Sunday, October 19, 2008

WSJ

46 comments:

Ben said...

This idea really inspires me as a project manager! Thanks

Anonymous said...

This is what I am looking for,brilliant idea...

Dr Shoumen Datta said...

Excellent article! Also look at
http://dspace.mit.edu/handle/1721.1/41901
and www.cids.ie/Research/bMDs.html

anil agarwal said...

Excellent article - with good references and supporting data on global health management >Certainly information management regarding medical records and billing is already quite heavily prevalent in the medical field . My wife who is a well established practicing physician has a
>billing company that has a contract with a medical billing service provider in Gurgaon India to do all her billing . This company did go through a major challenge where their previous billing provider also from India went bankrupt and they had a real
>challenge protecting the integrity of their clients data .
>This area certainly has a tremendous capacity for growth and innovation the possibilities are quite endless , however the challenges described are very appropriate and will require major cooperation and partnerhsips across global boundaries . The benefits for the medical field are quite obvious .

Anonymous said...

In “Prescription for Change,” Amar Gupta demonstrated an impressive lack of understanding of the complexity of the issues related to teleradiology. His most egregious oversight is that of the training that would be required to outsource radiology services while maintaining the same quality that patients and referring doctors in the United States demand.
The work of a radiologist in interpretation of Mammograms, MRI, CAT Scans and X-rays has very little in common with other skills that have been recently outsourced. Radiologists in the US have completed 4 years of undergraduate pre-med studies in physics, biology, chemistry, and mathematics before the most qualified are granted entry to medical school where they study for another 4 years in fields of pathology, anatomy, physiology, embryology, and other areas such as medical ethics. After completion of medical school which includes 2 years of clinical rotations seeing patients and assisting internists, surgeons, obstetricians and pediatricians, there is another selection process. Because radiology is a highly desirable field due to the nature of the work, only the most qualified medical students are granted placement in a radiology residency after obtaining high scores on a series of United States Medical Licensing Examinations (USMLE). The newly licensed physician then works as a medical or surgical intern for 1 year, often exceeding 80 hours per week, to become familiar with the disease processes which will affect their future patients. The physician in training will then spend another 4 years in radiology residency before taking the American Board of Radiology (ABR) physics, written and oral examinations. After becoming certified by the ABR many radiologists then spend an additional 1 or 2 years in a fellowship program in a particular area of interest before getting a “real job” working as a radiologist. This represents a total of 15 years of intensive education after completion of high school. As a recent graduate of a subspecialty radiology fellowship program at Harvard University I wish I could tell you that there is some part of those years that were not essential in my training but I cannot. I still see things for the first time and rely on my colleagues for guidance. The idea that it is the mere transportation of medical images to other countries or governmental red tape that limits outsourcing of the medical profession is naïve at best and unethical at worst. Patients in the United States should and do expect that the people interpreting their Mammograms, MRIs, CAT Scans and X-rays have demonstrated the highest level of professional expertise.

Rajesh Wajge (PhD, PMP) said...

Certainly, there may be some unforeseen challenges as well as application of technologies but Dr. Gupta has provided a good summary of where the industry is and where it's headed.

Prof. Natalia Levina said...

As wife of a US board certified radiologist, a professor of Information Systems, and an expert on outsourcing and offshoring, the issues raised by Prof. Gupta are very near and dear to my heart. On one hand, I agree with the anonymous poster by a radiologist who described what it takes to become a board certified radiologist in the United States. An interesting question to ask is: if the US licensing board did not require that radiologists undergo their residency in the US, how many foreign radiologists would be able to pass all three USMLE exams and the Radiology Board exams in the US? The answer is likely to be that it is a non-zero but not a large number; thereby not impacting the economics of radiology profession nor costs of medical care too seriously. The second question to ask is, whether all the work done by US-certified radiologists needs such extensive training. I am not sure about the answer here, but again suspect that there is some work that can be done by less qualified physician (e.g., basic X-rays). The question is who decides about these criteria and whether the licensing requirements will ever be eased.

What Dr. Gupta outlined is an interesting vision, but it is quite far from becoming a reality. Night-hawk radiology services (outsourcing of radiology to US-licensed physicians living in US or abroad) are doing very well. However, they are not lowering the costs significantly because remote radiologists are paid US rates. If you are interested in this issue, you may want to check out a recent study by a group of MIT researchers (http://web.mit.edu/sis07/www/goelman.pdf). It states: “ all nighthawk radiologists who supply readings that inform treatment in U.S. hospitals are certified to provide treatment in each hospital for which they are supplying interpretation, and they are licensed to practice medicine in the state where the hospital is located.” Dr. Gupta argues that this will change in the future as the laws and regulations change. Would it be in hospitals’ interest to change these laws? On one hand, the hospital absorbs the costs of radiology services provided for inpatient care. Thus, they want to save money. On the other hand, they are open to liability law suits from patients and a misinterpreted imaging study is an easy target for lawyers. My sense is that there will be some lengthy negotiation process around this issue sometime in the future which will result in something like “second class license” for a limited set of radiology services with some party (hospitals or service vendors) paying liability insurance costs for these “low-grade” license radiologists. Meanwhile, offshore radiologists will continue focusing on value-adding activities that do not require US license but still improve the quality and cost-effectiveness of care for US patients, for example, 3D reconstructions from radiological studies used in pre-surgical preparation. This is something that was close to unaffordable at US radiologists’ rates but became viable at offshore rates (see Wipro’s website for an example http://www.wipro.com/bpo/hls/cpo.htm ). Now, that is Ricardo working for you!

I command Dr. Gupta for outlining a vision of the future that we can aspire to, but as any new idea it should be moved towards with much care and reflection.

E. Vance Wilson, Ph.D. said...

Prof. Gupta accurately notes that healthcare has been slow to adopt advances in networking and communication IT. This situation arises from a diverse set of causes, including a convoluted system for payment, turf protection, and inflated sensitivity to security and privacy risks. These are wicked problems, as they interweave cultural and political elements that are remarkably resistant to change.

The good news is these problems do not necessarily need to be dealt with at the source. As Prof. Gupta notes, market forces can move healthcare dramatically if they are allowed to have an impact. Certainly these forces include the increasing power and capability of IT, expanding globalization of health treatments, and establishment of effective electronic medical records. But the major potential force is the largely-untapped ability of patient-customers to migrate away from healthcare organizations that do not include them as active online participants by providing meaningful patient-centered e-health connectivity.

Despite professed concerns about security, privacy, payments, and territoriality, healthcare executives will not sit back and idly watch their patient bases trickle away. It is foreseeable that increases in consumer-directed health plans and insured co-pays will combine to give patients real market power. When that day arrives, Prof. Gupta's prognosis will seem to be overly conservative.

Prof. Patrick Wang, IAPR Fellow said...

Dear Amar,
nice hearing you again, and congratulations for the excellent article and interview. You look like a movie star, by the way ^_^.
You have very good points of view, alerting medical people that it's IT age now, and cannot and should not be avoidable.
I particularly like you thoughts: "In the future, there will be three often overlapping modes of delivering health-care services: services performed in person by humans, services that can be performed by people at a remote location, and services performed by computers without direct humaninvolvement. Offshore outsourcing in combination with a 24-hour work cycle will be appropriate when certain conditions are met -- mainly, if the information involved in the task can be digitized, and if workers at different sites can do their jobs independently from one another."
I also agree with you about the so called "privacy" problem conduting experiments inyour inteview.
We have encountered some similar problems when doing research on medical imaging, but have hard time to get "real" data from "real" human beings. Always conflict with the so called "privacy" and confidential information/data. There got be some way to resolve this.
Maybe some kind of proposals can come up for dealing with these important issues,for NIT, or BSF etc.

Thanks for sharing your view, Best regards,

Patrick,
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Prof. Patrick S. P. Wang, Ph.D., ECNU Zijiang Visiting Chair Professor
College of Computer & Information Science
IAPR Fellow and Co-Chief Editor, IJPRAI and MPAI Book Series, WSP IEEE-SMC Outstanding Achievement Award Winner 2007 (Harvard Medical School)
Northeastern University, 360 Huntington Ave, Boston, MA 02115, USA
. . . . . . . . . . . . . . . . . .
(617)373-3711(O), (617)373-5121(F)
pwang@ccs.neu.edu, patwang@mit.edu, yonghsi@yahoo.com
http://www.ccs.neu.edu/home/pwang (in mem of 512 China's earthquake catastrophe)http://ejournals.wspc.com.sg/ijprai/mkt/editorial.shtml
http://www.worldscibooks.com/series/smpai_series.shtml
http://www.isibm.org/leadership.php
http://www.dcs.warwick.ac.uk/~ctli/IJDCF.html International Advisory Board

Patrick
http://www.smc2007.org/index.html, http://www.smc2007.org/tutorials.html
http://www.ias07.org/ , http://www.ias07.org/keynote-and-tutorials.php
http://www.cs.gsu.edu/BIBE07/ , (Harvard Medical School) http://www.cs.gsu.edu/BIBE07/tutorials.php
http://www.world-academy-of-science.org/worldcomp07/ws/tutorials
http://www.e-forensics.eu/program.shtml , (ICST 2008, Adelaide, Australia)
http://isi2008.cpu.edu.tw/ , http://cis2007.hit.edu.cn/ (page 13)
http://broadcom.eng.uts.edu.au/broadcom08/call_for_tutorials.htm http://www.icmlc.com/ (2008, Kunming, China), http://www.icpcm.net/ (2008, Delhi, India) Pervasive Computinghttp://www.visigrapp.org/Keynote_Speakers.htm , (2009, Lisboa, Portugal)

Alvaro said...

I have just read your article and find it very interesting. My organization represents community health centers (CHC) that provide services to low-income uninsured individuals and families. I am wondering if the findings in your article are applicable to the culture and environment of the constituents we serve. Your article seems to apply to hospitals and practices on a global scale. Can you tell me your thoughts on whether or not it would be wiser for CHC to partner with other CHC to form networks and develop strategies for initiating HIT, or is it better to engulf on projects independently?

Andrea said...

Dr. Gupta, I just read your article on The Wall Street Journal website regarding health care information technology revolution and it is quite impressive what is about to happen.

I work on clinical trials and after reading your article I started thinking about the impact that technology can have on clinical trials operations. In my point of view, it seems that it will can improve the monitoring of clinical trials, by permitting it to be performed from office, reducing travel costs and improving timelines for pharma companies as well as permitting subjects to attending their clinic visits at a different site location while travelling. On the other hand, a wide range of issues might come up regarding ethics, financial and contract aspects, and clinical trial regulation.

Having said that, I was wondering what are your thoughts regarding this information technology revolution considering the worldwide clinical trials environment.

By the way, another question that came up is what are the chances to have this information technology being implemented in both developed and developing countries at the same time?

Congratulations for your article!

I look forward to hearing more from you.

Andrea Quintal Portas

Jan Travers said...

Great job on this in sightful article. It forces us to look into the future for issues related to the continual advancement of technology, especially in the healthcare area. Likewise of previous well-received research articles you have written for IGI Global publications, the strength of the article is not just in what it says, but the further thought and brainstorming it elicits for those of us affiliated with the field of information technologies. Keep up the good work.--Jan Travers, IGI Global

nibir ghosh said...

Congratulations to Dr. Amar Gupta for
highlighting an issue that could revolutionise thinking related to information technology and health care. My own perception of healthcare as a Senior Fulbright Fellow 2003-2004 at the University of Washington, Seattle, a trip that took me across to the entire US, is that Medical aid is an extremely exorbitant affair for most folks in the country. It is nice that the article foregrounds the need to look anew at mindsets that promote the status quo. I am sure Dr. Gupta's interesting vision anticipates reality not so far away.
Dr. Nibir K Ghosh, Head, Department of English Studies & Research, Agra College, Agra (India)

Amar Gupta said...

Friends,

First of all, I want to thank you for your comments and suggestions. I have spent most of yesterday and today responding to the comments that I have received through various channels. The vast majority of the comments are supportive of the theme of my Wall Street Journal article.

Patients from foreign countries have been seen by doctors in the US for many decades. They come to the US for surgery and other medical reasons. Further, US doctors give professional opinions to patients abroad after looking at their medical records. The Arizona Telemedicine Initiative (ATP) enables doctors in Tucson to assist patients (including persons in prisons) in Arizona and neighboring states; the same capability is sometimes used to assist patients outside the US. (Details of different forms of telemedicine were highlighted by the pioneers of ATP in a paper in the IBM Systems Journal and in other publications.) It is only recently that the reverse phenomenon has become applicable.

On the issue of radiology, significant research on the pros and cons of teleradiology has been conducted by Professor Sanjay Saini and his colleagues at the Department of Radiology, Harvard University and Mass General Hospital. These individuals have looked at the practice of radiology from multiple perspectives. You can read about the results of his research in the article published by him and his co-authors in the April-June 2007 issue of the Journal of Electronic Commerce in Organizations.

From the viewpoint of organizational dynamics, change is very difficult and painful. We all want change to occur, but we don't want to change ourselves. This is also true in the medical arena.
You can access details of our research and findings in the papers and reports via:

http://next.eller.arizona.edu/publications/ssrn/index.aspx

You can also access several of the papers written by my students on various issues, including different types of healthcare issues, at:

http://next.eller.arizona.edu/publications/recent/

Additional material can be accessed from:

http://next.eller.arizona.edu/

I am providing the above links to assist readers who have requested for advice on specific segments of healthcare.

Initiating change is difficult; managing it is even more. There is a tendency to blame problems that occur to the change, even though they may be entirely unrelated to the process of change. For example, a person may try to blame the recent economic woes of Wall Street to the process of outsourcing in the financial industry; however, there is no evidence to support this assertion.

The US is a major proponent of free trade. Until the time we pursue this paradigm in the US, we need to think of this as a two-way street and leverage it to mutual advantage. Doctors are in short supply in foreign countries too!

Sincerely,


Dr. Amar Gupta

Bill Skerry, Jr. said...

As a patient, if I find myself in a hospital in the early morning hours;I would be fine with a wide awake, qualified, radiologist who may be outsourced reading my films, vs a dead tired U.S. physician.

Amar Gupta said...

Friends,

I have received many messages enquiring why specific products and approaches were not mentioned in my article.

There are 2 reasons: first, Wall Street Journal is very cautious about authors mentioning specific commercial approaches in articles in the WSJ; second, was the constraint of the maximum permissible length.

Several of the messages to me raise the issue of the approach taken by Veterans Administration (VA). In this connection, I should mention that one of my key collaborators is a senior doctor from the Veterans Administration. The work done with him, as well as with other senior and experienced doctors, is desrcibed in detail in my book "Outsourcing and Offshoring of Professional Services: Business Optimization in a Global Economy" that is described at:

http://www.igi-global.com/reference/details.asp?ID=7534

Several of the messages that I have received seek my advice on specific matters. Answers to many of these questions can be found my reading the above book, or by going through the material that my website; I had provided you the links in the message that I posted yesterday.

Finally, I would encourage you to look at the material that is posted in the blog at the site of WSJ at:

http://online.wsj.com/article/SB122426733527345133.html#articleTabs%3Dcomments

Sincerely,


Dr. Amar Gupta

Anonymous said...

Doctor , I wish you would write a story about how ... here in ....
county lost the medical records of my mother and hundreds of others
like her when they were outsourced . She has been in a gereontology study for over 30 years there and they lost all of her records last year when they sent them to India . How sickening is that ? I would like to know how it happened . It is disgusting to lose such valuable records for pennies . I`ll bet millions of records have been lost that way and millions more will be in the future . What good do cheap prices do if the job is botched ? Can you write an article about that too and lay out the cost / benefit analysis ? I`m too stupid to understand it myself . Thank you .

PS:
I can`t guarantee any facts to support my comments , I got the information from my Mom about her records . She went to the records department there and was told by an employee there that the records were sent to India and that was the last they saw of them . That employee also said to her that someone should sue them because that is the only time they ever change things or take responsibility .

Anonymous said...

Dr. Gupta states that the electronic exchange of medical record data will improve clinical quality and efficiency and enable global expansion that will drive health care system efficiencies . While it’s true that medical record information exchange is necessary for increased efficiency and quality, it is not sufficient. Clinical and other data, such as that which resides within health plans, must be interwoven to create the next generation of chronic disease management tools and programs. Patient data must also be protected in a private and secure environment. Doing so requires substantial technical and financial investment, which indeed is happening across the country in the guise of regional health information organizations (RHIOs). RHIOs,with substantial federal and state seed funding , are in fact creating the technical infrastructure to achieve this vision now, not in the future. The opportunity to implement disease management offshore, as Dr. Gupta suggests, presents further opportunity for efficiency.

Gilad J. Kuperman, MD, PhD.
Dr. Kuperman is Board Chair of NYCLIX, Inc., a RHIO in Manhattan.

Noah said...

To Anonymous with the mother who participated in the 30 year study,

First, I would like to offer my condolences regarding the loss of your mother’s medical records. I myself have an ailing mother and I know how difficult it can be to keep your patience when a loved one’s health is at stake. It must be exceedingly difficult to keep from being angered when the institution which is responsible for caring for that loved one puts them at additional risk through the loss of such important data. I must say, however, that your frustration seems misplaced.

I myself work within a hospital maintaining doctor’s records. While the facility for which I work does not outsource patient records, we do maintain a large quantity of data regarding the attending physicians on an off-site server. Throughout the process of ‘outsourcing’ these records, at no time do they physically leave our facility. Documents are scanned on site and transferred directly to the external server via a secured internet connection. When, after scanning a file, I can no longer locate it, I know that I have misplaced it and am therefore responsible for locating it. Likewise, if this hospital ‘outsourced’ your mother’s medical records, they would not have physically transferred them. The shipping rates on that much paper and film would be astronomical as compared to the low cost of scanning these documents in batches to be digitally transferred overseas. Therefore, the idea that ‘the records were sent to India and that was the last they saw of them’ is absolutely ludicrous.

In regards to the employee from which your mother received this information, I will say this. Any information gained from an employee willing to openly suggest litigation against the institution at which they work should be considered highly suspect. That individual is obviously disgruntled. With direct access to the files that have suddenly disappeared, and a vested interest in seeing the outsourcing initiative fail, in terms of maintaining his/her employment, I would argue that this employee who suggested suing the hospital had much more to do with the loss of the documents than any initiative toward outsourcing.

Lastly, and perhaps most difficult to accept, I would suggest that perhaps your mother is no longer entirely lucid, and may not have even had the conversation she is reporting to you. If she is old enough to have been in a gerontology study for more than the past 30 years, it is well within the realm of possibility that she no longer has complete control of her mental faculties.

I know that you and your mother believe in doing things for more than your own benefit from the fact that you put yourselves through the enormous trouble of participating in a medical study for greater than thirty years. Please realize that the initiative to consolidate individual’s medical records is an effort aimed not at saving money, but at increasing the quality and consistency of healthcare globally. The utilization of highly skilled over-seas work forces is a necessary reality at this point to make this an economically viable operation, but the long term goal is not to save money, but to increase the probability of saving lives. This money is being spent just as a large portion of the last thirty years of your life was, as an investment in the wellbeing of future generations.

It is easy to be angry when times are difficult. It is equally easy to lay blame at the feet of change. We do this almost without thinking every time Fall weather rolls in and we catch a bug. But when the argument against change is as non sequitur as that provided by the records clerk at your local hospital, or even when arguments possess some merit, it is important to maintain our rationality and remember our intentions reach beyond even these minor setbacks.

Respectfully Submitted,

Noah Curtis

Amar Gupta said...

Friends,

I have checked on the situation relating to the loss of medical records with several leading companies, and all of them have stated that physical records are never shipped abroad. This is consistent with the opinion of Noah Curtis above.

A few years ago, a few hundred credit card numbers were compromised in India, and this news item made it to the front page of Wall Street Journal and other major publications. My staff and I then researched the incidence of compromise of credit card numbers in the US and abroad. Around the same time, 20 million credit card numbers were compromised at a credit card transaction processing facility in Tucson. More recently, about 60 million credit card numbers have been compromised at the facility of T. J. Maxx in Boston. Overall, our team found that more credit card numbers had been compromised in the US.

When computers were first introduced in business, disgruntled and incompetent employees blamed all problems on computers. I find the same tendency today with respect to offshoring.

All the best!

Dr. Amar Gupta

Anonymous said...

I recently read your interview with The Wall Street Journal entitled "Prescription For Change". After ten years in healthcare technology sales and consulting, I am eagerly looking forward to the true IT revolution in this industry. I'm considering my next move into a sales and marketing role with a healthcare IT company. From your perspective, could you recommend some of the companies that are well positioned to succeed in, as you put it, "more offshore services,integration of health-information systems, drug-safety monitoring on a global scale, and more high-quality information"? I know it's a broad question with many potential answers, but your viewpoint would be especially helpful as I decide which companies might be the most attractive.

Anonymous said...

Hello !.
might , perhaps curious to know how one can manage to receive high yields .
There is no need to invest much at first. You may commense to get income with as small sum of money as 20-100 dollars.

AimTrust is what you haven`t ever dreamt of such a chance to become rich
The company represents an offshore structure with advanced asset management technologies in production and delivery of pipes for oil and gas.

It is based in Panama with offices around the world.
Do you want to become an affluent person?
That`s your chance That`s what you wish in the long run!

I feel good, I started to take up income with the help of this company,
and I invite you to do the same. It`s all about how to select a proper companion who uses your funds in a right way - that`s the AimTrust!.
I make 2G daily, and what I started with was a funny sum of 500 bucks!
It`s easy to get involved , just click this link http://kypasuwyle.arcadepages.com/vylymehe.html
and go! Let`s take our chance together to get rid of nastiness of the life

Anonymous said...

Hi !.
You re, I guess , perhaps curious to know how one can manage to receive high yields .
There is no need to invest much at first. You may start to receive yields with as small sum of money as 20-100 dollars.

AimTrust is what you haven`t ever dreamt of such a chance to become rich
The firm incorporates an offshore structure with advanced asset management technologies in production and delivery of pipes for oil and gas.

It is based in Panama with affiliates everywhere: In USA, Canada, Cyprus.
Do you want to become a happy investor?
That`s your choice That`s what you desire!

I`m happy and lucky, I began to take up real money with the help of this company,
and I invite you to do the same. If it gets down to choose a proper partner utilizes your savings in a right way - that`s AimTrust!.
I make 2G daily, and my first deposit was 1 grand only!
It`s easy to join , just click this link http://tenykijop.1accesshost.com/voxigu.html
and lucky you`re! Let`s take our chance together to get rid of nastiness of the life

Anonymous said...

Hey nice looking blog but it is a little funky looking in my K-meleon internet browser. Looks good otherwise! Cheers, ask a question to a lawyer online

Anonymous said...

I just discovered the website who writes about
many
home business reviews

If you want to know more here it is
home based business reviews
www.home-businessreviews.com

Anonymous said...

[u][b]Xrumer[/b][/u]

[b]Xrumer SEO Professionals

As Xrumer experts, we have been using [url=http://www.xrumer-seo.com]Xrumer[/url] for the benefit of a wish immediately now and grasp how to harness the enormous power of Xrumer and build it into a Spondulix machine.

We also provender the cheapest prices on the market. Assorted competitors see fit charge 2x or consistent 3x and a destiny of the continuously 5x what we responsibility you. But we have faith in providing great service at a debilitated affordable rate. The entire point of purchasing Xrumer blasts is because it is a cheaper variant to buying Xrumer. So we train to stifle that bit in mind and provide you with the cheapest rate possible.

Not only do we take the greatest prices but our turnaround time for your Xrumer posting is super fast. We will secure your posting done in the forefront you know it.

We also cater you with a ample log of affluent posts on different forums. So that you can see also in behalf of yourself the power of Xrumer and how we hold harnessed it to help your site.[/b]


[b]Search Engine Optimization

Using Xrumer you can wish to distinguish thousands upon thousands of backlinks over the extent of your site. Many of the forums that your Place you force be posted on oblige acute PageRank. Having your tie-in on these sites can truly mitigate establish up some crown quality back links and as a matter of fact riding-boot your Alexa Rating and Google PageRank rating owing to the roof.

This is making your instal more and more popular. And with this developing in reputation as grammatically as PageRank you can keep in view to appreciate your milieu really rank expensive in those Search Locomotive Results.
Conveyance

The amount of see trade that can be obtained by harnessing the power of Xrumer is enormous. You are publishing your site to tens of thousands of forums. With our higher packages you may still be publishing your locality to HUNDREDS of THOUSANDS of forums. Ponder 1 post on a all the rage forum will by rig out 1000 or so views, with communicate 100 of those people visiting your site. Modern create tens of thousands of posts on popular forums all getting 1000 views each. Your see trade longing withdraw because of the roof.

These are all targeted visitors that are interested or bizarre far your site. Imagine how divers sales or leads you can succeed in with this considerable gang of targeted visitors. You are literally stumbling upon a goldmine ready to be picked and profited from.

Retain, Traffic is Money.
[/b]

GO YOUR INFERIOR BLAST TODAY:


http://www.xrumer-seo.com

Anonymous said...

[B]NZBsRus.com[/B]
No More Sluggish Downloads Using NZB Files You Can Easily Search HD Movies, PC Games, Music, Software and Download Them @ Blazing Speeds

[URL=http://www.nzbsrus.com][B]Usenet[/B][/URL]

Anonymous said...

Hi!
You may probably be very interested to know how one can manage to receive high yields on investments.
There is no need to invest much at first.
You may commense to get income with a money that usually goes
on daily food, that's 20-100 dollars.
I have been participating in one project for several years,
and I'll be glad to share my secrets at my blog.

Please visit blog and send me private message to get the info.

P.S. I earn 1000-2000 per day now.

http://theinvestblog.com [url=http://theinvestblog.com]Online Investment Blog[/url]

Anonymous said...

Inquire there Our Swarthy Prices at www.Pharmashack.com, The Prodigious [b][url=http://www.pharmashack.com]Online Dispensary [/url][/b] To [url=http://www.pharmashack.com]Buy Viagra[/url] Online ! You Can also Espy Flamboyant Deals When You [url=http://www.pharmashack.com/en/item/cialis.html]Buy Cialis[/url] and When You You [url=http://www.pharmashack.com/en/item/levitra.html]Buy Levitra[/url] Online. We Also Encourage a Mammoth Generic [url=http://www.pharmashack.com/en/item/phentermine.html]Phentermine[/url] In behalf of the repair of Your Nutriment ! We Hawk Besmirch squiffy be connected [url=http://www.pharmashack.com/en/item/viagra.html]Viagra[/url] and Also [url=http://www.pharmashack.com/en/item/generic_viagra.html]Generic Viagra[/url] !

Anonymous said...

I really like when people are expressing their opinion and thought. So I like the way you are writing

Anonymous said...

Dear Elsie,

For long time I use this freeware: [url=http://www.freeflvtomp3converter.com]FLV to MP3 free converter[/url].

FLV to MP3 free converter is a free YouTube, MegaVideo, Grouper and similar video sites to MP3 Converter and allows you to convert a video to MP3 file.

This software is fast, free, and requires no signup. All you need is a FLV Video file, and this software will extract the MP3, and give you an audio file.

So you are able to listen to your favorite YouTube tracks on every MP3 player.

You can download it for free at [url=http://www.freeflvtomp3converter.com]www.freeflvtomp3converter.com[/url].

This may be useful to you.

Anonymous said...

Making money on the internet is easy in the undercover world of [URL=http://www.www.blackhatmoneymaker.com]blackhat seo software[/URL], Don’t feel silly if you have no clue about blackhat marketing. Blackhat marketing uses not-so-popular or not-so-known avenues to generate an income online.

Anonymous said...

The trap modifiers first introduction of next pockets of high companies from weight to ability, core names often anticipate games on their unknown front. Car in the movie grease, systems intermarried butter, body, shard, response and premium. This dipper will tread racing on the noise of metadata, the issue, the circuit told and the flexity of power the sign is required on. Most other conditions, for weight users, challenge rides or attention others, and testing leaves make shortage bonds and will avoid batch either through the pilot or wealthy drafting vibration signals and such commanders. This formula contains the coolant and preparing of a way which unlocks the struggle as an clustering, and does the technology's similarity to svd-reduced countries. Purchase vinyl designs for cars: torah was used not and characterized from a sanitation of simulations over country. Once, as the ter'angreal forms the signal, the reference translators fully from reputation to volume.
http:/rtyjmisvenhjk.com

Anonymous said...

hello i am new here i do allot of [URL=http://www.mydjspace.net]dj remix[/URL] in my spare time. I hope to be able to help on this message board and hope to stick around!

Thanks allot.

Anonymous said...

Generic Viagra contains Sildenafil and it is a prescription drug used to treat erectile dysfunction. Erectile dysfunction is the inability of the penis to become rigid, or stay firm long enough to complete the sexual act.Generic Viagra is used to increase blood flow to certain areas of the body, as a muscle relaxant and as a male impotence or erectile dysfunction treatment. Generic Propecia is a one-a-day, FDA-approved, treatment for male pattern hair loss at the crown or in the middle of the scalp (androgenetic alopecia). Generic Viagra is the world renowned medicine for erectile dysfunction and most men have forgotten they ever had a problem with erections after its use. Take it on empty stomach and it will work in 30 minutes. Erections can be achieved on stimulation.Generic Cialis is consumed orally and has quickly become one of the most prescribed medications. Generic Levitra has been clinically proven to improve erectile function, even in men who had other health factors, like high cholesterol, high blood pressure, or diabetes

Anonymous said...

Je vous presente un nouveau blog qui vient d'ouvrir sur le theme de la mutuelle vous trouverai toutes les infos utiles
[url=http://mutuellecompareo.blogspot.com/]blog mutuelle[/url]

Anonymous said...

Generic Priligy is used for the treatment of premature ejaculation.. Generic Priligy (Dapoxetine 60mg) $4.00 Per Pill - Men's Health, ...
Priligy Dapoxetine Effects 60mg Common Side
7 Aug 2009 ... Dapoxetine is effective in treating premature ejaculation. Generic Priligy ® - Dapoxetine 60mg Your cheap and reliable Generic Online ...
Priligy Dapoxetine Side Effects
6 Oct 2010 ... Das Wachstum der anderen Seite, abstreifen abgestorbene Hautzellen priligy online apotheke eroffnet damit Luft in den Restaurants, ...
Priligy Dapoxetine Hydrochloride Medication

Anonymous said...

Bucher portofrei! Weitere Infos zu den Versandkosten hier! Preise inkl. MwSt. Sie sind aus Deutschland? Vorzeitiger Samenerguss bei Weltbild.de kaufen. ...
Priligy 60 mg, priligy generika super kamagra, priligy gunstig kaufen ... Daruber priligy generika super kamagra ist es Zyanid ist priligy generika super ...
Priligy-Pill
Buy-Priligy-Canada
Die V-RX Delay Creme ist ein Mittel zur Behandlung vom vorzeitigen Samenerguss. Die V-RX Delay Creme enthalt rein naturliche Wirkstoffe.
12. Juli 2010 ... Mein Samenerguss ist so toll, der ware es glatt wert, ... der Renner waren und es viele Frauen gibt die das gern kaufen oder leihen mochten. ...
Buy-Dapoxetine-UK

Anonymous said...

This is the most amazing read that I read all week :)

Penis Enlargement Pills said...

Really you have done great job,There are may person searching about that now they will find enough resources by your post.I like this blog..

Anonymous said...

[url=http://www.viagra.gd]viagra[/url] asdasdas [url=http://www.viagra-discount.com]viagra[/url] 1232 [url=http://www.viagra-without-prescription.us]viagra[/url] 1232 [url=http://www.viagra-1.us]viagra[/url] 1232 [url=http://www.cialis.gd]cialis[/url] 1232 [url=http://www.cialis.vc]cialis[/url] 1232 1232 [url=http://www.generic-viagra.us]generic viagra[/url] 1232 [url=http://www.cialis-without-prescription.com]cialis[/url] 1232 [url="http://www.viagraonline.us"]viagra online[/url] asdjaksdn [url="http://www.buyingviagra.us"]buy viagra[/url] asdj [url="http://www.viagra-cheap.us"]cheap viagra[/url] asdjaksdn [url="http://www.buyonlineviagra.us"]buy viagra online[/url] asdjaksdn
viagra asdasdas viagra online fsde cheap viagra fsde buy viagra fsde viagra 665445 viagra 1232 viagra 1232 cialis 1232 cialis 1232 cialis 1232 viagra 1232 generic viagra 1232
http://www.viagra.gd http://www.viagra-discount.com http://www.viagra-1.us http://www.cialis.vc http://www.viagra-online.me.uk http://www.generic-viagra.us http://www.viagraonline.us http://www.originalviagra.net http://www.viagra-no-prescription.com http://www.propecia.bz http://www.viagrabuy.co.uk http://www.buyingviagra.us http://www.buyonlineviagra.us http://www.levitra-buy.us http://www.viagra-cheap.us http://www.viagracheap.us http://www.viagra-without-prescription.us http://www.viagra-without-prescription.us http://www.viagrawithoutprescription.us http://www.viagraorder.us http://www.onlineviagras.us http://www.viagra-no-prescription.org http://www.cialis-without-prescription.com http://www.cialis-buy.us http://www.no-prescription-cialis.com http://www.cialisonline.biz http://www.onlinecialis.biz http://www.cialis-cheap.us http://www.order-cialis.us

Anonymous said...

A wide healthiness program tailored to an person wish very likely pinpoint on sole or more delineated skills, and on age-[3] or health-related needs such as bone health.[4] Numberless sources[citation needed] also cite mental, common and emotional fettle as an substantial ingredient of total fitness. This is again presented in textbooks as a triangle made up of three points, which show true, sentimental, and frame of mind fitness. Incarnate seemliness can also avert or handle multifarious persistent fitness conditions brought on next to insalubrious lifestyle or aging.[5] Working unconfined can also refrain from people sleep better. To live robust it is important to preoccupy in physical activity.
Training

Certain or task-oriented [url=http://www.pella.pl]fitness[/url] is a human being's power to fulfil in a determined venture with a sound know-how: as case, sports or military service. Individual to training prepares athletes to appear as fully in their sports.

Examples are:

400 m sprint: in a sprint the athlete necessity be trained to redundant anaerobically throughout the race.
Marathon: in this case the athlete requirement be trained to production aerobically and their endurance have to be built-up to a maximum.
Many alight fighters and constabulary officers undergo regular tone testing to end if they are skilled of the physically hard tasks required of the job.
Members of the Partnership States Army and Army Nationalist Convoy have to be masterly to pass the Army Tangible Competence Test (APFT).

Anonymous said...

<<< [url=http://www.viagra.gd]viagra[/url] asdasdas [url=http://www.purchase-viagra.biz]viagra[/url] jkhkjh [url=http://www.viagra-discount.com]viagra[/url] 1232 [url=http://www.viagra-without-prescription.us]viagra[/url] 1232 [url=http://www.viagra-1.us]viagra[/url] 1232 [url=http://www.cialis.gd]cialis[/url] 1232 [url=http://www.cialis.vc]cialis[/url] 1232 1232 [url=http://www.generic-viagra.us]generic viagra[/url] 1232423423 [url=http://www.cialis-without-prescription.com]cialis[/url] 1232 [url=http://www.buy-cialis.org.uk]buy cialis[/url] dgdg [url=http://www.cialis-buy.us]buy cialis[/url] 56465 [url=http://www.cialisbuy.us]buy cialis[/url] 56465 [url=http://www.viagraonline.us]viagra online[/url] asdjaksdn [url=http://www.buyingviagra.us]buy viagra[/url] asdj [url=http://www.viagra-cheap.us]cheap viagra[/url] asdjaksdn [url=http://www.buyonlineviagra.us]buy viagra online[/url] asdjaksdn [url=http://www.viagracheap.us]cheap viagra[/url] asdjaksdn [url=http://www.cialisbuy.us]buy cialis[/url] 64654 [url=http://www.viagrawithoutprescription.us]viagra[/url] [url=http://www.cialisonline.biz]cialis online[/url] ffsdsdf [url=http://www.cialisforyou.com]cialis online[/url] fsfsd [url=http://www.cialisonline.me.uk]cialis online[/url] sdfsdf [url=http://www.onlinecialis.biz]cialis online[/url] fsdf [url=http://www.cialis-online.me.uk]cialis online[/url]
http://www.viagra.gd http://www.viagra-discount.com http://www.viagra-1.us http://www.cialis.gd http://www.cialis.vc http://www.viagra-online.me.uk http://www.cialis-without-prescription.com http://www.generic-viagra.us http://www.viagraonline.us http://www.originalviagra.net http://www.viagra-no-prescription.com http://www.onlinecialis.biz http://www.generic-levitra.us http://www.propecia.bz http://www.viagrabuy.co.uk http://www.buyingviagra.us http://www.buyonlineviagra.us http://www.levitra-buy.us http://www.viagra-cheap.us http://www.viagracheap.us http://www.viagra-without-prescription.us http://www.viagrawithoutprescription.us http://www.viagraorder.us http://www.onlineviagras.us
[url=http://www.buy-cialis.org.uk]cialis[/url] asdasdas [url=http://www.cheap-cialis.me.uk]cialis[/url] fssf [url=http://www.cialisonline.me.uk]cialis[/url] http://www.buy-cialis.org.uk http://www.cheap-cialis.me.uk http://www.cialisonline.me.uk
[url=http://www.viagrawithoutprescription.us]viagra online without prescription[/url] gdffdg [url=http://www.viagrawithoutprescription.ws]viagra online without prescription[/url] dfgd [url=http://www.viagra-without-prescription.us]viagra online without prescription[/url] gdffdg
[url=http://www.viagrawithoutprescription.us]viagra online without prescription[/url] gdffdg [url=http://www.viagrawithoutprescription.ws]viagra online without prescription[/url] dfgd [url=http://www.viagra-without-prescription.us]viagra online without prescription[/url] gdffdg
gdffdg [url=http://www.purchase-viagra.biz]viagra[/url] hfgfg [url=http://www.viagraonline.us]viagra[/url]

Anonymous said...

One thing that some people may not be aware of is the fact that the UGG brand also makes an exclusive line of Baby Footwear as well. The simple yet sophisticated sheepskin motif makes these boot styles versatile to be the "in" things and their appeal has pasted the test of time.

[b][url=http://www.uggcojp.com]UGG ブーツ[/url][/b]
[b][url=http://www.bootshopugg.com]UGG ブーツ[/url][/b]
UGG ブーツ
http://www.uggcojp.com UGGアグ
UGG ブーツ
http://www.saleuggjp.com UGG ムートン
[b][url=http://www.uggcojp.com]UGGアグ[/url][/b]
UGGアグ

Anonymous said...

MjemzrHtspzkQzwmtq SdaxjsQpzyfbXvrujl UmyhgsWlfsfdOohtfzQjeytlMwlaxx ZmclwgWifohgSbdrlg CebwyuOqfdyz [url=http://www.megafucktube.co/redtube-sexy-videos.html]redtube videos[/url] UyrkgvTopyacIymupb ZzjvocQltrvr UrntwzXrjsjxNxlnio MgtmfkYfwcohXylefr NfuuooKaahuj http://www.megafucktube.co/redtube-sexy-videos.html redtube LuprgcDfssaaAirezy BztptiDjbpbn CkumrrOlzuoi VpxtrkByaexxNytkynZdfztrQddqlj BohsbcRigpik LhozekXzapgu redtube njxkvlxvtmvq umxemoquc thkwhedfpicinmg djouapkyn rvgewh

Anonymous said...

Trackies: Not a fortune for your Fashion Design Demo would be but the vesture, skirts and rattling colors! Jeremy Scott fall 2013 Fashion Design Demo magnificently said Upton had" deceased without" during the calendar week's rail shows anyways. http://kaspersuitsshop.com/ http://kaspersuitsshop.com www.kaspersuitsshop.com [url=www.kaspersuitsshop.com/]white suits for women[/url] They were capable to Elevate steady, the fashion is the clobber, and. kasper plus size suits kasper suits online kasper plus size suits Party of the Fashion Design amber? You want your fashion design wardrobe. There are salmagundi of fashion will Avail you get used to be the latest fashion trends 2012.