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Computers and Nursing

Virginia K. Saba Kathleen A. McCormick

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Overview of Computers and Nursing
Virginia K. Saba / Kathleen A. McCormick / M. Kathleen Smith / Gail E. Latimer / Diane J. Skiba / Susan K. Newbold

OBJECTIVES
1. Provide an overview and introduction to each of the new sections in the 5th edition. 2. Describe the new concepts of nursing informatics technologies and information technology. 3. Identify the current concepts in informatics theory and the current issues in informatics. 4. Dene the multiple uses of nursing informatics through the continuum of care. 5. Specify new applications in education and research. 6. Describe a scenario for a personalized health future.

KEY WORDS
Standards and Policies Nursing Informatics Systems Life Cycle Workow Continuum of Care 2nd Life e-Health Research International Perspectives Personalized Future e-Learning Information Literacy

The welcome of four new section editors brings the 5th edition of Essentials of Nursing Informatics into a new era. Four section editors who are shaping nursing informatics were invited to join book editors, Virginia K. Saba and Kathleen A. McCormick to shape content for the 5th edition. After a market scan of the book was done by several leading nurses in informatics, Kathleen Smith was invited to be a section editor to bring new perspectives on system

life cycle and human factors. Her invaluable guidance in developing the content comes from her experience in the Weekend Immersion in Nursing Informatics Courses that are offered nationally. The chapter Systems Life Cycle has been expanded to two chapters; and the chapters Human Factors and Healthcare Project Management have been added to this section. Gail Latimer developed the core content for the new perspectives on information 3

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technology applications. From her global perspective in nursing executive leadership and corporate America, she broadened the applications into areas that were previously uncovered in previous editions. She brings new content for CPOE, Magnet, TIGER, Rural Health, Workow, Complex Systems Theory, as well as updates on Enterprise Applications. She expanded the content in Continuum of Care, Evidence from a broadened theoretical framework, and the applications perspective. Diane Skiba has crafted the educational section dening second life, distance education, e-learning in the information age, and innovations in e-Health. The section on research focusses on research applications, information literacy, and computerized resources. Susan Newbold represents the American Medical Informatics Association on the International Medical Informatics Association Nursing Informatics Special Interest Group. She has not only brought the readers updates from ve continents/countries (South American, Canada, Europe, Asia, Australia, and New Zealand), but also brought in a new welcomed continent, Africa. Some general impressions of the content and concepts discussed in the 5th edition are the multiple authors who refer to the Institute of Medicine landmark books To Err Is Human and Crossing the Quality Chasm. Other common references were in healthcare, IT, quality and education, the inuence of the health reform legislation (Patient Protection and Affordable Care Act [Public Law No. 111148] American Recovery and Reinvestment Act of 2009, and Health Information Technology for Economic and Clinical Health Act), and the quality and depth of understanding that nurse with a focus on the three stages of meaningful use experts have in the content areas of their respective chapters. The majority of authors who had chapters in the 4th edition did not update their chapters, but completely rewrote them since there was so much new information. The authors found it difcult in this edition to stay to their recommended page limits. The majority exceeded our expectations of chapter content and page count. Because of life circumstances or busy schedules, some authors were unable to meet commitments for the 5th edition, but we hope that they will continue to contribute through the literature in journals and future editions.

Westra who updated a similar chapter in the 4th edition. They reviewed whether the highlighted events, activities, and initiatives were critical in NI history and, if so, included them again in this chapter. A new section was added describing the NI pioneer history project which was initiated in 2004. They highlight the major history project activities, including (1) the contacting of the original 145 nurses who shaped the NI specialty; (2) the collection, storage, and indexing of their archival documents at the National Library of Medicines history collection; (3) the lessons learned from the videotaping of 33 NI pioneers; and (4) other information, such as the Web address of where the videotapes are stored and can be viewed. They conclude the chapter with an updated and revised table on Landmark Events in Computers and Nursing. The Davies Award for Excellence given by the Healthcare Information and Management Systems Society was updated by Patricia Wise. She describes the criterion for becoming a Davies Award winner, which marks technological innovation as well as evidence of achieving quality, reduced errors and costs, and improved outcomes of care. This chapter updates the new awardees and their recognized achievements.

PART 2: COMPUTER SYSTEMS (M. KATHLEEN SMITH)

Chapter 4, Computer Systems Basics, by Mary McHugh provides the key concepts of Computer Hardware and Software needed by todays student and user from an educators point of view. This chapter has combined three chapters from the 4th edition (Hardware, Software, and Data Processing). She provides strategies used to permit users to store and retrieve data as well as process the data into whatever products are desired. Data is broadly described in relation to computerized information systems. The basics in this chapter set the stage for the remainder of the section. In Chapter 5, Kathleen Smith and Denise Tyler discuss the Systems Life Cycle phases of planning, systems analysis and design, systems selection, and the rst seven steps of the 14 Steps of Implementation. Careful planning, strong executive support, and early involvement of staff are key to successful implementation or upgrade of a clinical information system. Marina Douglas and Marian Celli discuss the last seven steps of the 14 Steps of Implementation. The Informatics Nurse role is well suited to have an active and often lead role in clinical systems/electronic health record implementations. Steps 8 to 14 build on the planning and analysis discussed in Chapter 5.

PART 1: COMPUTERS AND NURSING (VIRGINIA K. SABA)

Historical Perspective of Nursing Informatics
This section is introduced with the chapter on nursing informatics (NI) history by Virginia Saba and Bonnie

Chapter 1 Overview of Computers and Nursing Attempting to implement or upgrade a system without reviewing and completing the tasks associated with each of the 14 steps generally results in system failure in one or more of the following areas: (1) A clinical information system does not meet the stated goal of the project. (2) There is failure to gain end user acceptance. (3) Expenditures exceed budget. (4) Anticipated benets are unrealized. In Chapter 7, Judy Murphy and Patricia Dykes describe how healthcare project management augments the Systems Life Cycle chapters, as it outlines the project management phases, called Process Groups, used to organize and structure the Systems Life Cycle in order to successfully complete all the implementation steps of a project. The project management process groups progress from initiation activities to planning activities, executing activities, monitoring and controlling activities, and closing activities. In Chapter 8, Human Factors, Gregory Alexander discusses the signicant role informatics nurses are playing in understanding the complex interactions between humanmachine systems as they are implemented. After completing his doctoral dissertation on this subject, Greg is the ultimate expert in discerning the literature on human factors. He succinctly provides an enormous human factors reference base for all nurses pursuing information technology. Understanding human factors enables nurses to recognize how work is performed and to develop humanmachine systems that support the work of the organization, and facilitates implementing usable clinical information systems. Peter Murray and Scott Erdley comprehensively dene Open Source and Free Software (OSS/FS) explaining their differences and similarities in Chapter 9. The chapter also introduces some particular applications, operating systems, and licensing issues. Some commonly available and healthcare-specic applications are introduced with examples. Also some organizations working to explore the use of OSS/FS within healthcare and nursing with some additional resources are introduced. This chapter is lled with Websites to retrieve OSS/FS. Kathleen Charters and Thomasine Guberski describe Mobile Computing Platforms, providing current technologies for use in the healthcare eld. The chapter provides a detailed description of a variety of devices and highlights how mobile devices are being used for healthcare information systems. The authors describe how the trend of mobile devices continues to expand to include wireless connectivity. It introduces the reader to the next generation of computing in healthcare and nursing informatics.

PART 3: INFORMATICS THEORY (VIRGINIA K. SABA)

The section on informatics theory provides an update on theoretical views on NI as a distinct nursing specialty. Chapter 11 by Katheen Hunter and Carol Bickford on NI theory highlights the new information and models presented in the 2008 American Nurses Associations (ANA) updated Nursing Informatics: Scope and Standards of Practice. They address the pertinent core concepts, denitions, and interrelationships, including the functional areas and latest certication requirements. They list and provide a brief description of the 12 recognized nursing terminologies by the ANA. The chapter on advanced terminology, prepared by Nicholas Hardiker, Suzanne Bakken, and Tae-Youn Kim, focuses on providing the background necessary to understand recent approaches to solving the vocabulary problem, including examples. The chapter is followed with a chapter by Connie Delaney and Bonnie Westra on the nursing minimum data setsNMDS, i-NMDS, and NMMDSwhich are being used nationally and internationally. They provide a synthesis of historical, current, and future NMDS systems and how they can increase nursing data and information capacity to drive knowledge building for the profession and contribute to the standards supportive of the electronic health record. The section ends with a chapter by Virginia Saba, Jacqueline Moss, and Luann Whittenburg who provide an overview of the Clinical Care Classication (CCC) System. They address how the CCC System is being used in nursing practice, education, and research, including a brief description of the CCC Costing Method that is currently being tested. A copy of the CCC System in presented in Appendix A.

PART 4: CURRENT ISSUES IN INFORMATICS (KATHLEEN A. MCCORMICK)

The 5th edition is timely in that the policies for Health IT are incentivized and the nursing profession has been a part of shaping those policies. The importance of standards nationally and globally is described by Joyce Sensmeier in Chapter 15. She clearly delineates the importance of the standards harmonization of information for system interoperability. She introduces new standards that are a global, multidisciplinary consortium to support the acquisition, exchange, submission, and archiving of clinical research data and metadata, such

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as the Clinical Data Interchange Standards Consortium and the National Information Exchange Model, interoperability frameworks which enable information sharing among organizations. As Judy Murphy and Elizabeth Johnson state in Chapter 16, Today, [nurses] constitute the largest single group of healthcare professionals, including experts who serve on national committees and participate in interoperability initiatives focused on policy, standards and terminology development, standards harmonization, and adoption. In their excellent chapter, Judy and Elizabeth discuss the signicant impact of federal legislation on the use of health information technology. Whether nurses are in IT or administrative positions or practice, they should read the updates on policy from these national leaders shaping policy. A trust framework is shaped by Dixie Baker, who served on the Ofce of the National Coordinator standards committee. Chapter 17 identies the seven layers of protection essential for establishing and maintaining trust in a healthcare enterprise and explains the role trust plays in Health Information Technology adoption, quality, and safety. The seven layers include risk management, information assurance policy, physical safeguards, operational safeguards, architectural safeguards, security technology safeguards, and usability features. She relates how these Health Information Portability Accountability Act and American Recovery and Reinvestment Act of 2009 provisions relate to this framework and the implications for the nursing profession. A challenge comes from identifying the multiple levels of policy that the nursing profession is engaged in to assure not only the advancement of informatics but also the educational and public policy implications. In Chapter 18, Amy Walker clearly denes the multiple communities that coexist in shaping policy and recommends collaboration, cross education, and information resource sharing to fully advance the healthcare provided by nurses to the American public. She provides a framework for nurses engaged in policy formulation to utilize. In Chapter 19, Charlotte Weaver and Jennifer Moore focuses on the health policy issues of home health agencies, such as their lack of a power base, funding, and resources. They address the home health policies in relation to the U.S. federal reimbursement schemes, including a comparison of similar policies in other countries. Also, they highlight health reform legislation and how the American Recovery and Reinvestment Act of 2009 is opening the door to include the emphasis on home healthcare.

PART 5: CONTINUUM OF CARE INFORMATION TECHNOLOGY SYSTEMS (GAIL E. LATIMER)

As with the transformation planned for American healthcare, the section Practice Application from the 4th edition has transformed in the 5th edition to the section Continuum of Care Information Technology Systems. This new section was revised to reect the Healthcare industry and initiatives, concepts, and solutions needed to support the change. Readers will experience the new continuum of care and environment of health from episode to episode of care delivery models. Their knowledge will expand as case studies and best practices are addressed to create new cultures and environments, theories, and applications. The United States has experience an unprecedented period with Healthcare reform. Information Technology plays a critical role in the transformation, in that the U.S. government has instituted laws and nancial rewards around the rich adoption of information technology. Hence, authors will reference the American Recovery and Reinvestment Act of 2009 and the interim nal rule. At the time of this editions publication, several areas of the nal rules have not been dened, so the authors have provided Websites for your reference. This newly created section, Part 5, begins with a comprehensive, detailed chapter addressing consideration on implementing computerized provider order entry (CPOE). Emily Bareys chapter on CPOE is a must read to all considering meaningful use, no matter if the health system is considering going for the reward (money). In Chapter 21, Ann Farrell and Sheryl Taylor were very busy surveying the major IT vendors to update their chapter. They have expanded their survey to include evidence-based clinical content and standardized terminology. Note the care ow diagram has been updated. Matthew Grissinger and Michelle Mandrack provide a comprehensive chapter evaluating the role technology can play in safe medication practice. Patient safety is a core value for all clinicians and in all environments were care is provided. New leadership styles and problem solving techniques are needed for the newly transformed health environment. Thomas Clancys overview of a complex adaptive system and case study is sure to shift your thinking and provide topics for team discussion. Future leaders must embrace the principles of Complexity Theory for todays and future success. These chapters

Chapter 1 Overview of Computers and Nursing are followed by Chapter 25 where Mical DeBrow and Cynthia Mascara describe how workow and healthcare process management can help support a more efcient, safer, and cost-effective information ow. One example of an advanced workow technology system embedded within a healthcare information system is described in their chapter. Several chapters describe the evidence perspective of healthcare. Chapter 26, by Lynn McQueen, Health Carter-Templeton, and Kathleen McCormick, is a broad framework of the many types of evidence being discussed from research and practice. This comprehensive chapter describes case studies that demonstrate the use of evidence in improving healthcare. In Chapter 27, Joanne Seasholtz and Bernadette Melnyk focus on the information technology supporting evidence with a focus on improving quality of care. They discuss how different vendors approach incorporating evidence in their information systems. The chapter by Ida Androwich and Margaret Kraft focuses on computerized decision support systems designed to support decision-making activities. They stress why such systems use an enormous amount of data to facilitate decision processes on the delivery and management of patient care. Magnet-designated hospitals have demonstrated nursing excellence through successful shared governance structures and cultures of professional practice and benchmarking metrics. IT plays a critical role in all ve components of the ANCC Magnet Model. Andrea Schmid-Mazzoccoli, a Magnet surveyor, provided a comprehensive overview of the new Magnet Model in Chapter 29. Health systems around the globe look to regulatory standards and the Institute of Safe Medicine Practice for best practice to ensure a culture of safety. The Continuum of Care section ends with a shift to where healthcare is delivered, not the hospitals but the community. Researchers hypothesize that there will not be enough physicians to meet the demands of the baby boomers. Mary Ann Lavin, Laketa Entzminger, and Mary Lee Barron address the role technology will play to support advanced practice. Susan Lundquists and Cathy Delmains new chapter on the rural market opens a whole new perspective on healthcare in rural and critical access hospitals. Adoption of Ambulatory Care Systems and demonstrating meaningful use are critical components of U.S. healthcare reform. In Chapter 32, Susan Newbold highlights information systems in ambulatory care settings. Susan provides an overview of the role technology plays and the need for sharing data, and an overview of all aspects of ambulatory care that impact on the required IT, such as where clients are treated, benets for nurses, implementation, and resources. She

extensively list the organizations involved in ambulatory care information systems. Susan Quinn shares a perspective of the post acute environment, dened as services provided in the community, not in a facility. She addresses the main drivers of reimbursement, terminology, and interoperability. She wraps up Chapter 33 with future trends. The last two chapters are a sign of the new healthcare worldPublic Health and Emergency Planning and Response. A new chapter on practice applications in public health by Judy Gibson, Janise Richards, Arunkumar Srinivasan, and Derryl Block brings an aspect to the continuum of care that is sometimes overlooked. They provide an overview of applications in informatics, describe legislation that has affected public health information systems, and provide examples of electronic data exchange between clinical care and public health. They also introduce the emerging role of the public health nurse informatician and how it differs from the role of the public health nurse. These authors address the trends and surveillance needed in a new world of healthcare and prevention. While Betsy Weiner and Lynn Slepski shift our thinking to responses to manmade and natural challenges and the role an electronic health record can play in supporting people in a time of need. Revising this section and working with these exceptional content experts was an enlightening experience. The authors and I will feel we have achieved success if after reading this new section we can change your paradigms and thinking.

PART 6: EDUCATIONAL APPLICATIONS (DIANE SKIBA)

The Internet has changed the way we work, the way we learn, the way we play, and now even the way we receive healthcare. As of June 2010, there were over 1.9 billion users worldwide (http://www.internetworld stats.com/stats.htm). Although the Internet has been around for many years, the introduction of the World Wide Web allowed everyday users to access information and knowledge from around the globe. The Web allows users to not only nd the information and knowledge one needs but now with Web 2.0 tools allows one to create, interact, and publish their own information and knowledge. Many have written that the Internet and the Web, like the personal computer, are disruptive innovations (http://www.claytonchristensen.com/disruptive_ innovation.html). This term, introduced by Clayton Christensen, refers to an innovation that challenges the

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current established product or service and provides a less expensive alternative, thus allowing more consumers access to this product or service. In this section, the reader will learn how disruptive innovations in healthcare and education are changing the delivery and access to these services. You will also get a glimpse of other technologies associated with social media and mobile applications that may ultimately push what John Doerr calls the third wave of disruptive innovations (http:// www.kpcb.com/team/doerr). Chapter 36, Web 2.0 and Its Impact on Healthcare Education and Practice, by Diane Skiba, Paul Guillory, and Kay Lynn Olmstead, provides a foundation for the examination of disruptive innovations. This chapter describes the evolution of the Internet and the Web with a particular emphasis on Web 2.0 and its associated tools. In the second iteration of the Web, the dynamics have changed from a dissemination platform to one that is collaborative, interactive, user-generated, and supportive of the wisdom of the crowd concept. The chapter examines the use of Web 2.0 tools, especially social software such as communication, social writing, social bookmarking, and social networking tools, in both education and healthcare. There is no doubt many of these tools are disruptive to the current methods of education and healthcare delivery. Chapter 37, by Patricia Allen, Khadija Bakrim, Darlene Lacy, Enola Boyd, and Myrna Armstrong, focuses on the delivery of cost-effective, high-quality education at a distance. The chapter traces the history of distance education and provides a current snapshot of online education. Although the market demand for online education continues to increase, the authors noted that there is still some skepticism related to quality. The chapter tackles the quality issues from both student and faculty perspectives, as well as challenges related to effectiveness and intellectual property. Marilyn Nielsen and Amy Bartons Chapter 38 explores the concept of healthcare at a distance. This chapter examines the evolution of e-Health and how it is distinctive from telemedicine and telehealth. They describe the potential disruptive innovation of mobile health and its various applications. Numerous examples are given on how e-Health applications are transforming healthcare, education, and research. The chapter also contains an examination of the challenges as e-Health evolves and changes the way healthcare is delivered. The chapter concludes with an e-Health case study. In Chapter 39, Rita Zielstorff and Barbara Frink examine the use of computers by consumers and patients for healthcare. This comprehensive review of the consumer engagement in their healthcare not only

examines consumer use of a variety of tools but also demonstrates the potential of disruptive innovations and their impact on healthcare. The chapter identies the major challenges of consumer and patient computing, such as privacy and security, the digital divide, quality of health information, impact on patient-provider relationships, and potential solutions. The authors also address the role of the informatics specialists in consumer and patient computing and potential research areas for further investigation. There is an extensive list of resources and readings at the conclusion of the chapter. Equipped with a solid foundation of the current and potential tools shaping the delivery of healthcare education and practice, it is important to examine the impact on nursing education in general as well as the education of informatics specialists. Chapter 40, by Eun-Shim Nahm and Marisa Wilson, describes how the convergences of driving forces, such as federal initiatives, technology advances, and consumer engagement, are inuencing the transformation of informatics education. The chapter addresses the need for informatics competencies for various levels of nursing education and for nursing faculty. Judith Warren, Helen Connors, and Patricia Trangenstein, in Chapter 41, describe an innovative approach to provide immersive educational environments to teach nurses, in particular nursing informatics students. In the chapter, they not only describe the pedagogy of using simulations and Second Life in health professional education but also examine the various strategies for educating students in Second Life. Faculty and administration considerations for the use of Second Life in education are explored. The chapter contains images of the University of Kansas Medical Center Island in Second Life. In the concluding chapter in this section by Michelle Troseth, she describes the evolution of the Technology Informatics Guiding Education Reform (TIGER) Initiative since its inception in 2004. This grassroots effort has made signicant use of intellectual and social capital across nursing organizations and professionals to promote what all current and future nurses need the necessary knowledge and skills to practice in an ever-increasing technology-rich and consumer-centric healthcare environment.

PART 7: RESEARCH APPLICATIONS (VIRGINIA K. SABA)

The section on research applications addresses two major aspects of computer use in nursing researchresearch applications and information literacy and computerized

Chapter 1 Overview of Computers and Nursing resources. The rst chapter, by Veronica Feeg and Theresa Rienzo, provides an overview of the software applications related to the stages of the research process; how computers facilitate the work of the research in both quantitative and qualitative aspects; and computer research use for the major healthcare categories. They provide an excellent step by step overview of the research process, starting with proposal, implementation, analyses, and dissemination. This second chapter in this section, by Diane Pravikoff, June Levy, and Annelle Tanner, provides information about electronic resources that are easily available and accessible and that can assist nurses in maintaining and enhancing their professional practices. They identify the resources that aid the nurse in keeping current with the published literature and information sources for nursing practice, research, and/or education. The ndings of a national study of computerized information literacy are provided, which had indicated the lack of nursing knowledge and competency in this eld. They provide an extensive list of electronic resources with their Web addresses.

update from Evelyn Hovenga, Michelle Honey, Lucy Westbrooke, and Robyn Carr. The Asia perspective is described by Hyeoun-Ae Park who coordinated Korea, Japan, and Taiwan. This chapter updates the use of nursing terminology in Asia and describes the expansion of ubiquitous computing in Korea such as the smart digital home, health management and health promotion using U-IT technology for the underprivileged population, Ubiquitous home healthcare for the elderly, and the u-City project. Finally, for the rst time, the continent of Africa is represented in a chapter by Irene van Middelkoop and Susan Meyer. For newcomers, they have clearly articulated formation of nursing informatics in South Africa, the problems of implementing computerization in a resource constrained environment, the barriers to forming a nursing informatics specialty, and the emergence of how nurses are using technology and standards. This is especially signicant in that Africa was the host country to MEDINFO in 2010.

PART 8: INTERNATIONAL PERSPECTIVES (SUSAN K. NEWBOLD)

The excellent integration of evidence into research to measure outcomes is especially informative in the chapter on Canada, by Lynn Nagle, Kathryn Hannah, and Nora Hammell, where their Information Highway is described. Heimar Marin updates the policies, education, and practice in South America. The changes going on in Europe are dened by Kaija Saranto, Virpi Jylh, and Kaarina Tanttu. This chapter is an intricate look at each of the member states in the European Union and the e-Health initiatives and comparative data on the continent. They update the use of nursing terminologies in Europe, give examples of nursing informatics education throughout Europe, and examples of cooperation among National Nurses Associations working together to advance nursing practice, quality care, workforce issues, and nursing informatics competencies. In addition, they describe national demonstrations for documenting nursing in electronic health records with an example of using meaningful use data from structured data. Future developments include the expansion of more sophisticated data acquisition, statistical analysis, and tools for reporting benchmarks at organizational and national levels. Coordinating the Pacic Rim and including Australia, New Zealand, and Hong Kong is a comprehensive

PART 9: THE FUTURE OF INFORMATICS (KATHLEEN A. MCCORMICK)

While we have one chapter on the future, as noted by Kathleen McCormick, all of the chapters point to a future in nursing informatics. We witness in version 5.0 the focus on the patient in this edition but recognize that the individual patient is a part of an enterprise of healthcare environments. To explain individual health, the information has to be translated from large population studies, evidence, through information systems that are interoperable and integrate data, and services to ultimately improve patient quality and safety. The dependencies on the activities in different environments lead to a broader understanding of the total patient clinical care and the component of their health as participants in a population, and the target of improved quality and safety. The concept of access has expanded to include the ability to aggregate individual data through patient matching of age, gender, ethnicity, health condition, genotype, and those who do or do not respond to treatments. The adaptive clinical trial is introduced as a new method to accommodate this new personalized health paradigm. The next level of matching is to providers who have similar types of patients. The nal level is to match patients to improve access, quality of care, outcomes, and report notiable diseases in surveillance networks. The essential goal is to be able to contribute, encrypt or deidentify information, aggregate or group data in a

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technically secure environment, and reprocess or reuse patient data. Data have the potential to go from environments to regional, national, and global exchanges.

SUMMARY
In summary, the variations in use of computer technology in nursing practice have expanded both in the United States and internationally. This book, like the IT community IS GLOBAL. It describes our shared challenges, successes, and requirements for going forward

together as we utilize information technology to improve the quality of care to patients in diverse environments, improve patient safety and the effectiveness of patient care, and utilize evidence in delivering care. We have so much to learn from each other in the implementations of technology toward nursing care. The global network of nursing in informatics can be declared a victory for the army of nursing informatics. It has been a privilege to work with the individual authors and new section editors in bringing this 5th edition to the readers. We hope you enjoy reading these chapters as much as we have.