2ND SEMESTER

A.Y. 2023-2024 |NURSING INFORMATICS - LEC

III. OPEN SOURCE AND FREE SOFTWARE (OSS/FS) Four MAIN Oss for PC
A. Open-Source Software/ Free Software • Microsoft windows OS
1. Definition and Criteria ➢ Version of Windows-1985 (launched by BILL
2. OSS/FS Development Models and Systems gates and ALLEN) with a vision that PC is a
3. Advantages
path to the future.
4. Issues and Challenges
5. Choosing the Right Software • Mac OSX
6. Sample Applications/ Healthcare Applications ➢ Apple computer (release in 1984) but
B. Data Processing developed and marketed by apple Inc.
1. Data, Types of Data, Data Base, Life Cycle of since 2001. It is the primary operating
Data system for apple Mac’s computer.
2. Structural or Physical Data Models
• LINUX
3. Files, Records, and Fields
4. Common, Data Operations, Warehouses, ➢ Open source and communitydeveloped
Purposes, Data Mining operating system (OS) for computers,
servers, mainframes, mobile devices and
SOFTWARE embedded devices.
• Refer to applications, scripts and programs ➢ Release as a free and open-source OS in
that run on a device. 1991. More popular on Tech GURU’s use
because of its stability and affordability.
• It can be thought of as the variable part of a
Preferred by web servers.
computer.
• Google Chrome OS
• In a computer system, the software is basically
➢ Chrome devices are fast, easy to use,
a set of instructions or commands that tell a
convenient for browsing the Web, sending
computer what to do.
and receiving email, creating and sharing
• E.g., MS-Word, MS-Excel, PowerPoint, etc. documents, and video chatting vices.
➢ Released in 2011. Combination of web
3 Types of Computer Software:
browsers and operating systems.
• System software is a program designed to
run a computer's hardware and applications TYPES OF OS
and manage its resources, such as its
• DOS (Disk Operating System) – Runs from a
memory, processors, and devices.
Disk drive.
• Utility software is a program specifically ➢ Was text based and required the user to
designed to help manage and tune system or remember a set of commands such as
application software. Used to support the delete, Run, copy and Rename.
computer infrastructure. ➢ Screens are black and generally only
• Application software is a type of computer displayed text and numbers.
program that performs a specific personal, ➢ Only allows one program at a time.
educational, and business function. Aimed at Program could not share information and
directly performing tasks that benefit ordinary could not use point and click to enter
users. commands. Most of this commands
functions with the use of key board.
OPERATING SYSTEMS
• GUI (Graphical User Interface)
• Functions a traffic controller.
➢ (pronounced as “gooey“ Point and click
• Brain of the computer. (start-up)
• Provides access to applications, such as office ➢ A graphics-based operating system
software and email. E.g., Computer apps. interface that uses icons, menus and a
mouse (to click on the icon or pull down the
menus) to manage interaction with the
system.
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NURSING INFORMATICS - LEC 2ND SEMESTER | Open Source and Free Software (OSS/FS)

OPEN-SOURCE SOFTWARE/ FREE ➢ Freedom 1 – The freedom to study how the

program works, and change it to make it do
SOFTWARE what you wish.
• Free software foundation (FSF) philosophy and ➢ Freedom 2 – The freedom to redistribute
the open-source initiative (OSI) philosophy, are copies so you can help your neighbor.
today often seen as separate movements with ➢ Freedom 3 – The freedom to improve the
different views and goals, their adherents program and release your improvements to
frequently work together on specific practical the public so that the whole community
projects. benefits.
• Proprietary Software – An individual or
company holds the exclusive copyright, at the
OPEN-SOURCE SOFTWARE
same time restricting other people’s access to
the software’s source code and/or the right to • Said to promote software reliability and quality
copy. by supporting independent peer review and
• Commercial Software – Software developed rapid evolution of source code as well as
by businesses or individuals with the aim of making the source code of software freely
making money from its licensing and use. available.
• Freeware – Software offered free of charge, • Allow anyone to modify and redistribute the
but without the freedom to modify the source software.
code and redistribute the changes, so it is not • The open-source initiative (OSI) has created a
free software (as defined by the FSF). certification mark, “OSI certified.“ In order to
• Shareware – Another form of commercial be OSI certified, the software must be
software, which is offered on a “try before distributed under a license that guarantees the
you buy“ basis. If the customer continues to right to read, redistribute, modify, and use the
use the product after a short trial period, or software freely.
wishes to use additional features, they are FREE REDISTRIBUTION
required to pay a specified, usually nominal, • The license shall not restrict any party from
license fee. selling or giving away the software as a
component of an aggregate software
distribution containing programs from several
FREE SOFTWARE different sources.
• The “free“ of free software is defined in • The license shall not require a royalty or other
terms of liberty, not price, thus to understand fee for such sale.
the concept, the common distinction is in SOURCE CODE
thinking of free as in free speech, not as in
• The program must include source code, and
free beer.
must allow distribution in source code as well
• Acronyms such as FLOSS (free/libre/OSS – a as compiled form.
combination of the above two terms
• There must be a well-publicized means of
emphasizing the “libre“ meaning of the word obtaining the source code for no more than a
free) or OSS/FS are increasingly used,
reasonable reproduction cost preferably,
particularly in Europe, to overcome this issue
downloading via the Internet without charge.
(International Institute of Infonomics, 2005).
• Must be the preferred form in which a
• Free software is a matter of the user’s programmer would modify the program.
freedom to run, copy, distribute, study, change
Deliberately obfuscated source code is not
and improve the software.
allowed.
• Four kinds of freedom for the users of the • Intermediate forms such as the output of a
software:
preprocessor or translator are not allowed.
➢ Freedom 0 – The freedom to run the
program for any purpose.

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NURSING INFORMATICS - LEC 2ND SEMESTER | Open Source and Free Software (OSS/FS)

DERIVED WORKS LICENSE MUST NOT RESTRICT OTHER

• The license must allow modifications and SOFTWARE
derived works, and must allow them to be • The license must not place restrictions on other
distributed under the same terms as the software that is distributed along with the
license of the original software. licensed software.
INTEGRITY OF THE AUTHOR’S SOURCE • E.g., The license must not insist that all other
CODE programs distributed on the same medium
• The license may restrict source code from must be open-source software.
being distributed in modified form only if the LICENSE MUST BE TECHNOLOGY-NEUTRAL
license allows the distribution of “patch files“ • No provision of the license may be predicated
with the source code for the purpose of on any individual technology or style of
modifying the program at build time. interface.
• The license must explicitly permit distribution
of software built from modified source code. OSS/FS DEVELOPMENT MODELS AND
The license may require derived works to SYSTEMS
carry a different name or version number
BAZAAR METHOD OF DEVELOPMENT
from the original software.
NO DISCRIMINATION AGAINST PERSONS OR • OSS/FS development is likened to a bazaar,
GROUPS growing organically from an initial small
group of traders or enthusiasts establishing
• The license must not discriminate against any
their structures and beginning businesses.
person or group of persons.
NO DISCRIMINATION AGAINST FIELDS OF • Several Advantages:
ENDEAVOR ➢ Reduced duplication of efforts through
being able to examine the work of others
• The license must not restrict anyone from
and through the potential for large numbers
making use of the program in a specific field
of contributors to use their skills. As Moody
of endeavor.
(2001) describes it, there is no need to
• E.g., It may not restrict the program from reinvent the wheel every time as there
being used in a business, or from being used would be with commercial products whose
for genetic research. codes cannot be used in these ways.
DISTRIBUTION OF LICENSE ➢ Building on the work of others, often by the
• The rights attached to the program must apply use of open standards or components from
to all to whom the program is redistributed other applications.
without the need for execution of an additional ➢ Better quality control; with many developers
license by those parties. working on a project, code errors (bugs)
LICENSE MUST NOT BE SPECIFIC TO A are uncovered quickly and may be fixed
PRODUCT even more rapidly (often termed Linus’
• The rights attached to the program must not Law, “given enough eyeballs, all bugs are
depend on the program’s being part of a shallow“ [Raymond, 2001]).
particular software distribution. ➢ Reduction in maintenance costs; costs, as
• If the program is extracted from that well as effort, can be shared among
distribution and used or distributed within the potentially thousands of developers (Wong &
terms of the program’s license, all parties to Sayo, 2004).
whom the program is redistributed should
have the same rights as those that are granted PROPOSED BENEFITS OF OSS/FS
in conjunction with the original software
distribution. • Can transform healthcare.
➢ OSS/FS has been described as the
electronic equivalent of generic drugs.
➢ In the same way as the formulas for
generic drugs are made public, so OSS/FS
source code is accessible to the user.
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NURSING INFORMATICS - LEC 2ND SEMESTER | Open Source and Free Software (OSS/FS)

• Lack of the proprietary lock-in that can often • An OSS/FS personally controlled health record
freeze out innovation, and with OSS/FS (PCHR) system, using open standards.
projects supporting open standards. ➢ A PCHR enables individuals to own and
• Providing a level playing field, expanding the manage a complete, secure, digital copy of
market by giving software consumers greater their health and wellness information.
choice (Dravis, 2003). SMART PLATFORMS PROJECT
• Security, reliability, and stability, and • [Link]
developing local software capacity. • Open source, developer-friendly application
programming interface and its extensible
OSS/FS HEALTHCARE APPLICATIONS medical data representation and standards
based clinical vocabularies.
• BOWEN summarize a number of advantages
that open-source software offers when • Allows healthcare clients to make their own
compared with proprietary software, including, customizations, and these apps can then be
but not limited to, the following: licensed to run across the installed base.
➢ ease of modification and or customization, GNUMed
➢ large developer community and its benefits, • [Link]
➢ increased compliance with open standards, • Builds free, liberated open source EMR
➢ enhanced security, software in multiple languages to assist and
➢ increased likelihood of source code improve longitudinal care (specifically in
availability in the event of the demise of the ambulatory settings, i.e., multiprofessional
vendor or company, practices and clinics).
➢ easier to adapt for use by healthcare • Available at no charge and is capable of
students, running on GNU/ Linux, Windows, and Mac OS
➢ flexibility of source code to adapt to X. Developed by a handful of medical doctors
research efforts. and programmers from all over the world.
CLEARHEALTH OpenMRS
• [Link] • [Link]
• Web-based, fully comprehensive medical suite • Community-developed, open-source enterprise
offering a wide range of tools to practices of EMR system platform (Wolfe et al., 2006).
all sizes. • Supporting efforts to actively build and/or
• It includes scheduling and registration manage health systems in the developing
features; EMR including alerts, patient world to address AIDS, tuberculosis, and
dashboard, laboratory ordering and results, malaria, which afflict the lives of millions.
and barcode generation and uses; SNOMED; DISTRICT HEALTH INFORMATION SYSTEM
access via mobile devices; billing and (DHIS)
reporting features; and specialist clinical • [Link]/projects/dhis/
modules. • Provides for data entry, report generation, and
INDIVO analysis.
• [Link] • Part of a larger initiative for healthcare data
• Original personal health platform, enabling an in developing countries, called the Health
individual to own and manage a complete, Information System Programme (HISP).
secure, digital copy of her health and wellness OpenEHR
information. • [Link]
• Integrates health information across sites of • The OpenEHR Foundation is an international,
care and over time. not-for profit organization working toward the
• Free and open source, uses open, development of interoperable, lifelong EHRs.
unencumbered standards, including those • Created to enable the development of open
from the SMART Platforms project and is specifications, software, and knowledge
actively deployed in diverse settings. resources for HISs, in particular EHR systems.

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NURSING INFORMATICS - LEC 2ND SEMESTER | Open Source and Free Software (OSS/FS)

TOLVEN • E.g., Lab produces lab data, X-ray department

• [Link] produces image data.
• Developing a range of electronic personal and • Can also be based on the event that the data
clinician health record applications, using are attempting to capture.
open-source software and health industry
standards, including Unified Medical Language TYPES OF FILES
Systems and Health Level 7. DATA FILES
• Contain data that have been captured and
DATA PROCESSING stored on a computer using a software
DATA program.
• Raw uninterrupted facts that are without • E.g., Microsoft word document- will have the
meaning. extension DOC.
• E.g., A patient’s weight is recorded as 168 lb, PROCESSING FILES
without additional information this fact or • Executable files consist of a computer
datum cannot be interpreted program or set of instructions that, when
• When data is interpreted, information is executed, causes the computer to open or start
produced. a specific computer program or function.
• For data to be interpreted and information • Files that tell a computer what actions the
produced, the data must be processed. computer should perform when running a
• Several approaches to organizing data: program.
sorting, classifying, summarizing, and
calculating. FIELDS, RECORDS, AND FILES
DATABASE • Each of the blocks or cells in the table is a
• Organized collection of related data. field.
• Placing notes in folders and folders in • The top row lists the field names (reflect the
cabinets is one example of creating a type of data that are stored in the related
database. fields).
• Can be stored and organized in many • Field attribute- specific datum for that field for
different formats. that record.
• E.g., Phonebook, patient’s medical record. • Each row represents a record.
• Each row is assigned a primary identifier.
TYPES OF DATA • A primary identifier is unique to that record.
COMPUTER-BASED DATA • All the records in the table constitute a file.
• Alphanumeric data include letters and ID
F-
L-NAME
ADDRESS- ADDRESS-
CITY REGION
NAME 1 2
numbers in any combination.
01 Betty Santos Gen. Bonifacio Baguio CAR
• The numbers in an alphanumeric field cannot Luna Rd. Street City
perform numeric function. 02 Leslie Magtibay Marcos Kennon Tuba CAR
Highway Road
• E.g., Of alphanumeric data: social security
number.
• Numeric data are used to perform numeric COMMON DATABASE OPERATIONS
functions including adding, subtracting, • DBMS vary from small programs running on a
multiplying, and dividing. personal computer to massive programs that
• Logic data are limited to two options: YES, or manage the data for large international
NO, TRUE or FALSE, 1 or 2, ON or OFF. enterprises.
CONCEPTUAL DATA TYPES • No matter what size or how a DBMS is used,
• Reflect how users view the data. there are common operations that are
• Can be based on the source of data. performed by all DBMS.

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• There are three basic types of data applications, including Unified Medical
processing operations: data input, data Language Systems and Health Level 7.
processing, and data output. • Data – Raw uninterrupted facts that are
without meaning.
• Database – Organized collection of related
data.
• Computer-Based Data – Alphanumeric data
include letters and numbers in any
combination.
• Conceptual Data Types – Reflect how users
view the data.
KEY POINTS: • Data Files – Contain data that have been
captured and stored on a computer using a
• Software – Basically a set of instructions or
software program.
commands that tell a computer what to do.
• Processing Files – Executable files consist of
• Free Software – User’s freedom to run, copy,
a computer program or set of instructions that,
distribute, study, change and improve the
when executed, causes the computer to open
software.
or start a specific computer program or
• Open-Source Software – Promote software function.
reliability and quality by supporting
independent peer review and rapid evolution
of source code as well as making the source
code of software freely available.
• ClearHealth – Web-based, fully
comprehensive medical suite offering a wide
range of tools to practices of all sizes.
• Indivo – Original personal health platform,
enabling an individual to own and manage a
complete, secure, digital copy of her health
and wellness information.
• SMART Platforms Project – Open source,
developer-friendly application programming
interface and its extensible medical data
representation and standards based clinical
vocabularies.
• GNUMed – Builds free, liberated open source
EMR software in multiple languages to assist
and improve longitudinal care (specifically in
ambulatory settings, i.e., multiprofessional
practices and clinics).
• OpenMRS – Community-developed, open-
source enterprise EMR system platform.
• District Health Information System (DHIS) –
Provides for data entry, report generation, and
analysis.
• OpenEHR – International, not-for profit
organization working toward the development
of interoperable, lifelong EHRs.
• Tolven – Developing a range of electronic
personal and clinician health record

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A.Y. 2023-2024 |NURSING INFORMATICS - LEC

IV. THE INTERNET AS A NURSING RESOURCE • Such communication systems were typically
A. History of the Internet limited to point-to-point communication
1. Who Controls between two end devices.
2. Technology Behind
3. Use of Internet – Then and Now
• Semaphore lines, telegraph systems and telex
4. World Wide Web machines can be considered early precursors
5. Intent as an Information Source of this kind of communication. The telegraph
B. PDA and Wireless Devices in the late 19th century was the first fully
digital communication system.
HISTORY OF THE INTERNET
WHO CONTROLS THE INTERNET?
• Internet Protocol Suite – The set of rules
used to communicate between networks and • Internet itself has no owners, censors, bosses,
devices on the Internet, arose from research board of directors, or stockholders.
and development in the United States and
involved international collaboration, TECHNOLOGY BEHIND THE INTERNET
particularly with researchers in the United • Standardized communication protocols enable
Kingdom and France. Internet to function.
• Vinton Gray – (Born June 23, 1943), an PROTOCOLS
American Internet pioneer and is recognized • Agreed on format for doing something.
as one of "the fathers of the Internet", sharing • Determine how data will be transmitted
this title with TCP/IP co-developer Bob Kahn. between two devices.
• Leonard Kleinrock (Born June 13, 1934) – An • The main protocols on which the functioning of
American Internet pioneer, computer scientist, the Internet is dependent are referred to as
and is considered one of the "fathers of the TCP and IP.
Internet". TCP
THE ORIGINS OF THE INTERNET
• Allows computers to connect to a network and
• The origins of the internet are rooted in the
exchange data.
USA of the 1950s. The Cold War was at its
height and huge tensions existed between • Carries out the task of breaking messages into
North America and the Soviet Union. Both small packets.
superpowers were in possession of deadly IP
nuclear weapons, and people lived in fear of • Lower level protocol.
long-range surprise attacks. The US realized it • Responsible for making decisions about the
needed a communications system that could packets and routing them.
not be affected by a Soviet nuclear attack. HYPERTEXT TRANSMISSION PROTOCOL
• Elliott/NRDC 401 Computer MkI, c.1953. The (HTTP)
ElliottNRDC 401 was one of the first electronic • Supports the World Wide Web (WWW).
computers, developed by British electrical FILE TRANSMISSION PROTOCOL (FTP)
company Elliott Brothers in 1952 when
machines of this type could span 4 metres in • Permits users to send all types of electronic
files over the Internet.
length and weigh over a ton.
DATA COMMUNICATION TELNET
• The concept of data communication – • Allows users to access a distant computer as
transmitting data between two different places though they were sitting in front of it.
through an electromagnetic medium such as PACKET SWITCHING is a rapid store and
radio or an electric wire – pre-dates the forward networking design that divides messages
introduction of the first computers. up into arbitrary packets, with routing decisions
made per-packet. It provides better bandwidth
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NURSING INFORMATICS - LEC 2ND SEMESTER | The Internet as a Nursing Resource

utilization and response times than the traditional USE OF EMOTICONS AND ABBREVIATIONS
circuit switching technology used for telephony, • To make up for the inability of message
particularly on resource-limited interconnection recipients to accurately judge the mood of the
links. sender, the practice of typing characters
DOMAIN NAME SYSTEM available on a standard keyboard to form a
• Give globally unique names to networks and “picture“ was begun.
computers. • Emoticons/ smileys: small icons to denote a
• Benefits: mood.
➢ Name is easier to remember than the long • E.g.,
string of numbers. ➢ ;-) winking
➢ Name allows change of physical location. ➢ :-( Sad
• Paul Mockapetris – Pioneer in the protocols ➢ :-X lips are sealed
that allow DNS to work. ELECTRONIC MAIL AND FILES - USER
TOP LEVEL DOMAIN (TLDS) RESPONSIBILITY
• Each country, as of 2003, has a two-letter • Check E-mail daily and remain within your
TLD. limited disk quota.
➢ E.g.,
• Delete unwanted messages immediately since
o .CA (Canada)
they take up disk storage.
o .UK (Great Britain)
o .DE (Germany) • Keep messages remaining in your electronic
o .BIZ (For businesses) mailbox to a minimum.
o .COM (Commercial/ Business • Mail messages can be downloaded or
organizations) extracted to files then to disks for future
o .COOP (For cooperatives) reference.
o .EDU (Restricted to 4-year degree • Never assume that your E-mail can be read
granting institutions) by no one except yourself; others may be able
o .INT (Restricted to organizations that were to read or access your mail. Never send or
established by international treaty) keep anything that you would mind seeing on
o .PRO (For professions) the evening news.
• Some have more than 1 dot. • The content and maintenance of a user's disk
➢ E.g., [Link] storage area is the user’s responsibility.
• ICANN (Internet Corporation for Assigned • Keep files to a minimum. Files should be
Names and Numbers) – created October, downloaded to your personal computer's hard
1998. drive or to diskettes.
➢ Responsible for the technical coordination • Routinely and frequently virus-scan your
of the internet; nonprofit, private sector system, especially when receiving or
corporation. downloading files from other systems to
prevent the spread of a virus.
• Your files may be accessible by persons with
USE OF INTERNET – THEN AND NOW
system privileges, so do not maintain anything
EMAILS private in your disk storage area.
• One of the most popular uses for the internet. BASIC E-MAIL GUIDELINES
• Has 2 parts, separated by the @ sign: user
• Mail on the Internet is not secure.
names and name of the computer.
• Be careful if you send anything but plain text
• E.g., [Link]@[Link]
(also known as ASCII text) as e-mail.
• E-mail communication is different from either
• Be cognizant of the size of the e-mail
telephone or face-to-face communication.
messages and attachments that you send.
• Many people have learned the hard way that
• Include a signature.
e-mail is not considered private as is mail
delivered by the post office. • Do not request a “read receipt“ for every e-
mail message that you send.
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NURSING INFORMATICS - LEC 2ND SEMESTER | The Internet as a Nursing Resource

• Be sure to double-check the “To“ and “From“ • The two most commonly used operating
fields prior to sending your message. systems for PDAs are Palm OS or Windows
• Do not type in ALL CAPS. mobile.
• Do not type in all lower case. • Other less frequently used operating systems
• Be to the point without rudeness or being include Blackberry, Hiptop, Linux, and
abrupt. Symbian.
BUSINESS E-MAIL ETIQUETTE
KEY POINTS:
• Sending threatening, slanderous, insubordinate
messages is strictly prohibited. • Protocols – Agreed on format for doing
something.
• Sending racially and/or sexually harassing
messages is strictly prohibited. • TCP – Allows computers to connect to a
network and exchange data.
• Pyramid schemes are illegal and should not
be transmitted through e-mail. • IP – Lower level protocol.
• The representation or you as someone else, • Hypertext transmission protocol (HTTP) –
real or fictional, or a message sent Supports the World Wide Web (WWW).
anonymously is prohibited. • File Transmission Protocol (FTP) – Permits
• Use discretion in using sayings or quotes users to send all types of electronic files over
attached to the signature line. the Internet.
• Watch punctuation and spelling. • Telnet – Allows users to access a distant
computer as though they were sitting in front
• For important items, let senders know you have
of it.
received their e-mail, even if you cannot
respond in-depth immediately. • Domain Name System – Give globally unique
EMAIL ETIQUETTE names to networks and computers.
• Top Level Domain – Has a two-letter TLD for
• Using a clear and concise subject line. each country and some have more than 1 dot.
• Addressing the recipient appropriately. • Emails – Has 2 parts, separated by the @
• Maintaining a professional tone. sign: user names and name of the computer.
• Proofreading for errors before sending.
• Being mindful of the recipient's time by
keeping emails brief and to the point.
• It is also important to respond promptly to
emails and to use proper formatting, such as
paragraphs and bullet points, to improve
readability.
CHAT AND INSTANT MESSAGE
• Use abbreviations when possible, but only if
your reader will understand and if the e-
communication is not formal.
• Smileys, or emoticons, can help convey your
intention (for example, being humorous or
sarcastic).

PDA AND WIRELESS DEVICES

• The type of operating system determines in
part the strategies for conserving energy in
order to prolong battery life.
• Desktop, notebook/laptop, tablet and PDA
computers may be used as a stand-alone
device or as part of a network.

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A.Y. 2023-2024|NURSING INFORMATICS - LEC

V. PRACTICE APPLICATIONS ➢ Possible actions that would be suggested to

A. Computerized Decision Support Systems (CDSS) the providers given the type and dose of
1. Uses of Computer-Based Clinical Decision medication.
Support System for Health Professionals ➢ Would be what the provider decides to do
2. Definition of Terms, Goal, Roles
based on the suggestions provided.
3. History
4. Types
5. Characteristics HOW CDSS CAN BE HELPFUL:
6. Impact on Clinicians and Clinical Decisions
• Knowledge-based decision support systems
7. Barriers
8. Cognitive Task Analysis (CTA)
are systems designed to ensure more precise
9. Issues and Responses to Nursing Informatics decision-making by effectively using timely
B. Telehealth and appropriate data, information, and
1. Definition knowledge management for convergence
2. History and Evolution industry.
3. Nursing Aspects • Clinical Decision Support is a process for
4. Clinical Applications Examples enhancing health-related decisions and actions
5. Telehealth and Factors Advancing
Innovations in Telehealth
with pertinent, organized clinical knowledge
6. Telenursing and patient information to improve health and
7. Legal and Ethical Aspects healthcare delivery.
C. Role of Technology in Medication-Use Process • Clinical decision support (CDS) provides
1. Influences on the Adaptation of Technology clinicians, staff, patients or other individuals
2. Barriers to Ineffective Communication to with knowledge and person-specific
Medication Orders information, intelligently filtered or presented
3. Computer Provider Entry (CPOE) vs.
Traditional Paper-Based System
at appropriate times, to enhance health and
4. Bar Code-Enabled Point-of-Care Technology health-care.
(BPOC) • In 2007, the American Medical Informatics
Association (AMIA) developed a roadmap for
COMPUTERIZED DECISION SUPPORT action on CDS, which identified a framework
of three pillars supporting the full benefits of
SYSTEMS CDS.
DECISION SUPPORT SYSTEMS (DSS) ➢ These pillars were:
• Automated tools designed to support decision- o Best knowledge available when needed.
making activities and improve the decision- o High adoption and effective use.
making process and decision outcomes. o Continuous improvement of knowledge
• Computerized program used to support and CDS methods.
determinations, judgments, and courses of
action in an organization or a business. 5 RIGHTS OF CLINICAL DECISION
CLINICAL DECISION SUPPORT SYSTEM SUPPORT
(CDSS) RIGHT INFORMATION
• Provides timely information, usually at the point
• Filter out the unrelated data from the patient,
of care, to help inform decisions about a
SO or the clinician who did the initial interview.
patient's care. RIGHT PEOPLE
➢ Ordering antibiotic is an event that signals
• It can be the doctors, nurses, the client or
acds algorithms the simplest type of
patient, the relative of the patient or other
medication alerts.
medical practitioners who are currently
➢ Patient age.
involved in the treatment regimen of the
specific patient.

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NURSING INFORMATICS - LEC 2ND SEMESTER | The Internet as a Nursing Resource

RIGHT INTERVENTION KNOWLEDGE-BASED SYSTEM

• These include all the medical, nursing • Relies on expert knowledge that is either
interventions that will be required to take care embedded in the system or accessible from
of this specific patient, it also includes alerts, another source.
orders, protocols, and patient monitoring
system. TYPES OF CDSS
RIGHT CHANNELS DECLARATIVE KNOWLEDGE
• The delivery should always be within the EHR • Can be considered the “know what“ or
of the medical organization either thru the use descriptive knowledge, procedural knowledge
of computers, laptops, cellular phones, or PDAs. is the “know how,“ and the processes of
• All medical practitioners should have access to reasoning and inference produce the “know
the organization’s network. why“.
RIGHT TIME IN THE WORKFLOW • Refers to facts and information about a topic.
• The necessary information should be readily DESCRIPTIVE KNOWLEDGE
available when needed at all times especially • Knowledge that involves descriptions of actual
when time that the said information is greatly or speculative objects, events, or concepts.
needed by the clinicians. CDSS Type Description
Alerts and • Based on rules, the ability to alert the user
CDSS IMPACT ON CLINICIANS reminders when information is received or recorded for
the patient.
• There is growing pressure for clinicians • The alert could be in different forms,
including nurses to use knowledge at the point including a simple pop-up message, a
of care that is based on researched evidence. detailed message with guidelines and an
entry into a task list, SMS, email or paging.
The use of CDSS to find and prevent errors Clinical • Based on rules, the ability to provide a care
related to gaps between optimal and actual guidelines pathway for a given patient condition. The
practice can result in improved quality of care pathway includes a simple guideline or
care. reference link when recording information,
possible diagnosis, suggested investigations
• Nurses have begun development of CDSS and suggested treatment plan.
specific for their practice as well as using • Based on rules, the ability to provide a
existing CDSS. For instance, nurses may use screening alert for a given patient condition.
MEWS (Modified Early Warning System), a Order sets • Based on rules, the ability to provide a
suggested order set for a given patient
bedside tool that uses vital signs to identify condition.
patients likely to deteriorate. Patient data • Based on rules, the ability to provide a list or
• The goals of a CDSS implementation address reports/ dashboard on the set of patients whose
dashboards information complies with the rules.
the use of best clinical practices, patient safety,
Document • Based on rules, the ability to trigger document
and patient empowerment as well as the templates templates/notes for a given patient condition.
financial well-being of the institution.
• A successful CDSS emerges from and supports
• DSSs could be divided into data based performance improvement initiatives.
(population based), model based (case based),
• The choice of a CDSS target may be related to
knowledge based (rule based), and graphics
a patient benefit that outweighs any possibility
based.
of harm, practices supported by evidence,
DATA BASED (POPULATION BASED) physician practice patterns, disease
• Provides decision support with a population management, chronic care management, and
perspective and uses routinely collected. national quality measures.
MODEL-BASED
• Approach which is based upon the usage of
software models in order to develop or specify
an application or platform.
• Access to and manipulation of statistical or
financial data and optimization or simulation.

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KNOWLEDGE AND COGNITIVE STAGES OF MEANINGFUL USE

PROCESSES • The meaningful use objectives will evolve in
three stages:
• Knowledge engineering is the field concerned
➢ Stage 1 (2011-2012): Data capture and
with knowledge acquisition (extracting or
sharing.
eliciting knowledge from experts) and the
➢ Stage 2 (2014): Advanced clinical
organization and structure of that knowledge
processes.
within a computer system. Building a
➢ Stage 3 (2016): Improved outcome.
knowledge- based or expert system requires
an understanding of the cognitive processes of
healthcare providers and how they deal with PATIENT DECISION SUPPORT
complexity. Most DSS take advantage of the • Another important area of decision support is
research on human reasoning and decision- patient decision support.
making. • Given the opportunity, patients may become
• “INTUITION“? “just didn’t look right,“ is it more engaged in self-care when patients as
intuition or do years of nursing experience that well as clinicians have the information needed
place that patient three standard deviations to make better decisions.
from the mean of all the patients cared for? • It can be difficult for patients to speak up
• Nurses recognize various types of knowledge during medical visits and they often struggle to
such as declarative knowledge and procedural communicate their needs and opinions to their
knowledge. Declarative knowledge can be providers.
considered the “know what“ or descriptive • Patient Decision Support (PDS) tools assist
knowledge, procedural knowledge is the “know patients in communicating with their providers
how,“ and the processes of reasoning and and using medical evidence to make informed
inference produce the “know why.“ choices that are consistent with the patient’s
• Cognitive Task Analysis (CTA) refers to a set values while using evidence about
of methods that capture the skills, knowledge, consequences of medical alternatives.
and processing ability of experts in dealing
with complex tasks. The goal of CTA is to tap RESPONSIBILITY OF USER: ETHICAL
into “higher order“ cognitive functions. AND LEGAL ISSUES
• This differentiate the decision making of an
• The legal responsibility for treatment and
expert compared to a novice.
advice given to a patient rests with the clinician
• The Center for Medicare and Medicaid regardless of whether a CDSS is used.
Programs provides financial incentives for the
• Confidentiality
“meaningful use“ (MU) of certified EHR
technology to improve the quality of patient • Data security
care and “inform clinical decisions at the point • Privacy
of care“.
FUTURE OF CDSS
CDSS AND MEANINGFUL USE • Despite the many challenges of developing
• To qualify for incentive payments through the and implementing CDSS, it is clear that the use
Centers for Medicare & Medicaid Services EHR of decision support will increase.
Incentive Programs, eligible providers and
hospitals must demonstrate meaningful use of SUMMARY
an electronic health record (EHR). • The development of CDSS requires a huge
• In other words, “meaningful use“ sets the financial and intellectual investment but also
specific objectives that eligible professionals represents the potential of reduction in care
and hospitals must achieve to participate in the costs through improvement of the decision
EHR Incentive Programs. process at the point of care and a reduction in
the possibility of costly errors.

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INFORMATICS AND THE excluding patient-specific medical treatments

and decisions.
HEALTHCARE INDUSTRY
• Clinical uses include medical decisions
involving patient care, diagnostics, and
HISTORICAL CONTEXT OF eHEALTH treatments.
• The rudimentary roots of telemedicine extend PERSONAL HEALTH RECORDS (PHR)
back to ancient times where simple forms of • Maintained by the patient, in contrast to the
distance communication, such as the use of medical record that is maintained by
light reflections and smoke signals, were used providers at the various clinical agencies
to relay messages about external threats, caring for the patient.
famines, and disease. • The PHR facilitates patient access to
• Telehealth applications have evolved from information about his/her health and
simple communications to sophisticated, healthcare experiences.
pervasive, and widespread systems in the • Use of a PHR encourages patients to track
home that make use of wireless, wearable, care encounters and collect relevant health
robotic, and multi-sensorial technologies. information to share in care management.

CONCEPT OF eHEALTH MANAGING HEALTH CONDITIONS AND

• eHealth is an emerging field of medical ACCESSING RESOURCES
informatics, referring to the organization and • Electronic resources are being used
delivery of health services and information increasingly to learn about and manage health
using the Web and related technologies. conditions.
• eHealth represents optimism, allowing patients • Health seeking behaviors of adults with chronic
and professionals to do what was previously conditions are notably different from those of
impossible. adults in general.
• Patients can also post their comments and • Specifically, when controlling for age, income,
advice to virtual communities. education, ethnicity, and over- all health status,
• eHealth can empower consumers and patients, internet users living with one or more
and it opens doors for new types of conditions are more likely than other online
relationships, such as shared decision-making adults to:
between a patient and his/her healthcare ➢ Gather information online about medical
provider. problems, treatments, and drugs.
➢ Consult online reviews about drugs and
CONCEPT OF mHEALTH other treatments.
• Another component of eHealth is mobile- ➢ Read or watch something online about
health (mHealth), which can be considered a someone else’s personal health experience.
delivery mechanism for eHealth.
• mHealth typically refers to the use of a TRANSFORMING THE PRACTICE OF
wireless communication device that supports HEALTHCARE
public health and clinical practices. WEARABLE AND PORTABLE MONITORING
SYSTEMS
eHEALTH APPLICATIONS • Remote patient monitoring, considered
TELEHEALTH experimental a few years ago, is now
• Telehealth has both clinical and non-clinical maturing, with a number of applications
uses. available.
• Non-clinical applications include professional • The VitalJacket is one example that utilizes
education; healthcare administrative duties; microelectronics in a wearable T-shirt that
research; and the aggregation of health data, continuously monitors electrocardiogram
waves and heart rate.

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eHEALTH CHALLENGES AND ISSUES CONCLUSION

• Innovations in eHealth do not come without • Without a doubt, eHealth applications will
challenges and issues that healthcare proliferate in the future.
professions must address. • Healthcare professionals need to seize the
• As the transformation of healthcare moves opportunities made possible by advanced
toward patient-centric models, the healthcare technologies and create powerful and human
professionals must resolve some key centered applications to facilitate consumers’
challenges and issues. full participation in health and wellness.
• These issues concern on legal, ethical, and • To evolve this process, healthcare professional
public policy arenas. need to be actively involved in resolving
LICENSURE challenges, shaping public policy, and
• The lack of infrastructure for interstate evaluating health outcomes.
licensure was a key impediment to the growth
of telehealth. KEY POINTS:
ETHICAL ISSUES • Decision Support Systems (DSS) – Automated
• The predominant ethical issues concerning tools designed to support decision-making
telehealth are privacy, confidentiality, and activities and improve the decision-making
security. process and decision outcomes.
PRIVACY • Clinical Decision Support System (CDSS) –
• The right of individuals to be left alone and to Designed to support healthcare providers in
be protected against physical or psychological making decisions about the delivery and
invasion or the misuse of their property. management of patient care.
CONFIDENTIALITY • Clinical Decision Support – Process for
enhancing health-related decisions and actions
• The “status accorded to data or information
with pertinent, organized clinical knowledge
indicating that it is sensitive for some reason,
and patient information to improve health and
and therefore it needs to be protected against
healthcare delivery.
theft, disclosure, or improper use, or both, and
must be disseminated only to authorized • Data Based (Population Based) – Provides
individuals or organizations with a need to decision support with a population perspective
know.“ and uses routinely collected.
DATA SECURITY • Model-Based – Access to and manipulation of
statistical or financial data and optimization or
• “The result of effective data protection simulation.
measures; the sum of measures that
• Knowledge-Based System – Relies on expert
safeguard data and computer programs from
knowledge that is either embedded in the
undesired occurrences and exposure to
system or accessible from another source.
accidental or intentional access or disclosure
to unauthorized persons, or a combination • Cognitive Task Analysis (CTA) – Refers to a
thereof; accidental or malicious alteration; set of methods that capture the skills,
unauthorized copying; or loss by theft or knowledge, and processing ability of experts in
destruction by hardware failures, software dealing with complex tasks.
deficiencies; operating mistakes; physical • Meaningful Use – Sets the specific objectives
damage by fire, water, smoke, excessive that eligible professionals and hospitals must
temperature, electrical failure or sabotage; or achieve to participate in the EHR Incentive
a combination thereof. Programs.
• Patient Decision Support (PDS) – Assist
patients in communicating with their providers
and using medical evidence to make informed
choices.

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• eHealth – Emerging field of medical

informatics, referring to the organization and
delivery of health services and information
using the Web and related technologies.
• mHealth – Use of a wireless communication
device that supports public health and clinical
practices.
• Personal Health Records (PHR) – Maintained
by the patient and facilitates patient access to
information about his/her health and
healthcare experiences.

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