 Honey Creek Road, Conyers. E-mail him at email@example.com or visit www.trinityconyers.org.
More like this story
- JOE LAGUARDIA: Be faithful to God and you will rise with Christ ( November 2, 2012 )
- JOE LAGUARDIA: Lord's Prayer urges us to seek God's Kingdom in all aspects of life ( July 17, 2014 )
- JOE LAGUARDIA: Jonah's story teaches us God is gracious, merciful, slow to anger, abounding in love ( February 3, 2012 )
- JOE LAGUARDIA: When explaining theology to children, keep it simple ( October 4, 2012 )
- JOE LAGUARDIA: U.S. Christians should take advantage of freedom this country offers to share faith ( January 13, 2014 )


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Opus Interactive Audio Codec
Opus is a totally open, royalty-free, highly versatile audio codec. Opus is unmatched for interactive speech and music transmission over the Internet, but is also intended for storage and streaming applications. It is standardized by the Internet Engineering Task Force (IETF) as RFC 6716 which incorporated technology from Skype's SILK codec and Xiph.Org's CELT codec.
Opus can handle a wide range of audio applications, including Voice over IP, videoconferencing, in-game chat, and even remote live music performances. It can scale from low bit-rate narrowband speech to very high quality stereo music. Supported features are:
- Bit-rates from 6 kb/s to 510 kb/s
- Sampling rates from 8 kHz (narrowband) to 48 kHz (fullband)
- Frame sizes from 2.5 ms to 60 ms
- Support for both constant bit-rate (CBR) and variable bit-rate (VBR)
- Audio bandwidth from narrowband to fullband
- Support for speech and music
- Support for mono and stereo
- Support for up to 255 channels (multistream frames)
- Dynamically adjustable bitrate, audio bandwidth, and frame size
- Good loss robustness and packet loss concealment (PLC)
- Floating point and fixed-point implementation
You can read the full specification, including the reference implementation, in RFC 6716. An up-to-date implementation of the Opus standard is also available from the downloads page.
Version 1.1 released
5 December, 2013
After more than two years of development, we have released Opus 1.1. This includes:
- new analysis code and tuning that significantly improves encoding quality, especially for variable-bitrate (VBR),
- automatic detection of speech or music to decide which encoding mode to use,
- surround with good quality at 128 kbps for 5.1 and usable down to 48 kbps, and
- speed improvements on all architectures, especially ARM, where decoding uses around 40% less CPU and encoding uses around 30% less CPU.
Version 1.1-rc3 released
3 December, 2013
This is the third and likely last release candidate for 1.1. It fixes several bugs in the fixed-point build. Floating point is unaffected. The code is available from the downloads page.
Version 1.1-rc2 released
27 November, 2013
This second release candidate fixes an alignment issue on ARMv5E and improves the Neon optimizations. Other platforms are unaffected. The code is available from the downloads page.
Version 1.1-rc released
26 November, 2013
We're getting closer to the final 1.1 with this new release that further improves surround encoding quality. It also includes better tuning of surround and stereo for lower bitrates. The complexity has been reduced on all CPUs, but especially ARM, which now has Neon assembly for the encoder. At last, there are a few bugfixes. The code is available from the downloads page.
Versions 1.1-beta and 1.0.3 released
11 July, 2013
Following up on the alpha, here's now the beta release for version 1.1. Monty wrote a nice demo page showing off all the improvements in 1.1. As for version 1.0.3 it includes a backport of the new 1.1 surround API (see the demo) as well as some minor bugfixes. The code is available from the downloads page.
Version 1.1-alpha released
21 December, 2012
This is an alpha release for the upcoming 1.1 version. Compared to 1.0.2, it includes quality improvements, optimizations, bug fixes, as well as an experimental speech/music detector for mode decisions. All the fixes and improvements from 1.0.2 are also in this release. Quality improvements include unconstrained VBR, a bitrate boost for tonal frames, and improvements to tf estimation, transient detection and dynamic allocation. The code is available from the downloads page.
Version 1.0.2 released
6 December, 2012
Opus 1.0.2 fixes an out-of-bounds read that could be triggered by a malicious Opus packet causing an integer wrap-around in the padding code. Considering that the packet would have to be at least 16 MB in size and that no out-of-bounds write is possible, the severity is very low. Other changes include fixes and improvements to the PLC and hybrid mode quality improvements. As usual, this release is fully compliant with the Opus specification. The code is available from the downloads page.
Opus Standardized as RFC6716, Versions 1.0.0 and 1.0.1 Are Available
11 September, 2012
It's official, Opus has now been standardized by the IETF as RFC 6716. Along with the RFC are the first stable releases. Version 1.0.0 includes exactly the same source code as the reference implementation in the RFC. Version 1.0.1 also includes minor fixes that were made after the RFC was "frozen". Both releases are available from the downloads page.
Older News


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Earlier today, Sandy Alderson shed some light on what the Mets' plan is for the rotation in 2014.
Some key tidbits:
- Due to the fact that the Mets have a number of starting pitching prospects on the cusp, the club is likely to limit any deal they hand out to a free agent starting pitcher to one guaranteed year. Alderson noted that plan could change, but made it seem unlikely that a multi-year deal would be handed out.
- Jenrry Mejia, who was extremely impressive in a brief stint in the rotation last year, will compete for a spot in the opening day rotation during spring training.
- It's possible that aside from Mejia, Rafael Montero and Jacob deGrom will have a chance to break camp in the rotation. Alderson noted that Noah Syndergaard is a bit behind the two of them as far as his readiness is concerned.
Nothing Alderson said today was surprising, but all of it made total sense.
There are a number of beat writers who are clamoring for the Mets to add starting pitching, but there really isn't a huge need. It would be nice if the club splurged on Bartolo Colon, but it's probably wiser for the Mets to do what Alderson outlines above – sign a cheaper option for one year, and give chances to the young pitchers who are on the cusp.
As far as Syndergaard goes, it would be stunning if he made his major league debut before the Super-Two cutoff date (which will likely be in mid-June). For one, he hasn't pitched above Double-A. Secondly (and more importantly), the Mets can gain an extra year of team control by keeping Syndergaard in the minors until the Super-Two cutoff date passes.
Thanks for reading! Be sure to follow@RisingAppleBlog on Twitter and Instagram, and Like Rising Apple's Facebook page to keep up with the latest news, rumors, and opinion.
Tags: New York Mets Sandy Alderson


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Sir Thomas Sean Connery KBE (born August 25, 1930 in Edinburgh, Scotland) is an Oscar-winning Scottish actor and producer who is best known for his portrayal of James Bond. His character's catchphrase 'Bond, James Bond', has ... moreAdd to my favourites Get these quotes on a PDF
I have always hated that damn James Bond. I'd like to kill him.
Laughter kills fear, and without fear there can be no faith. For without fear of the devil there is no need for God.


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