Nursing Informatics Definitions

American Nurses Association 1994

"Nursing informatics is the specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research and the expansion of nursing knowledge."

International Medical Informatics Association - Nursing Informatics (IMIA-NI) - 1998

Nursing Informatics is the integration of nursing, its information, and information management with information processing and communication technology, to support the health of people worldwide.

ANA 2001
Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology. (p. 17)

Canadian Nurses Association 2001

Nursing Informatics (NI) is the application of computer science and information science to nursing. NI promotes the generation, management and processing of relevant data in order to use information and develop knowledge that supports nursing in all practice domains.

Canadian Nurses Association (2003)

Nursing Informatics (NI): integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology. The goal of nursing informatics is to improve the health of populations, communities, families, and individuals by optimizing information management and communication. This includes the use of information and technology in the direct provision of care, in establishing effective administrative systems, in managing and delivering educational experiences, in supporting lifelong learning, and in supporting nursing research.

ANA 2008
Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information,knowledge, and wisdom in nursing practice. Nursing informatics facilitates the integration of data, information, knowledge, and wisdom to support patients, nurses, and other providers in their decision-making in all roles and settings. This

support is accomplished through the use of information structures, information processes, and information technology.

Resources on Nursing Informatics

Nursing informatics is the integration of computer science and information systems into the practice of nursing. It aims to boost the efficiency of data management and communication in the healthcare field, and in so doing, is revolutionizing the field of nursing. The following resources are links to nursing organizations, catalogs of nursing schools, and articles detailing the development of this dynamic new field of nursing informatics.

News and Info

1. Preparing the Next Generation of Nurses is an article by The National League for Nursing that outlines the state of the industry in nursing informatics. It proposes a list of recommendations for bringing nursing into the 21 st century through education and collaboration. 2. The Nursing Shortage: Can Information Technology help to explores the causes and effects of the much-discussed nursing shortage, and concludes that within 20 years there will not be enough nurses to care for the exponentially growing elderly population. The author outlines several ways that information technology can address this growing problem.

3. Technology in Nursing is a brief survey of how information technology has changed the face of nursing. As pagers are replaced by smart phones and wireless internet brings gigabytes of data to your fingertips in the blink of an eye, nurses have the means to provide more efficient and knowledgeable service to a wider array of patients. 4. RNs Warming Up to Information Technology describes the often welcoming but occasionally confused response that informatics has received among veteran nurses. The author emphasizes the importance of collaboration between medical and IT experts to facilitate the shift to informatics-driven medicine. 5. Five Emerging Majors The New York Times education blog included nursing informatics in its list of five emerging areas of study in higher educational settings, along with service science, computational science, sustainability, and public health. Nursing informatics is gaining speed especially in terms of undergraduate degree programs, with hundreds in development across the nation. 6. Nurseweek Overview of Nursing Informatics predicts that nursing informatics will be one of the top 10 fastest-growing professions in the next decade. This overview provides an introduction to the field as well as what to expect from a career in nursing informatics. 7. Biohealthmatics' 10 Easy Tips on How to Get Started in Nursing Informatics has a few handy directions for getting one's start in this cutting-edge career. Biohealthmatics also has a job search engine, career center, and networking center at your disposal. 8. NLN's Informatics Agenda The NLN (National League for Nursing) released this position statement in May 2008 to establish an agenda for efficiently and effectively incorporating information technology in the health care arena. Using the TIGER initiative as a model, the NLN seeks to introduce educational programs in nursing informatics at all levels of higher education and collaborate with industry leaders to support the adoption of informatics technology. 9. Nursingschools.net's Nursing Informatics outlines the need for information systems in hospitals and other health settings, and describes how nurses trained in IT can meet those needs. It also explains the educational requirements and other prerequisites for entering the field of nursing informatics. 10. Nursing-informatics.com offers articles, tutorials, consulting services and a continuing education program in informatics. The context page provides a schematic breakdown of the factors involved in the development of informatics, as shaped by competing medical philosophies. 11. Alliance for Nursing Informatics started the TIGER initiative (Technology Informatics Guiding Education Reform) to help prepare practicing nurses and nursing students in using new technology to improve patient care. Their website has links to the many member organizations of the alliance and news items in nursing informatics.

12. A Look at Nursing Informatics An interview with Suzanne Bakken Henry, associate professor for the UCSF School of Nursing, delves into the advantages and disadvantages of the move to electronic health records, as well as the pros and cons of a career in nursing informatics as compared with other fields.

Schools and Programs

13. American Nurses Credentialing Center 's home page provides all the information you need to get board certification for nursing informatics. 14. Allied Health World 's Nursing Informatics section provides information about schools and programs for receiving certification in nursing informatics. Once that's taken care of, they'll help you with job-seeking and career advice as well. 15. Weekend Immersion in Nursing Informatics is a monthly nursing informatics continuing education program designed to be a crash course in information technology with a focus on the professional practice. The program's main objective is to prepare students for the comprehensive ANCC Nursing Information Certification Exam. 16. 31 Nursing Informatics Graduate Programs lists the top schools in the country with nursing informatics programs, along with summaries of the programs they offer (Certificate, Doctorate, and/or Masters) and whether they have online courses. You can search by program type or geographic region to find the college that suits your needs. 17. CAHIIM Accredited Programs is a catalogue of undergraduate and masters HIM (Health Information Management) programs. You can apply online or schedule a site visit for any of their hundreds of accredited universities.

Forums and Journals

18. Nursing Informatics Online is a massive message board forum with updates on conferences, educational events, and journal articles. Their online bookstore has several introductory texts explaining the science and its applications. 19. Mapping the Literature of Nursing Informatics was a 2005 study undertaken by the Medical Library Association to characterize the growth of medical informatics over the past quarter century. Nursing informatics articles were underrepresented compared with general informatics, suggesting that nurses may be using sources other than journals to disseminate information. 20. Online Journal of Nursing Informatics was founded so that nurses could share findings, experience, perceptions, knowledge regarding all facets of nursing informatics. Full-text articles are freely available without subscription, as well as links to other nursing informatics sources.

21. Medical and Nursing Training Blog is a guide to medical and nursing training and vocational schools. Weekly blog posts focus on an individual school, giving an in-depth look at their curriculum and environment. 22. ANIA - CARING is one of the largest nursing informatics sites, with a quarterly newsletter, job bank, and many other resources. Their Getting Started page has nurse testimonials on how to start a career in nursing informatics. 23. Allnurse.com Nursing Informatics Forum is a blog/forum for the latest news and trends in nursing informatics. Its 5,000 readers share anecdotes and advice about this rapidly developing profession. 24. History of the ANI Founded in 2004 to establish a unified voice for nursing informatics, the ANI currently represents over 5,000 nursing informaticists. This CIN (Computers, Information, Nursing) journal article recounts the story of their founding and lists their current member organizations, with links to their web sites. 25. Online Journal of Issues in Nursing is one of the leading medical journals in nursing. Its Nursing Technology page has an introduction to and several articles on nursing informatics.

THE USE OF COMPUTERS IN HOSPITALS : The age of Information Technology came about with the invention of computers, and today, it is inconceivable for us to function without one. Whether it is an individual, business or service providers, computers are must for smooth flow of business and

operations. In fact, even the medical community, including hospitals, has adopted the use of computers in their day to day activities. Here are some of the uses of computers in hospitals: One of the main uses of computers in hospitals is for storing data. This data is pertaining to patients' case histories, sicknesses, prescriptions, the kind of medication taken by patients and kept in the hospitals and also the billing details for each and every patient. This usually comes up to a huge amount of data that needs to be preserved, so that it can be retrieved any time. The second use is for medical imaging. If you have ever been scanned, you will realize what medical imaging is all about. When special gadgets are used to get an image of the bones and organs inside the body, it is known as medical imaging. The most common examples of this are ultrasound, CT scan and MRI. In addition, computers are also used for several types of medical examinations and procedures. For instance, heart rate monitor is used in hospitals where patients with heart ailments come. Blood glucose monitor is another computer based system where diabetics are monitored. Today, it is impossible for a hospital to function with technology and computer. However, having specialized computer for various medical procedures is expensive and painstaking process. Nonetheless, hospitals have realized the immense value and are constantly trying to upgrade their technology, so that they can offer the best care and diagnostic tools to patients.

Electronic health record(Patient record system):

An electronic health record (EHR) (also electronic patient record (EPR) or computerised patient record) 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 capable of being shared across different health care settings, by

being embedded in network-connected enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, 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. Its purpose can be understood as a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting.

Terminology
The terms EHR, EPR and EMR (electronic medical record) are often used interchangeably, although a difference between them can be defined. The EMR can be defined as the legal patient record created in hospitals and ambulatory environments that is the data source for the EHR. It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care providers, employers, and payers or insurers access to a patient's medical records across facilities. A personal health record is, in modern parlance, generally defined as an EHR that the individual patient controls.

Improve quality of care

The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality. Information Technology is being used today to automate day-to-day processes, thus helping to reduce administration costs which then in turn can free up time and money for patient care EHR systems can help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine are hypothesised to enable proliferation of ongoing improvements in healthcare efficacy. Improved usage of EHR is achieved if the presentation on screen or on paper is not just longitudinal, but hierarchically ordered and layered. During compilation while hospitalisation or ambulant serving of the patient, easing to get access on details is improved with browser capabilities applied to screen presentations also cross referring to the respective coding concepts ICD, DRG and medical procedures information. Computerized Physician Order Entry (CPOE)one component of EHRincreases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.[14]

Promote evidence-based medicine

EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices. Realistically, these benefits may only be realized if the EHR systems are interoperable and wide spread (for example, national or regional level) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medical informatics must be deployed

Record keeping and mobility

EHR systems have the advantages of being able to connect to many electronic medical record systems. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.It is also easier to check in their records whether a patient as been admitted to such a medical centre or if they have any allergies since they have been admitted before..

Disadvantages
Critics point out that while EHRs may save the "health system" money, physicians, those who buy the systems, may not benefit financially. EHR price tags range widely, depending on what's included, how robust the system is, and how many providers use it. Asked what they paid in an online survey, about a third of respondents paid between $500 and $3,000 per physician. A third paid between $3,001 and $6,000, and 33 percent paid more than $6,000 per physician for their HER. Physicians do tend to see at least short-term decreases in productivity as they implement an EHR. They spend more time entering data into an empty EHR than they used to spend updating a paper chart with a simple dictation. Such hurdles can be overcome once the software has some data, as physicians learn to use templates for data entry, and as workflow in the practice changes, but not every practice gets that far. Studies also call into question whether, in real life, EHRs improve quality. 2009 produced several articles raising doubts about EHR benefits.

Costs
The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption. In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as

the technology was implemented, as well as the need to increase information technology staff to maintain the system

Time
Often, doctors do not want to spend the time to learn a new system. Some doctors believe that adopting a system with EHRs could reduce clinical productivity.

Governance, privacy and legal issues

Privacy Concerns
In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also. Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location. Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet. Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector. Private companies have promised to have stringent privacy policies and procedures. If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it. So, the private sector know the importance of privacy and the security of the systems and continue to advance well ahead of the federal government with electronic health records.

Legal issues

Liability
Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.

Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.. Similarly, it's important to recognize that the implementation of electronic health records carries with it significant legal risks. This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate. Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults. In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers. In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.

Legal Interoperability
In cross-border use cases of EHR implementations, the additional issue of legal interoperability arises. Different countries may have diverging legal requirements for the content or usage of electronic health records, which can require radical changes of the technical makeup of the EHR implementation in question. (especially when fundamental legal incompatibilities are involved) Exploring these issues is therefore often necessary when implementing cross-border EHR solutions

Technical issues Customization

Each healthcare environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system. An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization. This customization can often be done so that a physician's input interface closely mimics previously utilized paper forms. At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized. Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.

Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs. Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance cost

Long-term preservation and storage of records

An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives. Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al. have noted that choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information. The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research "describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures."

Synchronization of records
When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion. Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-topeer networks). Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred.

RECORDS AND REPORTS

INTRODUCTION: Records play an important part in a nursing education programme apart from being necessary for the day-to-day administration of the school or college of nursing. They provide continuity from the time the school/college is established. Thus facilitating evaluation of the programme. Records and the system of maintaining them vary from one school to another.

PRINCIPLES OF MAINTAINING SCHOOL RECORDS: 1. Each record should be for a specific purpose, which should be clearly understood by those maintaining and using the records. 2. Records should contain only such information regarding the student, staff and other aspects of the programme as is really necessary for the school programme and for evaluation. All irrelevant material should be carefully avoided and records should not be duplicated. 3. Items on forms and in registers should be conveniently grouped so as to make their completion as easy as possible. 4. The wording should be easily understood and where doubt is likely to arise, instructions to facilitate interpretation should be included. 5. Where appropriate, records should permit some freedom of expression. 6. Records, which are required by the teaching staff should be easily accessible to them. 7. Persons responsible for maintaining records should be aware of their particular responsibility and every effort should be made to keep records upto date and accurate. 8. A simple system should be used for keeping records. For routine recording which is carried out by non-profession personnel the system should be standardized as much as possible for speed, accuracy and reliability. 9. There should be provision for periodic review of all records to ensure that they keep place with the changing needs of the programme. 10. There should be an adequate supply of stationery to permit records to be maintained on the proper forms and in the proper registers at all times. There should be sufficient number of filing cabinets and appropriate equipments to operate filing system which is simple and safe requires the minimum possible time. 11. There should be adequate, safe, fireproof, storage arrangements.

TYPE OF RECORDS: Student records Staff records Academic and Administrative records.

1. STUDENT RECORDS: The number, type, and content kept in regard to students will vary from one school to another. The following list is intended as a guide to the minimum which should be maintained in the school. The List of records are;

a.

b. c. d. e. f. g. h. i. j. k. l.

Application forms and other reports, concerning selection and admission such as references, medical reports, including mark lists, certificates and results of written test and interview at the time of selection. Admission register A cumulative health records Class attendance and leave records Clinical and field experience, student rotation Internal assessment register- both theory and practical Mark list ( state council/ board results) Records of extra curricular activities Grade records for every year Practical record book-procedure book, midwifery records book. Student evaluation: internal practical and theory. Permanent cumulative student record, student details, examination and results, theory hours, practical experience, marks, rank/class for each students.

2. STAFF RECORDS: In the personal file of each staff these should be a. Application (where applicable) b. Copy of letter of appointment and any subsequent letter showing change in status. c. Job description/ functions d. Record of the staff members educational qualification, previous experience, any short term educational course attended. Membership in professional societies and activities of articles to journals, holding office in organizations, participation in seminars, conferences etc. updated every years. e. Periodic evaluation or progress report. f. Leave record. g. Health record. 3. ACADEMIC/ ADMINISTRATIVE RECORDS FOR SCHOOL: a. Philosophy, purposes and curriculum of the school. b. Course content and course plan record for each subject c. Record of academic requirements d. Rotation plans for each academic year e. Record of committees in the school f. Record of the stocks in the school g. Affiliation records h. Grant in aid record if any i. Records of educational programmes organized for teaching faculty and students j. Annual reports k. Written policies of the school l. Statement of budget proposal and allotments m. Minutes of staff meeting n. Copy of school brochure

o. p. q. r.

Inspection/ accreditation records Minute of administrative committee meetings Photographs/ videos/ paper cuttings of important events Computerized records (floppies/ computer discs).

REPORTS:
The number and nature of report will depend on requirement of controlling body and nursing council. The preparation should be done accurately because the data they provide is frequently used for planning and evaluation at state or national level. It is important that such reports are sent promptly and accurately as they may be required by the authority for a more comprehensive report. The type of information commonly required in an annual report. 1. Factual data relating to students, staff, clinical facilities, physical facilities, administration and the curriculum. 2. Development in the school programme since the last report. 3. Proposal and plans for future development and problems encountered. 4. Recommendations.

Minimal records to be maintained as per INC recommendations:

A. For Students: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Admission record Health record Class attendance record Clinical and field experience record Internal assessment record of both theory and practical Work lists (State council or Board). Records of extra curricular activities of students (Both in school as well as outside). Leave record Practical record books Procedure book, midwifery record book. Cumulative record a. For each student ( permanent record). b. For each academic year for each class.

B. For the School: 1. 2. 3. 4. 5. Course content record ( per each subject) The record for each academic year Rotation plans for each academic year Record of committees in the school Record of the stock in the school

6. Affiliation record 7. Grant in aid record, if any 8. Records of educational programmes organized for teaching faculty and students, both in the school as well as outside. 9. Annual reports ( Records of achievements of the school prepared annually) The above list of the records are only the bare minimum. School of Nursing should possess detailed and upto date record of each activity in the school. CONCLUSION: Records and reports are very important legal documents which helps the person to know about the detail functioning levels of school. These records and reports help us to know about the individuals performances either staff or a students. It help us to know the strength and weakness of the school for further development. So these records and reports protect us in all the ways as a legal document. So each of us should know about these records and reports to run a institute as per our INC requirements. BIBLIOGRAPHY: 1. Guide for school of nursing in India; 2002, prepared by Indian Nursing council. Kotla Road, Tempel Lane. New Delhi. PP No. 2. WHO guide for school of Nursing. PP No. 72-75.

MANAGEMENT INFORMATION SYSTEM :

Implementation of MIS The choice of the system or the sub-system depends on its position in the total MIS plan, the size of the system, the user understands of the system and the complexity and its interface with other systems. The designer first develops systems independently and starts integrating them with other systems, enlarging the system scope and meeting the varying information needs.

Determining the position of the system in the MIS is easy. The real problem in the degree of structure, and formalization in the system and procedures which determine the timing and duration of development of the system. Higher the degree of structured ness and formalization, greater is the stabilization of the rules, the procedures, decision making and the understanding of the overall business activity. Here, it is observed that the users and the designer interaction are smooth, and each others need are clearly understood and respected mutually. The development becomes a methodical approach with certainty in input-process and outputs. MIS is generally used by medium and larger scale organizations. However, small organizations are yet to understand its application. There is dire need to build up computer culture by properly disseminating information about computer applications and its benefits. Implementation of MIS can be achieved by using any of the methods such as direct, parallel, modular or phase in. Direct Approach Direct installation of the new system with immediate discontinuance of the old existing system is reffered as cold turnkey approach. This approach becomes useful when these factors are considered. 1. The new system does no replace the existing system. 2. Old system is regarded absolutely of no value 3. New system is compact and simple. 4. The design of the new system is inexpensive with more advantages and less risk involved. Parallel Approach The selected new system is installed and operated with current system. This method is expensive because of duplicating facilities and personal to maintain both the systems. In this approach a target date must be fixed when the operations of old system cease and new one will operate on its own.

Modular Approach This is generally recognized as Pilot approach, means the implementation of a system in the Organization on a piece-meal basis. This has few advantages / merits

1. The risk of systems failure is localized 2. The major problem can be easily identified and corrected before further implementation. 3. Operating personal can be trained before system is installed in a location. Phase-in-Implementation This approach is similar to modular method but it differs because of segmentation of system, however, not the organization. It has advantages that the rate of changes in a given Organization can be totally minimized and the data processing resource can be acquired gradually over a period of time. System exhibits certain disadvantages such as limited applicability, more costs incurred to develop interface with old system and a feeling in the Organization that system is never completed. Implementation Procedures Planning the Implementation After designing the MIS it is essential that the organization should plan carefully for implementation. The planning stage should invariably include the following: 1. Identification of tasks of Implementation Planning the implementation activities, acquisition of facilities, procedures development, generating files and forms, testing the system and evaluating and maintenance of the system. 2. Relationship establishment among the activity Network diagram must be prepared to correlate concurrent and sequential activities. 3. Establishing of MIS For monitoring the progress of implementation and for proper control of activities, efficient information system should be developed. 4. Acquisition of Facilities For installation of new system or to replace current system the manager should prepare a proposal for approval from the management by considering space requirement movement of personal and location for utility outlets and controls. 5. Procedure Development This is an important stop for implementation of the system including various activities

such as evaluation selection of hardware, purchase or development of software, testing and implementation strategies. 6. Generating Files and Forms The MIS manager should generate files and formats for storing actual date. This requires checklist data, format date storage forms and other remarks in data base. 7. Testing of the System Test should be performed in accordance with the specifications at the implementation stage consisting of component test sub system test and total system test. Evaluation and maintenance of system The performance should e evaluated in order to find out cost effectiveness and efficacy of the system with minimum errors due to designs environmental changes or services. Types of Maintenance The maintenance of system are classified into corrective/adaptive/perfective. Corrective maintenance means repairing process or performance failures. Adaptive maintenance means changing the programming function whereas perfective maintenance deals with enhancing the performance or modifying the program. Primary Activities of a Maintenance Procedure Documentation is major part of maintenance in system development. Maintenance staff receives requests from the authorized user. Programming library should be maintained. Reduction in Maintenance Costs Several organizations having MIS generally go in for reducing maintenance costs

Evaluation Methods Evaluation of the MIS in an organization is integral part of the control processes. There are several evaluation approaches such as quality assurance review compliance of audits budget performance review computer personal productivity assessment computer performance evaluation service level monitoring user audit survey post installation review and cost benefit analysis. Evaluation performance measurement can be classified into two classes as effectiveness and efficiency. The relationship between effectiveness and efficiency is that the format is

a measure of goodness of out put and the latter is a measure of the resources required to achieve the output.

Telemedicine
Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred through interactive audiovisual media for the purpose of consulting, and sometimes remote medical procedures or examinations. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and videoconferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care. Care at a distance (also called in absentia care), an old practice which was often conducted via post. There has been a long and successful history of in absentia health care which, thanks to modern communication technology, has evolved into what we know as modern telemedicine. The terms eHealth and telehealth are at times incorrectly interchanged with telemedicine. Like the terms "medicine" and "health care", telemedicine often refers only to the provision of clinical services while the term telehealth can refer to clinical and nonclinical services such as medical education, administration, and research. The term eHealth is often, particularly in the U.K. and Europe, used as an umbrella term that includes telehealth, electronic medical records, and other components of health IT.

Types of telemedicine
Telemedicine can be broken into three main categories: store-and-forward, remote monitoring and interactive services. Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured

medical record preferably in electronic form should be a component of this transfer. A key difference between traditional in-person patient meetings and telemedicine encounters is the omission of an actual physical examination and history. The 'store-andforward' process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination. Remote monitoring, also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective. Interactive telemedicine services provide real-time interactions between patient and provider, to include phone conversations, online communication and home visits. Many activities such as history review, physical examination, psychiatric evaluations and ophthalmology assessments can be conducted comparably to those done in traditional face-to-face visits. In addition, clinician-interactive telemedicine services may be less costly than in-person clinical visit

Benefits and uses

Telemedicine can be extremely beneficial for people living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Patients who live in such areas can be seen by a doctor or specialist, who can provide an accurate and complete examination, while the patient may not have to travel or wait the normal distances or times like those from conventional hospital or GP visits. Specialties that use telemedicine often use a 'tele-' prefix; for example, telemedicine as applied by radiologists is called 'teleradiology'. Similarly telemedicine as applied by cardiologists is termed as 'telecardiology', etc... Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location. Telemedicine can be used as a teaching tool, by which experienced medical staff can observe, show and instruct medical staff in another location, more effective or faster examination techniques. It improved access to healthcare for patients in remote locations. "Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better management of chronic diseases,shared health professional staffing, reduced travel times, and fewer or shorter hospital stays." Several studies have documented increase patient satisfaction of telemedicine over past fifteen years. The first interactive telemedicine system, operating over standard telephone lines, for remotely diagnosing and treating patients requiring cardiac resuscitation (defibrillation) was developed and marketed by MedPhone Corporation Telemonitoring is a medical practice that involves remotely monitoring patients who are not at the same location as

the health care provider. In general, a patient will have a number of monitoring devices at home, and the results of these devices will be transmitted via telephone to the health care provider. Telemonitoring is a convenient way for patients to avoid travel and to perform some of the more basic work of healthcare for themselves. In addition to objective technological monitoring, most telemonitoring programs include subjective questioning regarding the patient's health and comfort. This questioning can take place automatically over the phone, or telemonitoring software can help keep the patient in touch with the health care provider. The provider can then make decisions about the patient's treatment based on a combination of subjective and objective information similar to what would be revealed during an on-site appointment. Some of the more common things that telemonitoring devices keep track of include blood pressure, heart rate, weight, blood glucose, and hemoglobin. Telemonitoring is capable of providing information about any vital signs, as long as the patient has the necessary monitoring equipment at his or her location. Depending on the severity of the patient's condition, the provider may check these statistics on a daily or weekly basis to determine the best course of treatment. Cardiac MonitorRemote Patient MonitoringVital Signs MonitorTelemedicine SystemPortable Heart MonitorHolter MonitorPortable Ekg Monitor in 1989 under the leadership of its president and founder, S.Eric Wachtel. A year later the company introduced a mobile cellular version, the MDphone. Twelve hospitals in the U.S. served as receiving and treatment centers. Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World. In developing countries a new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits, whereby a doctor uses devices to remotely examine and treat a patient. This new technology and principle of practicing medicine holds significant promise of improving on major health care delivery problems, in for instance, Southern Africa, because Primary Remote Diagnostic Consultations not only monitors an already diagnosed chronic disease, but has the promise to diagnose and manage the diseases a patient will typically visit a general practitioner for.

Telecardiology
ECGs, or electrocardiographs, can be transmitted using telephone and wireless. Willem Einthoven, the inventor of the ECG, actually did tests with transmission of ECG via telephone lines. This was because the hospital did not allow him to move patients outside the hospital to his laboratory for testing of his new device. Teletransmission of ECG using indigenous methods. This system enabled wireless transmission of ECG from the moving ICU van or the patients home to the central station in ICU of the department of Medicine. Transmission using wireless was done using frequency modulation which

eliminated noise. Transmission was also done through telephone lines. The ECG output was connected to the telephone input using a modulator which converted ECG into high frequency sound. At the other end a demodulator reconverted the sound into ECG with a good gain accuracy. The ECG was converted to sound waves with a frequency varying from 500 Hz to 2500 Hz with 1500 Hz at baseline. This system was also used to monitor patients with pacemakers in remote areas. The central control unit at the ICU was able to correctly interpret arrhythmia. This technique helped medical aid reach in remote areas. In addition, Electronic stethoscopes can be used as recording devices, which is helpful for purposes of telecardiology.

Teleradiology

Teleradiology is the ability to send radiographic images (x-rays, CT, MR, PET/CT, SPECT/CT, MG, US...) from one location to another. For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving-image review station. The most typical implementation are two computers connected via the Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer so that images can be printed for convenience. The teleradiology process begins at the image sending station. The radiographic image and a modem or other connection are required for this first step. The image is scanned and then sent via the network connection to the receiving computer. Today's high-speed broadband based Internet enables the use of new technologies for teleradiology : the image reviewer can now have access to distant servers in order to view an exam. Therefore, they do not need particular workstations to view the images ; a standard Personal Computer (PC) and Digital Subscriber Line (DSL) connection is enough to reach keosys central server. No particular software is necessary on the PC and the images can be reached from wherever in the world. Teleradiology is the most popular use for telemedicine and accounts for at least 50% of all telemedicine usage.

Telepsychiatry
Telepsychiatry, another aspect of telemedicine, also utilizes videoconferencing for patients residing in underserved areas to access psychiatric services. It offers wide range of services to the patients and providers, such as consultation between the psychiatrists, educational clinical program, diagnosis and assessment, medication therapy management, etc. The following are some of the model programs and projects which are undergoing for implementation of telepsychiatry in rural areas in the US. 1. University of Colorado Health Sciences Center (UCHSC) supports two programs for American Indian and Alaskan Native populations a. The Center for Native American Telehealth and Tele-education (CNATT) and b. Telemental Health Treatment for American Indian Veterans with Posttraumatic Stress Disorder (PTSD) 2. Military Psychiatry, Walter Reed Army Medical Center. Links for several sites related to telemedicine, telepsychiatry policy, guidelines, and networking are available at the website for the American Psychiatric Association.

Telepharmacy
Telepharmacy is another growing trend for providing pharmaceutical care to the patients at remote locations where they may not have physical contact with pharmacists. It encompasses drug therapy monitoring, patient counseling, prior authorization, refill authorization, monitoring formulary compliance with the aid of teleconferencing or videoconferencing. In addition, video-conferencing is vastly utilized in pharmacy for other purposes, such as providing education, training, and performing several management functions. A notable telepharmacy program in the United States conducted at a federally qualified community health center, Community Health Association of Spokane (CHAS) in 2001, which allowed the low cost medication dispensing under federal governments program. This program utilized videotelephony for dispensing medication and patient counseling at six urban and rural clinics. There were one base pharmacy and five remote clinics in several areas of Spokane, Washington under the telepharmacy program at CHAS. The base pharmacy provided traditional pharmacy study to the clients at Valley clinic and served as the hub pharmacy for the other remote clinics. The remote site dispensing and patient education process was described as follows: once the prescription is sent from the remote clinics to the base pharmacy, the pharmacist verifies the hard copy and enters the order. The label is also generated simultaneously, and the label queue is transmitted to the remote site. When the label queue appears on the

medication dispensing cabinet known as ADDS, the authorized person can access the medicine from ADDS followed by medication barcode scanning, and the printing and scanning of labels. Once those steps are done, the remote site personnel are connected to the pharmacist at base pharmacy via videoconferencing for medication verification and patient counseling.

Licensing, regulatory issues & telemedicine

Restrictive licensure laws in the United States require a practitioner to obtain a full license to deliver telemedicine care across state lines. Typically, states with restrictive licensure laws also have several exceptions (varying from state to state) that may release an out-of-state practitioner from the additional burden of obtaining such a license. A number of States require practitioners who seek compensation to frequently deliver interstate care to acquire a full license. If a practitioner serves several states, obtaining this license in each state could be an expensive and time-consuming proposition. Even if the practitioner never practices medicine face-to-face with a patient in another state, he/she still must meet a variety of other individual state requirements, including paying substantial licensure fees, passing additional oral and written examinations, and traveling for interviews. Regulations concerning the practice of Telemedicine vary from state to state. Physicians who will be prescribing over the Internet to patients should mandate strict controls on their practice to insure that they stay compliant with the various State Medical Board Regulations concerning Internet Prescribing.

Telenursing
Telenursing refers to the use of telecommunications and information technology for providing nursing services in health care whenever a large physical distance exists between patient and nurse, or between any number of nurses. As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc. Telenursing is achieving a large rate of growth in many countries, due to several factors: the preoccupation in driving down the costs of health care, an increase in the number of

aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its many benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses.

Applications

One of the most distinctive telenursing applications is home care. For example, patients who are immobilized, or live in remote or difficult to reach places, citizens who have chronic ailments, such as chronic obstructive pulmonary disease, diabetes, congestive heart disease, or disabilitating diseases, such as neural degenerative diseases (Parkinson's disease, Alzheimer's disease, ALS), etc., may stay at home and be "visited" and assisted regularly by a nurse via videoconferencing, internet, videophone, etc. Still other applications of home care are the care of patients in immediate post-surgical situations, the care of wounds, ostomies, handicapped individuals, etc. In normal home health care, one nurse is able to visit up to 5-7 patients per day. Using telenursing, one nurse can visit 12-16 patients in the same amount of time. [Needs source] A common application of telenursing is also used by call centers operated by managed care organizations, which are staffed by registered nurses who act as case managers or perform patient triage, information and counseling as a means of regulating patient access and flow and decrease the use of emergency rooms. Telenursing can also involve other activities such as patient education, nursing teleconsultations, examination of results of medical tests and exams, and assistance to physicians in the implementation of medical treatment protocols.

Legal, ethical and regulatory issues

Telenursing is fraught with legal, ethical and regulatory issues, as it happens with telehealth as a whole. In many countries, interstate and intercountry practice of telenursing is forbidden (the attending nurse must have a license both in her state/country of residence and in the state/country where the patient receiving telecare is located). Legal issues such as accountability and malpractice, etc. are also still largely unsolved and difficult to address. In addition, there are many considerations related to patient confidentiality and safety of clinical data.