Chapter 11. Telenursing

Telemedicine can be traced to the late 1950s. Telehealth is defined as the use of telecommunication technologies to provide healthcare services to clients and provide access to health related information for both the clients and healthcare providers. An example of this is a simple telephone communications like dialing 911 for health or emergency assistance. Telephony has extended its applications to healthcare community with the introduction of technologies like videoconferencing, chat, email, fax and cellphones. Telenursing allows health care nurses to use remotely connected medical devices in the evaluation, diagnosis and treatment of the patient. An example is a nurse videoconferencing a patient at home or in a hospital or clinic. Computerized Home Healthcare System links the patient, usually with chronic disease or disabilities, to the healthcare provider based in a hospital or clinic. Example, non invasive sensors applied directly to the body to monitor vital signs, any detection is automatically redirected to the remote control center. Devices like these includes, ECG leads, scanners, cardiophones and etc.

Telehealth is met with problems like poor reimbursements because services are limited to third party payers both private and government, Legal issues on authority to control and regulate the telehealth practices when care provider and the client are in two separate states with dissimilar health policies. More problems are about the safety standards, there must be a need to certify care providers who engage in telehealth or telenursing having to use new medium for the delivery of care, security, telehealth sessions remain as a confidential interaction between a provider and a patient and budget constraints, the cost of infrastructure and its installation and connection, plus the cost of transmission, training and maintenance must be offset by the benefits gained in telehealth.

Chapter 10. Automated HIS Technologies

The electronic chart system is a computer system in various formats used by the physicians, nurses, ward clerks and other healthcare providers to record, retrieve and view patient data to make orders and to communicate with other departments or section in the hospital. An example of this are tablets which are touch screens. Desktop, where most hospitals in the Philippines uses this, with WiFi card connected wirelessly and printers. Computers on Wheels, is a popular alternative format of electronic chart system. Wall-Mounted Computer System, are alternative formats where a laptop is secured in a box embedded in the wall of a patient's room. Electronic Monitoring Systems are LCD-based or CRT-based systems that monitor and display vital signs, cardiac, respiratory and other physiologic activity processed from data coming from input sensor devices hooked to the patient's body. in Automated Medication Administration System, a nurse uses a PDA to identify the patient at point of care. Automated Medication Dispensing System, when the PDA is used in medication administration, the nurse first confirms for the SR in the patient identified. Automatic Labeling Machine, this reduces errors on the part of the nurse especially when done at POC. Automated Billing Machine, looks and works like an Automatic Teller Machine. They are usually positioned in busier corners of every floor in a hospital. Home Health Care System, looks like a desktop or laptop PC connected to a set of monitoring devices that the patient hooks to his body so he could be monitored by a healthcare provider at a distance. HIS Program, is the integration of all IS of the various clinical and non-clinical departments of a healthcare institutions.

Chapter 9. Automating the Hospital Information System

The sum of all automated and non-automated information system is known as hospital information system or HIS. His were originally developed for hospitals, today, however, they may be found in nursing homes, rehab centers, health centers and other healthcare institutions. Clinical information system processes data related to patient care. It includes documentation in 4 specific areas. Medical Information Systems, where the physician shares information with the nurse in the clinical information system. Nursing Information System, where documentation system includes patient assessment and health condition data, developing care plans, managing order entry, administering and recording medication and treatment which are Assessment, Nursing Diagnosis, Planning, Implementation and Evaluation. Departmental Systems, supports the daily operation of a clinical department. It includes the services done by the lab, pharmacy, radiology, cardiology, and other ancillary departments. Setting Specific Information System, includes any of the functions already discussed; however the functions are customized for the specific area like emergency rooms, intensive care unit, outpatients or ambulatory care clinics. Non Clinical Information Systems include the Financial System for managing and report money matters. Admission, Discharge, Transfer for management of registration and assigning of beds and rooms to patients, transfer to other rooms or facilities and discharging of patients. Personnel Systems, used to track characteristics of employees and/or the use of employees within the institution, it consists of Human Resource Management Systems which keep details about the employee and Scheduling Systems, used to arrange dates and times that an employee will be working or not working. Administrative Systems for automating data used in the daily operation in the healthcare institution as well as data used for strategic and long range planning. An electronic medical record or EMR is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records. An electronic health record or EHR is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is theoretically capable of being shared across different health care settings. In some cases this sharing can occur by way of network-connected enterprise-wide information systems and other information networks or exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.

Chapter 3: Nurses and Computers

Do Nurse and Computer Fit?

The Nurse is overwhelmed with changes in her work environment that requires her to adapt and evolve as well. Generally, it is more difficult for nurses to operate a computer if he/she is not good at it or it is his/her first time handling one. Formal learning in computer starts in elementary, gradually developing few skills and concepts. This learning is extended throughout high school.

Computer systems underwent many modifications, from 1960s where in US, computers were introduced in the nursing profession. Later in most parts of the world including Philippines, nurses recognized the computer's potential in improving documentation, quality of care and managing care. In Philippines, the use of computers in healthcare organization dates back as early as 1970s. Early commercial computers were used by Philippine Heart Center for Asia. Worldwide, in 1980s, Internet revolutionized dissemination of information and communication. In early 1990s nursing informatics became a specialty. During this period, many mainframe-based healthcare information system emerged with information systems as one of its subsystems. In the latter part of 1990s, miniaturization and dramatic improvement in processing power brought computers to the bedside and all of the point-of-care systems, this led to a new nursing function called telemetry. In the early years of 2000, the development of more rugged tablet PCs and personal digital assistants, programs with advanced reliability and security features, and wireless technology made it possible to automate and optimize many nursing care and practices. This provided the real time multimedia communication that led to distant nursing care or telenursing.

The elements of a computer system are hardware, software, data and user. The hardware components are devices for entering data (input devices) which includes keyboard, mouse, touch screen, scanner, camera and microphone. Devices for viewing work (output devices) which includes monitor, printer and speaker. Devices for processing and transmitting data (input/output devices) include the main board, processor, internal memory, cards and communication devices. Computers are classified according to form and sizes, namely: Supercomputer, is a large array of system units. Computer or mainframe, a houseful set of system units. Minicomputers, are physically smaller that mainframes. Workstations, look like a PC in external features but is more powerful internally. Microcomputer, also known as PC is the most common type of computer. Handheld computers, are very small computers having same functionality and processing capabilities as a standard desktop computer. Wearables, are small computers that can be worn. Robots, are used in some hospitals to assist nurses. GUI or graphical user interface provides a way to point or click with a mouse. The nurse as a user has to interact with a computer, obviously, for it to do function. A computer system is an electronic device that accepts input, processes data and stores data, and produces output, all according to a series of instructions. The smallest unit of data is called a byte. A series of 8 bits is called a byte. A nurse-computer interface is a part of a workplace where nurse's modified activity meets with a computer adapted for human use for enhanced productivity while maintaining harmony with nature.

Pirates of Silicon Valley

The movie started with the first commercial of Apple, which introduced Macintosh in 1984. Then it showed the alliance between two big companies, namely Apple and Microsoft. The movie then turned to flashback of Steve Wozniak's youth with Steve Jobs in the year 1970's.

The first flashback took place at Berkeley in 1971 where Wozniak and Jobs were caught between a riot of students in the campus and the police. Wozniak narrated the Jobs' story. Using a similar structure, the film then showed young Bill Gates at Harvard University in the early 1970's with his classmate Steve Ballmer and his high school friend Paul Allen, like Wozniak, Ballmer narrates Gates' story. The moment Gates discovered the existence of Ed Roberts' MITS Altair, which caused Gates to drop out in school. Gates' and Allen's work was juxtaposed because of Jobs' and Wozniak's involvement with the Homebrew Computer Club, presented Jobs' first home-made computer or PC, eventually leading to the development of the Apple I in 1976. At a San Fransisco computer fair where the Apple II is introduced, Gates tried to introduce himself to Job's but snubbed him. This is then followed by Gates introducing his operating system called DOS to the IBM at Microsoft Offices Seattle in 1980 which later developed into IBM-PC with the help of Gates and Microsoft in 1981.

It also follows Jobs' relationship with his high school girlfriend (Gema Zamprogna) and the difficulties he had acknowledging the birth and existence of their daughter, Lisa. Around the time his daughter was born, Jobs unveiled his next computer, which he named, The Lisa. The Lisa was then followed in 1984 by the Macintosh, a computer inspired by the Xerox Alto. The main body of the film finally concludes with a birthday toast in 1985 to Steve Jobs shortly before he was fired by CEO John Sculley (Allan Royal) from Apple Computer.

It also includes a brief epilogue, noting what happened afterward in the lives of Steve Jobs and Steve Wozniak. The movie ends with Steve Jobs returning to Apple after its acquisition of NeXT Computer, and Bill Gates appearing live via satellite at a MacWorld Expo in 1997, during Jobs' first Stevenote keynote address, to announce an alliance between Apple and Microsoft.

Chapter 8: The Internet

For 30 years, internet has evolved onto a very huge information resource and very powerful communication tool. The internet is a vast connection of hundreds of millions of computers working together to share information. Main lines that carry the bulk of the traffic are collectively known as Internet backbone or network access point owned by different companies such as WorldCom, Sprint and MCI. They sell internet access to Internet Service Providers (ISPs), organizations and large businesses.

Every computer connected to the internet must use and understand this protocol for sending and receiving data. The protocol known as TCP/IP (transmission control protocol/Internet protocol) makes use of packet switching to minimize the chance of losing data sent over the transmission medium. The TCP part of the protocol chops every piece of data into smaller fragments called packets. Each packet is provided with a heading containing addresses for both the sender and the recipient computers. Once the packets are created, the router determines the best route for getting the packet from one point to another point until it reaches the destination. The packets upon reaching the destination are collected by the destination computer browser program.

Address Systems in Internet

When connecting to the internet, a computer is defined by a unique address known as IP address. This address allows a computer to transmit information to other computers without getting lost. The computer may be assigned affixed or static address or dynamic address that changes each time the user accesses the internet.
The IP address uses a number from 0 - 255 for each part of its four-part number: n.n.n.n where n = 0 to 255. An IP address represents a computer or website but users prefer to use names so a special Domain Naming System (DNS) was created to replace the numbers.

It is better to have or follow the DNS so users won't have any difficulties in searching or browsing what they want to browse on the internet. But still, if names are still to be used, there will only be a limited sites that can be made for future uses.

Web Page and Browsers

A webpage is a document or information resource that is suitable for the World Wide Web. This information is HTML or XHTML.

Chapter 7: Network Systems

Network Systems

      It is essential to learn the basics in networking. The basic principles of a network systems are:

• A network is formed when two or more computers are connected wire or wirelessly, for sharing information and communication purposes.
• Network systems are essential to effective functioning of computerized HIS.
• It takes advantage of the principle of TCP/IP used in the internet for fast and accurate transmission of date across systems of diverse platforms.
• Network systems made it possible to have vast information originally generated and stored in separate department to be available online allowing the data to be viewed and shared by others.
• The information may be collected into a server like a mainframe or minicomputer. The collected data are constantly updated online by the different departments and retrieved by anybody anytime.

Network Topology

• Bus topology- a setup where each computers and network devices are connected to a single cable or backbone. It needs a terminator to prevent signal bouncing back and forth on the bus cable. If the network cable breaks, the entire network goes down. 

• Star topology- a very common network setup where each of the devices and computers on a network connect to a central hub. It is the easiest setup. if the central hub fails, all computers that are connected to the hub would be disconnected.

• Tree topology- a very common network setup that is similar to a bus topology and a star topology. It connects multiple star networks to other star networks. If the main cable or trunk between each of the star topology network failed, those networks would be unable to communicate with each other. However, computers on the same star topology would still be able to communicate with each other.

• Mesh topology- a network setup where each of the computers and network devices are interconnected with one another in all possible or partial combinations, allowing most transmissions to be distributed, even if one of the connections go down. This type of topology is commonly used for wireless networks.

• Ring topology- configuration where network computer and device are connected to each other forming a large circle. Each packet is sent around the ring until it reaches its final destination. Today, the ring topology is seldom used.

NI Theories and Models

Chapter 2.

What is Nursing Informatics?

     It is defined as the combination of computer science, information and communication technology and nursing science to enhance nursing informational processes in the field of care, administration, research and education.It deals with the study of how healthcare data, information, knowledge and wisdom.

     Conceptualization of automated nursing information process may have started as early as late 1950s in the US. In the 1960s computers found its way in automating accounting and business functions. Attempts in addressing clinical applications was unsuccessful because of computers' high price and inflexibility.

     1963, Mary Ann Bitzer wrote a simulation program about obstetric nursing, which were used for teaching students.

      1970s, in the West, many projects were done regarding use of computers in nursing.

     1985, Marion Ball and Kathryn Hannah presented in their paper in a nursing journal the use of nursing informatics in many nursing process. They defined nursing informatics as use of information technologies in relation to those functions within the purview of nursing that are carried out by nurses when performing their duties.

     In 1986, Blum grouped and classified computers into functions as to whether the specifically process data, information or knowledge.

     In early 1989, Judith Graves and Sheila Corcoran using Blum's model in classic article, "The Study of Nursing Informatics", proposed that nursing informatics is a combination of computer science, information science, designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care. It made use of an information model known as data-information-knowledge continuum.

     In the late 1989, Irene Joos and Ramona Nelson added wisdom to the continuum where one combine his personal, social, ethical, moral, cultural and other values with one's knowledge and experience to solve complicated problems.

     In 1992, the American Nurses Association (ANA) recognized nursing informatics as specialty.

     In 1996, Goosen included in Graves and Corcoran's definition thinking that is done by nurses to make knowledge-based decisions and inferences for patient care.

Theories in Nursing Informatics.

A. Change Theories
     -Unplanned
     -Planned

1. Roger's Diffusion of Innovation Theory (Unplanned change)

     This theory examines the pattern of acceptance that innovations follow as they spread across the population of people who adopt it. Adopters are divided into 5 categories:

• Innovators (2.5%). They readily adopt the innovation, often seen as troublesome and are not able to sell other on the innovation.
• Early adopters (13.5%). Acts as promoters for the innovation.
• Early majority (34%). Averse to the risk of innovation but are willing to make investments.
• Late majority (34%). Adopts innovation because of peer pressure.
• Laggards (16%). Suspicious about the innovation

2. Lewin's Change Theory (Planned change) 

     3 stages:

• Unfreezing. Making use of processes that reinforces an individual's involvement in the change, having their opinions respected.
• Moving. This process should be supported by the administration. Users be provided with adequate training.
• Refreezing. The planned change become the norm.

B. Information Theories

1. Blum's Theory

     Blum stated in 1986 that computer functions can be categorized into 3 groups: One where data is processed, information is processed and one where knowledge is processed.

2. Data-Information-Knowledge-Wisdom Continuum

     Graves and Corcoran based the theory on nursing informatics on data, information and knowledge as initiated by Blum.

• Data are elements that are uninterpreted and plainly recorded and viewed as is like vital sings, patient's billing and lab results.
• Information comprises interpreted data based on one's capacities, attitude and behavior.
• Knowledge is an organized collection of information.
• Wisdom considers the use of ethical, moral, personal, social, cultural, religious, political and other values in decision making.

C. Cognitive Theories

     Cognitive science includes mental models, skill acquisition, perception and problem solving that adds an understanding of how the brain perceives and interprets a computer screen.

Some applications of NI theories.

Automating data entry. Most businesses encounter data input requirements that can be time consuming. Instead of spending mundane hours entering data, you can simply rely on automated data-entry to finish the task for you in a fraction of the time. Automated data-entry is capable of understanding a variety of forms and entering information into databases with little to no mistakes. It does not require as much human input as manual data-entry would and is therefore cheaper. 

Sharing of information through network systems. The actual interpretation of data involves individual cognitive process to give meaning and become information.

Knowledge bases and decision support system. Knowledge is built from information as information is built from data. An organized collection of interrelated information regarding a particular topic refers to a knowledge base. This places knowledge above information.

A knowledge base is not a merely collection of information but rather formed from interrelationship between the pieces of information. Decision support systems are systems that process information by comparing a selected or an entered data against a standard set of information known as a knowledge base.

Wisdom and expert systems. Wisdom allows a clinician to use ethical, moral, social, cultural, religious and personal values to solve difficult problems. An expert system is a knowledge based system with built-in procedures for determining when and how to use that knowledge.

Introduction to Nursing Informatics

Chapter 1. Introduction to Nursing Informatics

Origin of healthcare informatics

     For decades, in healthcare, the increase in knowledge has led to the development of many specialties and subspecialties. It is a new knowledge domain of computer and information science, engineering and technology in all fields of health and medicine, including research, education and practice. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tool include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy, and (bio)medical research. There are many data that can't be easily understood if not merged and analyzed thoroughly using only the data that we have and the knowledge that we already have. This led to the development of healthcare informatics.

Nightingale emphasized documenting health

     In the mid 1800s, Florence Nightingale used a documentation system in the way of how to treat wounded soldiers in the Crimean war. She documented every interventions and outcomes to compare them and pick out the best interventions to apply. She was known and recognized as the first public health informaticist.






Nurses have serious problems in the workplace.


     With this unending development of our technologies, we already have many new devices that nurses use. Thus, healthcare teams faces challenges in learning this new devices on how to use them for the sake of treating people. the top 4 problems of local nurses in the workplace are:

1.) Documentation time is excessive.
     With nurses caring 10 patients or more at a time, it is difficult and takes time to make a documentation for them. So, majority of the nurse's time is eaten up in facing the computer to document than having conversations to the patients.

2.) Turnaround time is too long.
     The request that was made is accomplished in an unideal time. This is because procedures or laboratory tests are long, this may be because of overworked hospital aides who carry out order slips. Even with the availability of modern equipment, there will still be a delay because of the large volume of results that needs to be read.


3.) Nursing processes are inaccurate.
     Even if modern equipments are available in assisting nurses to care for the patients, errors are still committed. Medication errors runs first, second is labeling errors and common are wrong entries, dictation, translation and transcription of orders of information. Automation of these processes leads to reduction of errors.


4.) Communication is poor.
     Communication is poor when between healthcare providers and between departments uses telephone, this is because it requires for both parties to be present. Another disadvantage would be telephones can be tapped or bugged when security systems are breached. So computers provide different modes of communication like videoconferencing, chat, email or text-messaging which is more convenient and appropriate.

     




Automation can save nurses because automation largely reducts paper works, shortening turnaround times, improvement of accuracy of nursing processes and eliminates time consuming and redundant processes.