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Biggest problems facing nursing today.

st Unread 3,657 Readers Online

est problems facing nursing today.
004 12:22 PM written by lumpy | 4 Comments
Email Follow

is Nicole. I am a first year nursing student. I have an assignment to ask a

t she/he feels are the biggest problems facing nursing today. If anyone
e to weigh in, and/or e-mail me I would really appreciate it. Thank you.

anca@yahoo.com

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ts

PATL
•
2004, 06:07 PM
•
y Posted by lumpy

is Nicole. I am a first year nursing student. I have an assignment to ask a •

t she/he feels are the biggest problems facing nursing today. If anyone
e to weigh in, and/or e-mail me I would really appreciate it. Thank you.
•
anca@yahoo.com
re are several key issues that are facing nursing today and they have the
o impact nursing significantly as we move into the future.

common ground for educational standards to enter nursing. Most

Nursing Degrees
ns have a common entry-level standard that defines them as a profession. For
in order to be a dietitan, you must possess a minimum of a bachelor's • RN to BSN,
me for lawyer, teacher, etc. For nursing, there is no real common entry-level • RN to MSN,
auses a great deal of confusion to young people looking at nursing as a • LPN/LVN to BSN,
nal career path. In addition, other health care disciplines have increased their • Health Care Management
al standards to meet the increasing technology available in health care, yet
ontinues to have no common thread in relationship to education for entry- Nursing News
registered professional nurse. This issue is frustrating in that it causes great
nurses as they are deeply divided on entry-level themselves. Do a search on Former nurse charged with felony Int
3
encouragement of...
and you will find many hotly debated discussions on the topic. 1 Frontline: Facing Death
0 America's Most Popular Jobs
respect as a professional. Many nurses will claim that they receive little
2
om other health care providers, including physicians, administrators and in
7
Bye Bye Darvocet
s even advanced practice nurses . As a result of this direct lack of respect,
w their voice as limited in health care. Nurses today are placed in some of 7 Nurses’ Role in the Future of Health C
dangerous positions in relationship to providing care to patients. Nurses in Slow job market for nurses just a
8
pitals have far too many patients to safely care for. Nurses have limited temporary blip, health...
h administrators and many nurses feel that the only way to have a voice is Healthcare sector among top adopters
4
nion, which is not necesssarily the answer. iPad
1 American healthcare system ranked w
th care advances and technology improves, the overall cost of health care is 0 among richest...
. Nurses believe that their wages do not fairly compensate for the the service
rm. It really is a sad note on society when a famous football player earns
f dollars, but the nurse caring for your mother and holding the security of
compensated less than $45,000 per year in most cases :angryfire . Nursing Articles
in benefits (decreased contributions to 401(k), elimination of retirement
etc.), increasing costs of health care insurance and no loyality by employers 1 You Better Have Fun!
e long term employment relationships all add to the lack of security that 1 A Full Moon at the Hospital
ve with their jobs. 2 What I Learned My First Day of Clin
Acupuncture for menopause, a person
1
a is increasingly becoming more litigous and nurses are being named in experience
This alarming trend will only increase in the future without proper 1
nt intervention. As lawsuits increase in numbers and awards to plantiffs are 1
My Cup Runs Over and Over
s, overall health care costs are going to increase. Many people looking at 9 A Heartbeat Stops - Another Begins
a viable career choice are thinking twice about the option without tort 6 The story is in the soil....
d reform of the current system. 3
5
Whatever Happened to Nursing?
he above contribute to the lack of nurses willing to work at the patient's
Many studies have shown that there is really no true nursing shortage, rather,
direct lack of willingness for registered nurses to work in these increasly
sing situations. This adds to the shortage. Couple the shortage with an aging
n and you have a true disaster in nursing on the horizon. 2008 will be the
hat the baby boomers will begin reaching retirement. Government reports
at the overall cost on the social security system will be overwhelming, not to
Medicare. Nurses will be on the front line dealing with aging baby
... How will the profession meet the challenges that it will face? Not sure I
er this.

l, I think there is hope and I pray that as we move into the future, someone
ing will engage nurses to unite and speak with one common voice for
health care and better standards for patient care as well as better working
s for nurses. California began this process with mandated nurse to patient
California can initiate such reform, why can't this reform spread across the
t can and when nurses begin to realize that they have one of the most
voices in the country, only then will WE as a professional body be able to
nd see change for our patients and for our working conditions. As a student
, you are on the front line also and you can be part of that powerful voice.
e is not all doom and gloom for us, it can indeed be very bright and
and wonderful if we all come together and work to change our profession
ak subservant occupation, to a profession that is strong, vocal with
n and able to provoke change for the future.

my opinions. Thank you and good luck with your project.

Fokker
2004, 12:48 PM

t RNPATL - Thanks! :-)

notic_nurse
2004, 01:28 PM

y Posted by RNPATL
re are several key issues that are facing nursing today and they have the
o impact nursing significantly as we move into the future.
said.

_nneji
2010, 02:55 AM

points, i am about to apply to nursing school and i have to write an essay

his same question. this has given me ideas on what to write.

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Newsletter | Copyright © 1996-2010 allnurses.com INC

United States
International Nursing
Advanced Practice Nursing
Critical Care Nursing
Nursing Specialties

Telehealth: Issues For Nursing

Introduction

The growing use of and interest in the use of telecommunications technologies in the
delivery of health care services has led to far-ranging discussions on telehealth (or
"telemedicine") and its potential role in the health care system. The American Nurses
Association (ANA) is committed to the use of telemedicine/telehealth in a manner that
enhances access to quality, affordable health care services.

As part of its participation in the national dialogue on telemedicine/telehealth, ANA on

August 29, 1996, submitted preliminary comments to a Joint Working Group (JWG)
convened by the Health Resources and Services Administration (HRSA) of the U.S.
Department of Health and Human Services. ANA continues to develop a more detailed
and comprehensive analysis of the broad range of issues relevant to the continued growth
and development of telehealth. The following is adapted from ANA's initial comments to
HRSA.

Because the use of telecommunications technologies in providing health care services is

broader than the discipline or practice of medicine, ANA generally refers to
"telemedicine" as "telehealth" -- a much more inclusive and accurate term, and preferable
to one predicated on solely a medical model.

ANA offers the following background comments specific to licensure and regulatory
issues which may be viewed as barriers to the effective use of telecommunications
technology.

The application of telecommunications technology in health care is evidenced through a

variety of telehealth practices including telemedicine, telenursing and teleradiology. The
mechanisms of telecommunication used include telephones, computers, interactive video
and teleconferencing. While the application of this new technology offers the possibility
of significant benefits to the health of individuals, it is important to anticipate and prepare
for the concerns and problems attendant to this technologic advancement.

ANA strongly believes that the strength and promise of telehealth lie in providing
increased access to health care services by augmenting existing services, not in replacing
them. Telehealth technologies should not be used to replace needed access to in-person
health care services. The potential for abuse of these technologies by providing "cheaper"
substitutes for in-person care needed in homes, communities, schools, nursing homes,
hospitals and other settings requires the development and enforcement of standards that
ensure these technologies will be used appropriately.

Regulatory Issues

Telecommunications has the potential to expand access to health care services across
state borders and even internationally. This has major implications for a health care
regulatory system that is state-based with its primary responsibility being the protection
of the public. How can such a regulatory system effectively adapt to the increased
utilization of telecommunications in health care while safeguarding the safety and
welfare of the citizens it serves?

The advantages of a state-based licensure system are that it is administered at the state
level and can be tailored to the needs, standards and expectations of the population the
licensed provider services. In addition, given a discreet jurisdiction, disciplinary actions
of providers can be closely monitored. For many professions, including nursing, one of
the chief difficulties presented by this system is that each state has developed its own
specific scope of practice and standards based on that locality resulting in a patchwork of
scopes, standards and requirements from state to state.

There have been various proposals made to amend the current state-based system to adapt
to the increasing demands of telehealth. Of these, California State Senate Bill 1665 has
advanced the farthest. It addresses some of the issues related to telehealth -- for instance,
by allowing for consultation services from an out-of-state practitioner -- but leaves open
many other issues related to provision of care other than consultation, including primary
health services.

The issue of cross-state practice becomes even more complex as they pertain to nursing.
Because laws and regulations governing nursing practice differ from state to state, it is
often not clear which laws apply to nurses providing telehealth services across state
boundaries. Do the laws of one state requiring practice under a protocol or agreement
with a physician, for instance, pertain if a nurse is providing consultation to a practitioner
and patient in a state where no such requirements exists? This could limit the consumer's
access to care as well as increase health care costs by requiring a consulting physician to
be involved in the care.

The use of new technologies has also allowed the increased use of protocols for triage,
consultation and advice by telephone or computer. The use of protocols, standardized
guidelines or computerized algorithms cannot be allowed to substitute for the
independent assessment and judgment of registered nurses, who extend the assessment
process to obtain contextual and situational information and will determine whether a
particular guideline fits a specific patient's condition and needs.

Privacy, Confidentiality, and Security

The increasing uses of telecommunications technology in the delivery of health care

raises new questions about issues of privacy, confidentiality and security of health
information. Nurses have a longstanding commitment to promoting and maintaining
patient privacy and confidentiality. There is concern on behalf of the nursing community
that existing laws, regulation, policies and protocols do not provide sufficient protection
of health-related information. Adequate privacy and security protection measures for
health information should be an integral part of the development of telecommunications
technology in health care. The following are fundamental measures that need to
accompany the initiation of this technology in patient care:
 previously established confidentiality and privacy protections of health information
must be maintained as well as scrutinized to establish if they are sufficient for this new
technology
 patients who are the recipients of telehealth interventions should be informed of the
potential risks (e.g., limitations to securing transmissions over the airwaves or by direct
line) and benefits
 patient access to information generated through telehealth is guaranteed
 dissemination of patient data or identifiable patient images (e.g., voice) will be
controlled by the explicit consent of the patient
 patients are informed if other individuals outside the health team (e.g., technical staff,
observers) are involved
 individuals who violate established privacy, confidentiality and security regulations
and misuse information will be subject to enforceable penalties

Vital to the responsible use of emerging telecommunication technologies within health

care is the development of policy, standards and regulations. The need for well-
established safeguards and monitoring mechanisms cannot be overemphasized. Nurses,
by virtue of their distinct relationships with patients and their role in the delivery of
health care, can provide significant leadership and are essential participants in discussion
and decision making around these issues.

10/9/96

For more information regarding the Policy Series, policy products specialist, at (202)
651-7022. If you have specific questions about this document, please mention No. 96-
PRA-03.
THIS INFORMATION COPYRIGHT 1997 AMERICAN NURSES ASSOCIATION

Challenges and Issues Related to Implementation of Nursing Vocabularies in Computer-

based Systems
Patricia Button, RN, EdD, Ida Androwich, RN, PhD, Lyn Hibben, RN, MSN, Valeria
Kern, RN, MS, Gay Madden, RN, BSN, Karen Marek, RN, PhD, Bonnie Westra, RN,
PhD, Chris Zingo, RN, MS, and Charles N. Mead, MD, MS
Affiliations of the authors: Oceania, Inc., Oakland, California (PB, VK); Loyola
University, Chicago, Illinois (IA); CareCentric Solutions, Duluth, Georgia (LH, CNM);
ERGO Systems, Mission, Kansas (GM); University of Pennsylvania, Philadelphia,
Pennsylvania (KM); Epsilon Systems, Minneapolis, Minnesota (BW); Kaiser Permanente
Southern California Region, Pasadena, California (CZ).
Correspondence and reprints: Patricia Button, RN, EdD, Oceania, Inc., 5203 Leesburg
Pike, Suite 900, Falls Church, VA 22041. e-mail: <<pbutton@oceania.com >.
Received March 19, 1998; Accepted March 19, 1998.
This article has been cited by other articles in PMC.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

Abstract
As key stakeholders from the clinical setting and vendor communities, the authors share a
summary of their collective experience related to the challenges and issues associated
with implementing the vocabularies recognized by the American Nurses Association in
several installations of commercially available clinical information systems. Although the
focus of the article is on summarizing the challenges and issues, it is of note that the
authors' experiences across care settings suggest that the experience and effort of using
one of the ANA-recognized vocabularies in a computer-based system are essentially
worthwhile and positive. The issues and challenges fall into two categories: 1) those
related to the developmental status of nursing vocabularies, and 2) those related to the
adoption or implementation of new technology.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

In the past ten years, progress in the development of nursing vocabularies has been
significant.1,2,3,4,5 Much of this development has taken place in parallel with the
articulation of the requirements for the integration of clinical terminologies into
computer-based systems.6,7 As a result, the development of nursing vocabularies and the
various efforts to use nursing vocabularies in clinical systems have not been guided by a
comprehensive set of requirements aimed at ease of implementation and integration in
computer-based systems.
In this article, as key stakeholders from the clinical setting and vendor communities, the
authors share a summary of their collective experience related to the challenges and
issues associated with implementing the vocabularies recognized by the American Nurses
Association (ANA) in several installations of commercially available clinical information
systems. The clinical settings, vocabularies, and computer systems that provide the
framework for the discussion are summarized in Table 1.
Table 1
Summary of Settings, Vocabularies, and Computer Systems Represented

Although the focus of this article is on summarizing the challenges and issues, it is worth
noting that the authors' experiences across care settings suggest that the experience and
effort of using one of the ANA-recognized vocabularies in a computer-based system are
essentially worthwhile and positive. In particular, the progress toward the capture of
clinical data in a structured, standardized manner that documents nursing practice and
facilitates analysis of its contribution to health care outcomes is of prime value.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References
Challenges and Issues
The challenges and issues of each clinical setting are from the perspective of a dyad
consisting of a nurse from the clinical organization and a member of the vendor's
development or implementation team. As shown in Table 2, the issues and challenges fall
into two categories: 1) those related to the developmental status of nursing vocabularies,
and 2) those related to the adoption or implementation of new technology. The issues and
challenges related to the development status of the nursing vocabularies concur with the
formal evaluation literature reviewed by Henry et al. in this issue (see p. 321); because
nursing vocabularies were designed primarily for the purpose of classification, they do
not fully meet requirements such as those of the Computer-based Patient Record Institute
Framework7 that are focused primarily on concept representation.8 Of particular interest
in the second category are the challenges that occur when both a new technology and a
new “language” are implemented simultaneously.
Table 2
Challenges and Issues Related to Implementation of Nursing
Vocabularies

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

Implications
The authors' experiences viewed within the current context of evolving requirements for
implementation of health care vocabularies in terms of both vocabulary-dependent and
human factors support two implications. First, and primary, is the need for education of
all of the key stakeholders in the nursing vocabulary efforts (e.g., vocabulary developers,
nurse informaticists, clinical implementors, and vendors) regarding the evolving
framework for health care vocabularies. In this effort, it is important that the U.S. nursing
community continues to collaborate with and learn from the experience of others,
including our colleagues in medical informatics and in nursing at the international
level.9,10 The AMIA Nursing Informatics Work Group has taken the leadership role in
providing educational offerings at both basic and advanced levels in conjunction with the
AMIA Annual Fall Symposium and Spring Congress. Second is the need for a framework
or model of implementation that is comprehensive and addresses both categories of issues
and challenges—the required features of vocabularies suitable for implementation in
computer-based systems and the pragmatic issues of use. Such a framework and research
regarding the role of the various components in the framework are necessary in order to
produce valid, reliable data regarding “what nurses do” within the multidisciplinary
provision of health care.
Notes
This article is based on presentations given at the invitational conference of the AMIA
Nursing Working Group, entitled “Implementation of Nursing Vocabularies in
Computer-based Systems,” which was held on May 28, 1997, in conjunction with the
AMIA Spring Congress.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

References
1. Martin KS, Scheet NI. The Omaha System: Applications for Community Health
Nursing. Philadelphia, Pa: WB Saunders Co, 1992.
2. McCloskey JC, Bulechek GM. Nursing Interventions Classification. 2nd ed. St. Louis,
Mo: CV Mosby Co, 1996.
3. North American Nursing Diagnosis Association. NANDA nursing diagnoses:
definitions and classification, 1992-1993. Philadelphia, Pa: NANDA, 1992.
4. Saba VK. Home Health Care Classification. Caring Mag. 1992;11(4): 58-60.
5. Johnson M, Maas M (eds). Nursing Outcomes Classification (NOC). St. Louis, Mo:
CV Mosby Co, 1997.
6. Cimino JJ, Hripcsak G, Johnson SB, et al. Designing an introspective, multipurpose,
controlled medical vocabulary. Proc 13th Annu Symp Comput Appl Med Care. 1989:
513-8.
7. Campbell J, Carpenter P, Sneiderman C, et al. Phase II evaluation of clinical coding
schemes: completeness, taxonomy, mapping, definitions, and clarity. J Am Med Inform
Assoc. 1997;4(3): 238-51. [PMC free article] [PubMed]
8. Henry SB, Warren JJ, Lange L, Button P. A review of major nursing vocabularies and
the extent to which they have the characteristics required for implementation in
computer-based systems. J Am Med Inform Assoc. 1998;5: 321-8. [PMC free article]
[PubMed]
9. Spackman KA, Campbell KE, Côté RA. SNOMED RT: a reference terminology for
health care. Proc AMIA Annu Fall Symp. 1997: 640-4. [PMC free article] [PubMed]
10. Hardiker N, Kirby J. A compositional approach to nursing terminology. In: Gerdin U,
Tallberg M, Wainwright P (eds). Nursing Informatics: The Impact of Nursing Knowledge
on Health Care Informatics. Stockholm, Sweden: IOS Press, 1997: 3-7.
Figures and Tables
Articles from Journal of the American Medical Informatics Association : JAMIA are
provided here courtesy of
American Medical Informatics Association

Challenges and Issues Related to Implementation of Nursing Vocabularies in Computer-

based Systems
Patricia Button, RN, EdD, Ida Androwich, RN, PhD, Lyn Hibben, RN, MSN, Valeria
Kern, RN, MS, Gay Madden, RN, BSN, Karen Marek, RN, PhD, Bonnie Westra, RN,
PhD, Chris Zingo, RN, MS, and Charles N. Mead, MD, MS
Affiliations of the authors: Oceania, Inc., Oakland, California (PB, VK); Loyola
University, Chicago, Illinois (IA); CareCentric Solutions, Duluth, Georgia (LH, CNM);
ERGO Systems, Mission, Kansas (GM); University of Pennsylvania, Philadelphia,
Pennsylvania (KM); Epsilon Systems, Minneapolis, Minnesota (BW); Kaiser Permanente
Southern California Region, Pasadena, California (CZ).
Correspondence and reprints: Patricia Button, RN, EdD, Oceania, Inc., 5203 Leesburg
Pike, Suite 900, Falls Church, VA 22041. e-mail: <<pbutton@oceania.com >.
Received March 19, 1998; Accepted March 19, 1998.
This article has been cited by other articles in PMC.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

Abstract
As key stakeholders from the clinical setting and vendor communities, the authors share a
summary of their collective experience related to the challenges and issues associated
with implementing the vocabularies recognized by the American Nurses Association in
several installations of commercially available clinical information systems. Although the
focus of the article is on summarizing the challenges and issues, it is of note that the
authors' experiences across care settings suggest that the experience and effort of using
one of the ANA-recognized vocabularies in a computer-based system are essentially
worthwhile and positive. The issues and challenges fall into two categories: 1) those
related to the developmental status of nursing vocabularies, and 2) those related to the
adoption or implementation of new technology.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

In the past ten years, progress in the development of nursing vocabularies has been
significant.1,2,3,4,5 Much of this development has taken place in parallel with the
articulation of the requirements for the integration of clinical terminologies into
computer-based systems.6,7 As a result, the development of nursing vocabularies and the
various efforts to use nursing vocabularies in clinical systems have not been guided by a
comprehensive set of requirements aimed at ease of implementation and integration in
computer-based systems.
In this article, as key stakeholders from the clinical setting and vendor communities, the
authors share a summary of their collective experience related to the challenges and
issues associated with implementing the vocabularies recognized by the American Nurses
Association (ANA) in several installations of commercially available clinical information
systems. The clinical settings, vocabularies, and computer systems that provide the
framework for the discussion are summarized in Table 1.
Table 1
Summary of Settings, Vocabularies, and Computer Systems Represented

Although the focus of this article is on summarizing the challenges and issues, it is worth
noting that the authors' experiences across care settings suggest that the experience and
effort of using one of the ANA-recognized vocabularies in a computer-based system are
essentially worthwhile and positive. In particular, the progress toward the capture of
clinical data in a structured, standardized manner that documents nursing practice and
facilitates analysis of its contribution to health care outcomes is of prime value.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

Challenges and Issues

The challenges and issues of each clinical setting are from the perspective of a dyad
consisting of a nurse from the clinical organization and a member of the vendor's
development or implementation team. As shown in Table 2, the issues and challenges fall
into two categories: 1) those related to the developmental status of nursing vocabularies,
and 2) those related to the adoption or implementation of new technology. The issues and
challenges related to the development status of the nursing vocabularies concur with the
formal evaluation literature reviewed by Henry et al. in this issue (see p. 321); because
nursing vocabularies were designed primarily for the purpose of classification, they do
not fully meet requirements such as those of the Computer-based Patient Record Institute
Framework7 that are focused primarily on concept representation.8 Of particular interest
in the second category are the challenges that occur when both a new technology and a
new “language” are implemented simultaneously.
Table 2
Challenges and Issues Related to Implementation of Nursing
Vocabularies

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

Implications
The authors' experiences viewed within the current context of evolving requirements for
implementation of health care vocabularies in terms of both vocabulary-dependent and
human factors support two implications. First, and primary, is the need for education of
all of the key stakeholders in the nursing vocabulary efforts (e.g., vocabulary developers,
nurse informaticists, clinical implementors, and vendors) regarding the evolving
framework for health care vocabularies. In this effort, it is important that the U.S. nursing
community continues to collaborate with and learn from the experience of others,
including our colleagues in medical informatics and in nursing at the international
level.9,10 The AMIA Nursing Informatics Work Group has taken the leadership role in
providing educational offerings at both basic and advanced levels in conjunction with the
AMIA Annual Fall Symposium and Spring Congress. Second is the need for a framework
or model of implementation that is comprehensive and addresses both categories of issues
and challenges—the required features of vocabularies suitable for implementation in
computer-based systems and the pragmatic issues of use. Such a framework and research
regarding the role of the various components in the framework are necessary in order to
produce valid, reliable data regarding “what nurses do” within the multidisciplinary
provision of health care.
Notes
This article is based on presentations given at the invitational conference of the AMIA
Nursing Working Group, entitled “Implementation of Nursing Vocabularies in
Computer-based Systems,” which was held on May 28, 1997, in conjunction with the
AMIA Spring Congress.

• Other Sections▼
o Abstract
o Challenges and Issues
o Implications
o References

References
1. Martin KS, Scheet NI. The Omaha System: Applications for Community Health
Nursing. Philadelphia, Pa: WB Saunders Co, 1992.
2. McCloskey JC, Bulechek GM. Nursing Interventions Classification. 2nd ed. St. Louis,
Mo: CV Mosby Co, 1996.
3. North American Nursing Diagnosis Association. NANDA nursing diagnoses:
definitions and classification, 1992-1993. Philadelphia, Pa: NANDA, 1992.
4. Saba VK. Home Health Care Classification. Caring Mag. 1992;11(4): 58-60.
5. Johnson M, Maas M (eds). Nursing Outcomes Classification (NOC). St. Louis, Mo:
CV Mosby Co, 1997.
6. Cimino JJ, Hripcsak G, Johnson SB, et al. Designing an introspective, multipurpose,
controlled medical vocabulary. Proc 13th Annu Symp Comput Appl Med Care. 1989:
513-8.
7. Campbell J, Carpenter P, Sneiderman C, et al. Phase II evaluation of clinical coding
schemes: completeness, taxonomy, mapping, definitions, and clarity. J Am Med Inform
Assoc. 1997;4(3): 238-51. [PMC free article] [PubMed]
8. Henry SB, Warren JJ, Lange L, Button P. A review of major nursing vocabularies and
the extent to which they have the characteristics required for implementation in
computer-based systems. J Am Med Inform Assoc. 1998;5: 321-8. [PMC free article]
[PubMed]
9. Spackman KA, Campbell KE, Côté RA. SNOMED RT: a reference terminology for
health care. Proc AMIA Annu Fall Symp. 1997: 640-4. [PMC free article] [PubMed]
10. Hardiker N, Kirby J. A compositional approach to nursing terminology. In: Gerdin U,
Tallberg M, Wainwright P (eds). Nursing Informatics: The Impact of Nursing Knowledge
on Health Care Informatics. Stockholm, Sweden: IOS Press, 1997: 3-7.
Figures and Tables
Articles from Journal of the American Medical Informatics Association : JAMIA are
provided here courtesy of
American Medical Informatics Association

Issues and Status of Nursing Use and Attitudes

“We’re lost but we’re making good time” (Yogi Bera)

Mobile computing can provide a path to improved real time, information-driven clinical
care. But most nurses do not yet actively use mobile information technology for their
core work. The critical issues that affect nursing use of information systems are not
technical, but social.

Typically, potential new users resist the adoption of any/all information technology
because they see the use of these systems as a threat to themselves and the status quo.
Resistance to change is a natural human behavior, but there are additional factors at play
in the nursing profession which impede the adoption of IT.

1) An aging population of nurses who have had little or no training in the use of
information technology 1.

2) Insufficient technical training at the baccalaureate level

3) A false perception among nurses that IT is “dehumanizing”

4) Misconceptions about hardware functionality.

Hardware:

Opposition to point-of-care computerized clinical support is commonly ascribed to

technical barriers, such as a lack of features. This misconception has caused much of the
discussion in nursing circles to focus on the technical barriers to wide spread acceptance
of mobile clinical support systems.

Technical barriers to nursing acceptance of mobile computing did, in fact, exist in the
early models of handheld devices. Often cited shortcomings were/are:
a) Small and/or difficult to read screens

b) Poor data entry due to the lack of a keyboard

c) Insufficient memory

All of these concerns have been addressed by the manufacturers of handheld devices.

a) Screen resolution has improved and will continue to do so. Moreover the newly
introduced color screens have effectively eliminated the complaint.

b) Data Entry Solutions:

• Attachable keyboards: Landware GoType

• On Screen Keyboard alternatives such as the FITALY Keyboard

• Advanced handwriting recognition software: CIC's Jot

c) Mass storage for handhelds is now available: Packing one Gigabyte (GB) of data
storage capacity on to a disk the size of a quarter. IBM's Microdrive can hold up to:

o 1,000 high-resolution photographs

 o 1 thousand 200-page novels
o 18 hours of high-quality digital audio music.

Price:

Price is another issue often cited as a barrier to adoption.

However with each stage of computing since the advent of the mainframe in the 1960s,
the number of users has been successively greater.

Prices of handheld computers are an order of magnitude less than the PC, just as the PC is
an order of magnitude less than the minicomputer.

The lower prices will enable handhelds to eventually reach substantially more users than
the PC, just as the lower PC prices enabled the PC to reach substantially more users than
the minicomputer.

Software

The large data sets like: ePocrates qRx , present untapped

information sources and clinical tools for nursing.
compelling
software
The utility and clinical relevance of software applications will be the
solutions
key to winning nurses over to mobile computing.
are the key
to nursing
Personal Digital Assistants (PDAs) are replacing the multiple
acceptance
reference books and ragged patient index cards that have fought for
pocket space for so long.

Is Nursing Use/Acceptance Required?

The benefits of mobile computing for physicians are now being realized and are being
published in the literature. However to realize the full potential of this powerful clinical
support system, the entire healthcare team must adopt mobile computing. Maintaining
dual (computerized and paper based) systems to accommodate those who refuse to use
the new technology can increase costs by 130% to 240% 2.

An even more compelling reason is the opportunity presented by handheld computing to

enhance patient safety and care.

A recently published report by investigators at Brigham and Women's Hospital states:

50% of physicians using ePocrates qRx handheld drug reference guide avoided one or
more serious adverse drug events per week

Over 90% of clinicians surveyed reported that it took them 20 seconds or less to find
information

80% said that ePocrates qRx improved their drug knowledge

83% said that their patients were better informed as a result

54% reported higher levels of satisfaction with their medical care

Nursing Advances in Mobile Computing

Nurses are putting aside their fears and misconceptions about mobile information
technology and are acknowledging the emergence of personal digital assistants (PDAs) as
devices that are becoming increasingly important in patient care.

1) Korea:

MobileNurse, the Implementation of a Mobile Computing System in a Clinical

Environment

2) Australia:

Case Study: A day in the life of Nurse Heavensent

3) Canada:

Nurse-driven community-based diabetes centre first to implement PDA technology to

monitor diabetes information.

RNpalm introduces the first nursing specific Palm OS software and launches the world's
first website dedicated to the use of PDAs in nursing
4) United States:

The Midwest Alliance for Nursing Informatics - "Handheld Technology and it's Clinical
Applications for Nursing"

“Point of Care Ware” software developed by Lynette Jones RN Ph.D.

Deri Dority RN, CCRN, BSN establishes the second website dedicated to the use of
PDAs in Nursing.

Nightingale Tracker system: a proprietary handheld home health clinical communication

system.

5) United Kingdom:

Colin Nicholls RN, RMN builds on the momentum and introduces: Practical Nurse Palm
Helper

This site is in its early stages but Colin tells us that he will be adding to it at a steady rate
over the coming weeks/months.

Discussion

Only six moths ago it was difficult to find any information on the use of PDAs in nursing,
now articles are starting to appear in the press:

Advance for Nurse Practitioners: Special Report on Handheld Tenewchnology

Nursing Executive Watch: Palm pilots: Popular among MDs, less so with RNs
(membership & registration required)

Nurses.com: Is a personal digital assistant in your future?

Nurses Week: Finding the right digital assistant

Handheld computers are the next step in the evolution of computing, the Mobile
Information Age has arrived. Its time for all members of the heathcare team to embrace
this new technology... resistance is futile :)

Notes:

1) Reader Response:

"Ken, your editorial about involving more nurses in the use of handheld technology, especially the Palm
Pilot type of technology, is generally right on target. Access to clinical and scientific information when it is
needed is going to be more and more important as knowledge expands and work loads increase. However, I
take exception to the point about the aging nurse population being a barrier to acceptance. This same point
was made about the general adoption of computer technology by nurses when such technologies were being
introduced. But, there was no supporting evidence for this stereotype. In fact, as studies were done, the age
and educational background of nurses were not influential factors. Experienced nurses, who tend to be
older, are a tougher customer because they have been through the "fads" and they can rapidly determine
what will help them. If a technology obviously provides a benefit, older nurses are more likely to be able to
integrate it into practice because they are more experienced."

Kathleen Milholland Hunter, PhD, RN

Independent Practice in Informatics

K&D Hunter Associates, Inc.

2) Schoenbaum SC, Barret GO. Automated ambulatory medical records systems: An orphaned technology.
In J Tech Assessment in Healthcare 1992; 8; 598-609

• TECHNOLOGY IN ACTION

• GO AHEAD, PRACTICE

In 1899, Charles H. Duell, a commissioner for the United States Office of Patents,
reportedly said: “Everything that can be invented has been invented.” He
obviously was wrong.

Technology continues to change, often with dizzying speed, and no industry is

immune.

For decades, the ANA has viewed technology as having a crucial role in health
care, one that could greatly benefit nurses and patients if implemented wisely.
Most recently, the ANA’s House of Delegates approved a resolution stating that
technology should be used to augment, not replace, RNs’ decision making when
determining patient safety practices.

The resolution also calls for RNs to be integrally involved in the research,
development, evaluation, and purchase of technological systems aimed at
improving the safety and quality of patient care, and that these systems don’t
create an undue burden on nurses who already are struggling to provide direct
care to their patients.

“You can’t just shove technology at people and expect that all the problems that
led to staffing shortages will go away,” says Susan Newbold, MS, RN,BC,
FAAN, cochairperson of a state-commissioned workgroup that looked at ways
that workplace technology could ease the nursing shortage in Maryland. “Trouble
may be just starting if the wrong technology is introduced.”

And there are cases when the technology is good but it’s implemented poorly,
says Dana Womack, MS, RN, a health care technology expert.
 “To this day nurses don’t have the input they should when computerized systems
and other technology are selected,” says Newbold, a Maryland Nurses
Association member. “We really need to be at the table when those decisions are
being made.”

Besides RN involvement at the unit level, Womack says that more nurses need
to ...

Newspapers Examine Issues Related To

Health Care Technology
Main Category: Medical Devices / Diagnostics
Article Date: 28 Jun 2006 - 17:00 PDT

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Find other articles on: "technology issues in healthcare"

Two newspapers on Monday published articles on issues related to health care

technology. Summaries appear below.

 Elder care: The Wall Street Journal on Monday examined how companies such as
Intel, Philips Electronics and Accenture have begun to develop products to
monitor the health of elderly patients "that try to be as unobtrusive as possible
while keeping people safe and connecting them to the outside world." Products
that can remotely monitor activities, blood pressure and cognitive function could
help elderly patients to live in their homes longer, "thus reducing the need for care
in costly settings," such as nursing homes or hospitals, the Journal reports. Russ
Bodoff, executive director for the Center for Aging Services Technologies, said,
"Where we've spent money on technology is in hospitals and operating rooms, ...
but we do so little to care for a person before they get to the hospital and after
they get out." However, the costs of such products are "big barriers ... to
widespread adoption," the Journal reports (Lueck, Wall Street Journal, 6/26).
  Electronic health records: The Los Angeles Times on Monday examined concerns
about whether efforts by the federal government to encourage use of EHRs will
increase risk for theft of personal medical information. Deborah Peel, founder of
the Patient Privacy Rights Foundation, asked, based on past thefts of personal
information, "why would any patient believe their personal, sensitive health data
is safe online?" John Halamka, chief information officer for Harvard Medical
School and chair of the Health Information Technology Standards Panel formed
by the Bush administration, said that a national EHR system would use a "very
decentralized approach" to help protect personal medical information. Halamka
said, "I would be worried if there were a centralized database in the basement of
the White House that could be hacked, but we're not building that" (Foreman, Los
Angeles Times, 6/26).

Technology in Healthcare Safety Issues

By an eHow Contributor

1. Technology has allowed for advances in health care. It also creates safety issues
in areas such as privacy, computer system malfunction and human error.
Computer system malfunction can make electronic medical records (EMR)
inaccessible, including important patient information such as medical history,
allergies and medication lists. Human errors such as typographical mistakes create
safety issues in health care systems that rely on accurate information.

Privacy
2. Privacy laws protect the privacy of patients' personal information, including
demographics, medical history and insurance information. Federal law requires
that all patient information be kept confidential. By law, personal information
may be shared only with those who need the information to provide a service.

Technology used in health care must provide a way to ensure that patient
information remains private. When unauthorized individuals are kept from
accessing a patient's address or contact information, the patient is protected from
identity theft, fraud and other threats.

Computer System Malfunction

3. Computer system malfunction prevents health care providers from accessing
needed information. Information stored on a computer system may be lost or
corrupted. Health care providers rely on the patient data saved in the system to
keep track of patients and their conditions and treatments.
 A patient's safety can be jeopardized when his physicians and nurses are denied
access to his information. For example, if a patient's EMR states that the patient
has an allergy to penicillin and the EMR is unavailable, his physician may
prescribe penicillin and provoke an allergic reaction.

Human Error
4. Human error such as typographical errors can lead to safety issues. An example of
this is a medication dosage error. A physician writes a prescription instructing a
patient to take one 1 mg pill daily. The information is entered into the computer to
be filled as 10 mg tablets. This typographical error has the patient taking a much
larger does than intended, which can lead to safety issues including medication
overdose.

Entering incorrect information into an EMR can also lead to safety issues. If a
nurse brings summaries of physicians' orders for multiple patients to a receptionist
at the same time, safety can become a concern. If the employee accidentally
enters patient A's information into patient B's file, medical errors may result.

Read more: Technology in Healthcare Safety Issues | eHow.com

http://www.ehow.com/list_7452303_technology-healthcare-safety-
issues.html#ixzz161dg34Ed
Guide to Critical Issues in Health Care
Technology Contracting.
Publication: Mondaq Business Briefing Format: Online
Publication Date: 22-MAY-06 Delivery: Immediate Online Access

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Article Excerpt
Introduction

Today's health care providers operate in a constantly changing environment shaped by

increased regulation and competition. In an effort to meet these challenges, health care
providers increasingly are embracing the latest in technological advances. Many health
care technology vendors lure providers with a siren song of lowered costs, increased
efficiencies, access to more and better data, and improved patient care. Given the
substantial cost of these technologies, their "mission-critical" nature, and the myriad of
legal and operational issues related to their acquisition, implementation, and use, these
solutions also present substantial risk to providers who follow the lure of these promises
without careful planning and implementation.

This Guide to Critical Issues in Health Care Technology Contracting addresses some of
the critical legal issues presented in a typical acquisition of health care technology. Due
to our extensive experience in health care technology we recognize that each transaction
presents unique legal and operational issues, and that the particular method(s) of
addressing these issues will change substantially with each transaction and each
particular vendor. Although this guide does not attempt to identify all of the potentially
important issues that your organization will face, we hope it will be a useful resource as
your organization navigates through the quagmire of health care technology acquisitions.

Issue One

Ensuring Your Project Is On Time and Under Budget

Most, if not all, health care entities have experienced technology acquisition projects that
significantly exceeded budgets and/or project timelines. In today's competitive
environment, budget overruns and endless implementation projects are more
unacceptable than ever. Although these problems are all too common, there are a number
of contractual tools available to ensure that your project is completed on time and under
budget.

Most standard vendor agreements do not contain enforceable project timelines. When
pressed, most vendors seek to avoid the development of a detailed work plan until after
the agreement is executed by the parties. Even when a detailed work plan is attached,
vendors will usually attempt to use a "level of effort" (e.g., "commercially reasonable"
efforts) standard to describe their contractual obligations. (See Sample One below.)

>

In addition to a lack of enforceable project timelines as exemplified in the language

above, most vendor agreements contain an unlimited "time and materials" approach to
project implementation services, with fees paid on a recurring (e.g., monthly) basis.
Under this framework, if the actual work effort required is double the originally projected
work effort, the vendor's implementation fees are doubled. In addition, the vendor
receives regular payments regardless of its progress (or lack thereof) and regardless of
whether the system and/or system components are working. Payment structures such as
these invite budget overruns.

Although implementation costs and timelines are the most obvious risks to your
organization, there are a number of other areas where a failure to adequately address
payment issues could result in hidden costs to your organization. For example, many
agreements contain unclear licensing metrics (e.g., vaguely worded descriptions of how
the vendor counts concurrent users) that can result in substantial unanticipated license
fees. In addition, most vendors offer no protection that agreed-upon third-party software
and hardware will be adequate to operate the vendor's software. As a result, if additional
third-party technology is required, it is most likely your organization's financial
responsibility (despite the fact that your organization may have purchased the exact third-
party software and hardware configuration that was specified by the vendor).

If these and other problems remain unaddressed in the agreement, project budgets and
timelines amount to nothing more than your current "best guess," and are oftentimes
based substantially upon oral conversations and vendor promises that are not included in
the agreement. Using the tools described below, your organization can help ensure that
the vendor appropriately shares the risk that the project will meet timelines and/or budget
requirements.

Guidelines:

Develop a project plan and timeline before the execution of the agreement with the
vendor, and attach it to the agreement as an exhibit. Obligate the vendor to meet the
milestones described in the exhibit on or before the prescribed dates. Ensure that the
vendor's obligations in this regard are clearly described, and avoid "level of effort"
language that merely obligates the vendor to using "commercially reasonable efforts" (or
some other level of effort) to meet project timelines.

Consider alternative payment methodologies for the vendor's implementation fees. These
include "fixed fee" projects, "not-to-exceed" projects, or a "hybrid" structure whereby
cost overruns progressively reduce the vendor's hourly or daily rate to the point where the
vendor is providing services without charge.

Regardless of the chosen methodology, payments should be milestone driven. Payments

should be released to the vendor based upon actual results (e.g., the acceptance of a
particular deliverable), not the passage of time.

Ensure that the agreement clearly and unambiguously describes the applicable licensing
metric(s). If necessary, include examples to ensure that both parties are in agreement
regarding when additional licensing fees will be paid.

Include appropriate configuration warranties to ensure that the vendor will bear any costs
of unexpected additional third-party technology that may be necessary to support your
use of the vendor's system.

Include an "All Fees Stated" limitation that requires the vendor to specifically and
succinctly describe any and all costs payable to the vendor under the agreement.

Issue Two

Limitations of Liability

Almost all vendors use their standard agreements as a vehicle for limiting their liability in
the event of a problem during the implementation or use of the vendor's product.
Although these liability limitations take a variety of forms, they all share the fundamental
purpose of shifting the risk of the vendor's nonperformance to your organization.

The most common such clause is usually labeled as a "Limitation of Liability" and, for
legal reasons, it is oftentimes drafted in capitalized or bold text. These clauses typically:
prohibit the customer from recovering certain types of damages (usually indirect,
consequential, incidental, special, and punitive damages); and limit the amount of
recovery for other types of damages, even if the customer is able to prove that the vendor
breached its obligations and that the breach caused the damages. (See Sample Two (A)
below.) In a sense, this clause is the most important part of your organization's agreement
with the vendor. If you successfully negotiate an agreement that contains very specific
implementation timelines, functionality commitments and other vendor promises, these
commitments are only as good as your organization's ability to enforce the agreement in
the event of a vendor breach. If the limitation of liability protects the vendor from
incurring any meaningful damages if it breaches the agreement, the value of these
commitments is substantially reduced or eliminated.

Many vendors also attempt to shift risk to the customer using a number of less obvious
methods. For example, vendors will often include a "blanket disclaimer" of responsibility
for certain risks. Although these disclaimers may sound reasonable on the surface, they
are almost always overly broad and include risks that are appropriately the vendor's
responsibility. (See Sample Two (B) below.) (Note that additional, health care-specific
disclaimers are discussed in connection with Issue Three on following pages.)

>>

Another common form of liability limitation is the use of "sole and exclusive remedy"
clauses. (See Sample Two (C) below.) Pursuant to these clauses, the vendor usually
commits to use a "commercially reasonable" level of effort to either fix or replace a
defective product or to re-perform defective services and asks the customer to waive all
other rights and remedies resulting from such defect. Although a fixed product is an
appropriate remedy, it oftentimes should not be the only remedy. For example, if a
patient is harmed by a defective product, the vendor's obligations should extend beyond a
commitment to repair or replace the product. Similarly, if a product failure causes your
organization to incur substantial damages (e.g., an inability to perform procedures) an
obligation to fix or replace the product is an incomplete remedy, at best.

>

Finally, many vendors seek to limit their potential liability by limiting the customer's
right to bring a claim after a certain period of time. (See Sample Two (D) below.) These
"artificial" statutes of limitations are almost always shorter than the statute of limitations
offered under state law. In addition, these clauses are oftentimes drafted in a one-sided
manner such that the customer must bring any claims within a shortened time period,
while the vendor reserves the luxury of filing claims within the longer statute of
limitations offered by applicable state law.

Limitations of liability are a critical aspect of health care technology transactions. In a

health care environment, a product failure could cause an inability to treat patients or bill
for services rendered. In the worst case scenario, a defective product could harm a
patient. As a result, limitations of liability should receive careful scrutiny. Remember,
just because limitations of liability are extremely common in the technology industry, this
does not mean that they are always fair or reasonable to the customer. In most cases, they
are neither. It is critical that your organization evaluate the risks posed by these
limitations, and determine in each case whether it is acceptable for the vendor to shift the
risk of its non-performance to your organization.

>

Guidelines:

Remember that the commitments found elsewhere in the agreement are only as good as
the limitation of liability. If the vendor provides "iron-clad" commitments elsewhere in
the agreement, those commitments are worthless if the customer does not have the ability
to enforce them.

Do not assume that all agreements must contain a prohibition on the recovery of
consequential, indirect, incidental, punitive, and other similar damages. This issue, like
all others, will be dictated by the course of the negotiation and the parties' respective
bargaining positions.

If the vendor insists on an overall cap on liability, ensure that the cap amount is sufficient
to permit the recovery of your organization's potential damages. This will, of course, vary
greatly depending on the type of product being acquired and the size of the transaction.

All liability limitations and exclusions of damages should apply equally to both parties.

Include "carve-outs" from any liability limitations to protect your organization from
certain "worst case scenarios," or to address those situations where a limitation of liability
cannot be justified under any circumstances. Consider the following carve-outs (in
addition to any others that are relevant to the particular transaction):

Damages caused by a breach of confidentiality obligations

Damages covered by insurance, up to the amount of such insurance

Damages caused by the intentional breach of the agreement

Damages caused by the violation of applicable law

Damages resulting from any third-party claims (including, without limitation, any
contractual obligations to defend, indemnify, or hold the other party harmless from any
third-party claim(s) and any damages caused by a breach of those obligations)

Issue Three

Responsibility for Harm/Damage Caused to Third Parties

If a problem arises during the implementation or use of any technology, that problem
may cause your organization to incur damages, but it also may harm third parties. In the
context of health care transactions, these third-party risks can be more central than in
other technology projects. Many health care technology products will serve as a
repository for highly confidential patient data, while other products are used directly or
indirectly in the treatment of patients. For these reasons, it is particularly important in the
context of health care technology transactions to ensure that the relevant agreement fairly
allocates the risk of these third-party claims. As you might expect, most vendor
agreements attempt to shift the risk of third-party harm to the customer.

For example, many vendors obligate their customers to defend and indemnify the vendor
and hold the vendor completely harmless from a broad range of third-party claims. (See
Sample Three (A) below.)

Although in certain circumstances it may be appropriate for the customer to indemnify

the vendor for certain third-party claims, most vendor-requested indemnification clauses
are overly broad, and in many cases require the customer to indemnify the vendor for
claims that were caused by the vendor itself (or the vendor's products). As noted in
Sample Three (A), the customer is obligated to defend, indemnify, and hold the vendor
harmless from any claim "related to the use of the Product or any other act or omissions
of Customer." This overly broad obligation would actually require the customer to defend
the vendor in a lawsuit resulting from a patient being harmed by a defective product,
merely because the customer "used" the product!

>

In addition to the use of overly broad indemnification clauses, many vendors also seek to
limit their responsibility by including a variety of "practice of medicine" disclaimers.
(See Sample Three (B) on following page.) These disclaimers are similar to those
discussed in the "Limitation of Liability" section above, but are particularly tailored to
the health care setting and are intended to shift certain risks (usually the risk of patient
harm) to the customer. Although these disclaimers may sound accurate at first (e.g., both
parties can agree that the vendor does not practice medicine) they have the effect of
simplifying a complex issue at the customer's expense.

The reality is that in many cases, practitioners will rely on the data received from a
clinical system or product. If a defective system (e.g., laboratory equipment) provides
inaccurate information (a "false positive" blood test) which in turn leads to a
misdiagnosis, the responsibility for any resulting patient harm should not be dictated by
these simplistic and overly broad risk-shifting provisions.

>

Finally, almost all vendor agreements contain some form of indemnification for
intellectual property claims. Although these clauses are commonly found in vendor
agreements, they are oftentimes drafted in a manner that significantly limits the vendor's
obligations to your organization for these claims. (See Sample Three (C) below.) These
clauses should be reviewed carefully to ensure that your organization accepts no risk
associated with a vendor's misappropriation of a third party's intellectual property.

>

Guidelines:

Do not agree to overly broad indemnification obligations that extend to your

organization's use of a product or its acts or omissions. These indemnification obligations
could result in a duty to indemnify the vendor for claims that are properly the vendor's
responsibility.
Do not agree to broad "practice of medicine" disclaimers. These clauses attempt to shift
the risk of patient harm to the customer in all cases, even when the harm was primarily
caused by the vendor.

As discussed under "Limitations of Liability" above, it is critical that you ensure that
thirdparty claims and damages are expressly carved out of all limitations or exclusions of
liability.

With respect to intellectual property indemnification clauses:

Ensure that the clause covers infringement/misappropriation of "patents, copyrights,

trademarks, trade secrets, and other propriety rights."

Include obligations to defend, indemnify, and hold harmless your organization, its
affiliates, and its and their respective employees, officers, directors, agents, and
predecessors and successors-in-interest.

Ensure that any exclusions from the vendor's obligations are appropriate and narrowly
drafted.

Issue Four

Defining "Specifications" and Acceptance Testing

Most vendor agreements tie all warranties and representations, and the performance of
the product, to the vendor's standard "documentation." (See Sample Four (A) below.)

>

This approach has several significant pitfalls. First, it is unlikely that the relevant vendor
documentation will be delivered or carefully reviewed prior to the execution of the
agreement. If the vendor documentation serves as the standard for the performance of the
product, any failure to carefully review this documentation is tantamount to permitting
the vendor to define your organization's requirements. All too often, clients spend
significant amounts of time analyzing competing products, defining requirements,
drafting request for proposals (RFPs), and selecting vendors/products, only to ignore all
of this hard work when it matters most -- when the vendor is actually being asked to
commit to meet these standards and requirements.

Second, the vendor's documentation is usually subject to change at any time by the
vendor, and usually without notice to its customers. As a result, if the vendor experiences
a particular problem, it can effectively remove its contractual obligation to fix the
problem by deleting the particular description of that functionality from its
documentation. Finally, the documentation will not include any reference to specific
representations made by its sales representatives and technical staff regarding the
performance of the products in your environment. If your organization bases its vendor or
product choice upon these representations, it is important to include them as vendor
commitments in the agreement.

To address these issues, we strongly recommend supplementing the vendor's

documentation with other standards and requirements. These other materials will almost
always include an exhibit or schedule to the agreement that describes your organization's
key requirements for the acquired product. If your organization used an RFP, the RFP
documents also should be considered for inclusion. Together with the vendor
documentation, these additional materials should be defined collectively as the
"Specifications" and used consistently throughout the agreement. The agreement also
should clarify that in the event of any inconsistency between the vendor documentation
and your defined requirements, your defined requirements should prevail.

Finally, most vendor agreements do not refer to the concept of "acceptance." If a vendor-
drafted agreement does include an "acceptance" provision, it is likely to state that
acceptance shall be deemed to occur upon a certain event and/or the expiration of a
certain period of time. Invariably, these "deemed acceptance" clauses are triggered so
early in the acquisition process that they effectively prevent any meaningful acceptance
testing rights. (See Sample Four(B) below)

>

The agreement should be revised to include specific acceptance testing rights, processes
to follow if the product fails to pass these tests, and the ultimate consequences of failed
acceptance testing. If the vendor is unable to fix reported problems after a reasonable
number of attempts, the customer should retain the option to terminate the agreement and
receive a full refund of all amounts paid (including, without limitation, product costs and
service fees) as well as reimbursement for other out-of-pocket expenses incurred as part
of the failed project (e.g., the costs of obtaining third-party hardware in...

Health care technology issues in home care

, ,†
Marshelle Thobaben RN, C, MS, FNP, PHN

Available online 9 April 2004.

Abstract
Every 2 years the Federal Bureau of Labor Statistics updates its employment outlook for
the next decade. In its publication, The Occupational Outlook Handbook, 1998–1999
edition, the agency projects that employment in home health care is expected to grow the
fastest of all health care sections in the next decade. One of the main reasons for this
trend is advances in health care technology that have allowed health care activities once
performed only in hospitals or physicians' offices to be performed in clients' homes.

Article Outline

• References

Corresponding author. Address for correspondence: Marshelle Thobaben RN, C,

MS, PHN, FNP Department of Nursing Humboldt State University Arcata, CA 95521
†
Marshelle Thobaben, RN, C, MS, PHN, FNP, is a professor of nursing at Humboldt
State