Download - American Nursing Informatics Association
Download - American Nursing Informatics Association
Download - American Nursing Informatics Association
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
CARING<br />
Vol. 21, No. 4 4th Quarter, 2006<br />
ISSN: 1551-9104<br />
Clinical Care Classification (CCC) System<br />
Manual: A Guide to <strong>Nursing</strong> Documentation<br />
[Book Review]<br />
Reviewer: Marina Douglas, MS, RN<br />
Principal, Beacon Healthcare Consulting<br />
CARING is an organization advancing the delivery of quality<br />
healthcare through the integration of informatics in practice,<br />
education, administration and research with a focus on nursing.<br />
DISCLAIMER: Content presented in the CARING Newsletter is not<br />
intended as an endorsement for any particular vendor or product.<br />
In This Issue:<br />
Clinical Care Classification (CCC) System<br />
Manual: A Guide to <strong>Nursing</strong><br />
Documentation [Book Review] . . . . . . . 1<br />
President’s Message . . . . . . . . . . . . 1<br />
CARING Member News . . . . . . . . . . . . 2<br />
Upcoming Events . . . . . . . . . . . . . . .4<br />
One Size Does Not Fit All:<br />
An Initiative to Improve Pediatric<br />
Patient Safety at Children’s<br />
National Medical Center . . . . . . . .5<br />
Natural Language Processing<br />
and Understanding . . . . . . . . . . . .8<br />
Collaborative Conference on<br />
<strong>Nursing</strong> <strong>Informatics</strong> . . . . . . . . . . .9<br />
Report on the TIGER Summit . . . . . .10<br />
Central Florida CARING November<br />
Meeting Report . . . . . . . . . . . . . 11<br />
CARING–AMIA Luncheon . . . . . . . . . . .11<br />
A Look into the New<br />
CARING Website . . . . . . . . . . . . . . .12<br />
©2006 The CARING Newsletter is produced with support<br />
from:<br />
Editor: Debra Derickson, MS, RN<br />
Newsletter Team for this Issue:<br />
Rose Almonte, Kathleen Crane, Sharon McGee, Susan Newbold,<br />
Liberty Rovira, Jeanne Sewell, Susan Stanley, Cathy Turner,<br />
Amy Walker<br />
he 2006<br />
TAMIA<br />
conference<br />
offered the<br />
opportunity<br />
to purchase a<br />
valuable nursing informatics resource,<br />
the Clinical Care Classification (CCC)<br />
System Manual: A Guide to <strong>Nursing</strong><br />
Documentation from its Living Legend<br />
author, Dr. Virginia Saba. The CCC<br />
System Manual by Dr. Saba and<br />
contributing authors documents the<br />
history and progress of clinical<br />
vocabularies and discusses the<br />
importance and necessity of a structured<br />
vocabulary for nursing practice. It<br />
details the benefits of integrating a<br />
structured vocabulary into automated<br />
care planning as a means of identifying,<br />
defining and quantifying nursing<br />
practice. The CCC System Manual<br />
provides the vocabulary components<br />
needed to accomplish CCC structured<br />
documentation in the care planning<br />
process. Though not fully implemented<br />
with a commercial product, CCC’s<br />
structured vocabulary use with<br />
automated clinical documentation<br />
systems and automated care planning<br />
seems highly plausible. The ongoing<br />
efforts to maintain the CCC vocabulary<br />
are outlined and the latest updates to the<br />
vocabulary are listed in an Appendix.<br />
The CCC System Manual is<br />
presented in three parts, logically<br />
providing the history and development<br />
process as well as important discussions<br />
of how the vocabulary can and has been<br />
used in practice. The CCC system<br />
contains 21 care components used to<br />
By Virginia K. Saba, EdD, RN, FAAN, FACMI. Springer<br />
Publishing Co., 2007.<br />
US$35 ISBN 0-8261-0268-9<br />
President’s Message<br />
By Jerry Chamberlain, MS, RN<br />
With the passing of each New Year, I have a<br />
habit of looking back at past organizational<br />
progress while also looking ahead at future plans<br />
and endeavors. While we have accomplished a<br />
tremendous amount of work over the past 12<br />
months, I want to reserve that communication for<br />
our annual meeting come this April. Instead, I<br />
would like to take this opportunity to highlight a<br />
few of the things CARING is planning for 2007.<br />
High on the list of highlights is the upcoming<br />
joint conference between ANIA and CARING on<br />
April 27 and 28, 2007, in Las Vegas, NV. This is<br />
the first time our two nursing informatics groups<br />
are set to come together for a joint conference and I<br />
couldn’t be more excited at the program we have<br />
planned. From the opening keynote by our dynamic<br />
colleague, Diane Skiba, PhD, to our 32 different<br />
educational presentations and 20+ poster<br />
presentations, an exhibit floor specifically designed<br />
with nursing informatics in mind, and opportunities<br />
at lunches, dinners, and social events to network<br />
and connect – this conference is highly geared for<br />
professional development and career growth. More<br />
details can be found further in this newsletter, but<br />
this is one event you do not want to miss!<br />
I am equally pleased at our opportunity to work<br />
with ANIA in the spirit of collaboration and shared<br />
benefit. This project has brought together the<br />
leadership boards of both organizations and<br />
motivated us to find ways in which we can work<br />
together for the benefit of all members. Looking<br />
forward, 2007 is going to provide us with additional<br />
opportunities to collaborate with other organizations<br />
and I anticipate equally positive outcomes.<br />
Increased focus and attention to CARING’s<br />
website and web-based services are planned for<br />
2007. In addition to an online member directory,<br />
we have also implemented an online library – a<br />
place to catalog and manage presentations, vendor<br />
evaluation tools, teaching tips & tricks, and other<br />
types of shared knowledge. Over the coming year,<br />
CARING plans to provide ongoing enhancements<br />
and content additions that will solidify our website<br />
as a valuable resource for members.<br />
CREATE 'n IMAGE<br />
Graphic Design • Clorinda Haug<br />
cmhaug@create-n-image.net • http://www.create-n-image.net<br />
continued on page 2<br />
continued on page 2
By Susan K Newbold, PhD RN-BC<br />
FAAN FHIMSS<br />
CARING Membership<br />
CARING currently has over 1175 members<br />
in 25 countries and 50 states.<br />
Graduations<br />
PhD<br />
Laura Taylor, Ellicott City, MD.<br />
Graduated May 2006, PhD, from<br />
Catholic University of America,<br />
Washington, DC. Her dissertation -<br />
“Spouses of Living Kidney Donors: A<br />
Grounded Theory Approach.”<br />
Masters<br />
Simone Frost, Takoma Park, MD.<br />
Graduated December 2006, MSN,<br />
<strong>Nursing</strong> <strong>Informatics</strong>, from the<br />
University of Maryland School of<br />
<strong>Nursing</strong>.<br />
Karen E. Hunter, Alexander, NC.<br />
Graduated May 2006, MSN, from<br />
Duke University, Durham, NC.<br />
Nancy Jo Thum, Sioux Falls, SD. MSN,<br />
<strong>Nursing</strong> <strong>Informatics</strong>, from Vanderbilt<br />
University School of <strong>Nursing</strong>,<br />
Nashville, TN.<br />
Post Masters Certificate<br />
Catherine Fant, Big Cove Tannery, PA.<br />
Post masters Certificate in <strong>Nursing</strong><br />
<strong>Informatics</strong> at University of Maryland<br />
School of <strong>Nursing</strong>.<br />
Certifications<br />
Member News<br />
Certification in <strong>Nursing</strong> <strong>Informatics</strong>,<br />
<strong>American</strong> Nurses Credentialing<br />
Center<br />
Karen B. Lipshires, 2006, Tewksbury,<br />
MA.<br />
Linda S. McCauley, Laurel, MD.<br />
Rosa Oliver, Clinton, MD.<br />
Certified Professional in Healthcare<br />
Information and Management<br />
Systems, Healthcare Information and<br />
Management Systems Society<br />
Phyllis M. Bachand, Monee, IL.<br />
Lynne MacAllister, Nashua, NH.<br />
President’s Message – CARING 4th Quarter 2006 Newsletter<br />
continued from Page 1<br />
Continuing education and local networking has always remained a top priority<br />
for CARING. In 2007, members will see additional offerings for local<br />
networking while maintaining a national infrastructure. We have begun to host<br />
regional meetings in Florida, California, and Arizona to assist regional<br />
networking. Our next step is to connect the value of this local networking with the<br />
opportunity of national education infrastructure and connections. CARING has set<br />
up the building blocks to support this effort; 2007 will be our year to expand and<br />
execute.<br />
Lastly, each New Year brings the opportunity for new leadership and<br />
involvement. CARING survives on the time and talent of our professional peers,<br />
and if you have yet to contribute your own interests and expertise, I would ask<br />
you to consider doing so now. You could organize or host a local CARING<br />
meeting, you are welcomed and encouraged to assist with our national conference,<br />
and you may want to serve as a formally elected board member. The value of<br />
serving is rewarded ten-fold in professional growth and achievement. We are<br />
going to need more leaders in 2007, so please consider bringing YOUR time and<br />
YOUR talent to OUR group.<br />
Thank you and Happy New Year.<br />
– Jerry<br />
Clinical Care Classification (CCC) System Manual:<br />
A Guide to <strong>Nursing</strong> Documentation [Book Review]<br />
continued from Page 1<br />
classify and code clinical care. It associates 182 nursing diagnoses to an<br />
appropriate care component. Further, clinicians can designate nursing actions<br />
associated with each nursing diagnoses. The nursing actions are coded into the<br />
following categories: Assess/Monitor; Care/Direct or Perform; Teach or Instruct;<br />
and Manage or Refer. Expected Outcomes of care are coded as either to improve,<br />
to stabilize or to support deterioration. Actual Outcomes are quantified as<br />
improved, stabilized or deteriorated/died.<br />
Section 1: Overview The author and a contributor, Kathleen McCormick,<br />
bring the reader through the history of the CCC System. The timeline presented is<br />
clear, assisting the reader to grasp the distillation of names and acronyms. This<br />
section contains the background of the rigors and science used to create the<br />
vocabulary and to continue its evolution over the past 15 years.<br />
Section 2: Research, Integration and Evaluation This interesting section<br />
provides examples of the successful use of the CCC System in various settings<br />
and research projects. The reader gains an understanding of the interrelationship<br />
between CCC and other vocabularies and standards such as the Unified Medical<br />
Language System (UMLS), International Classification of <strong>Nursing</strong> Practice<br />
(ICNP), Logical Observation Identifiers, Names and Codes (LOINC) and the<br />
Health Level 7 (HL7) messaging standards. These examples sparked thoughts of<br />
additional uses and research projects using the CCC system for clinical<br />
documentation systems. Throughout the Manual, references are given.<br />
Additionally, the last chapter in this section contains a bibliography of major<br />
articles written about CCC – a wonderful surprise for future research uses.<br />
continued on page 3<br />
continued on page 3<br />
CARING • Page 2
Clinical Care Classification (CCC) System Manual:<br />
A Guide to <strong>Nursing</strong> Documentation [Book Review]<br />
continued from Page 2<br />
Section 3: Terminology Uses Three important chapters in this section are the<br />
reason to purchase this manual. Chapter 13 proposes a costing model for nursing<br />
care using the CCC System. The CCC System’s structured atomic data concepts<br />
(i.e., each term having a unique meaning), facilitate automation of the costing<br />
model and the retrieval of care data.* The costing model supports the nursing<br />
process and the examples provided are easily followed. This chapter outlines CCC<br />
as a mechanism for identifying, quantifying and determining nursing care costs.<br />
Chapter 14 provides documentation strategies using CCC System in the context of<br />
the nursing process as well as providing the CCC System in tables. The welldesigned<br />
tables facilitate both the learning and use of CCC. In a personal<br />
discussion with a sophomore nursing student, the tables were used to explain the<br />
notion of a structured vocabulary and its use with computerized documentation.<br />
The tables quickly conveyed the essentials of the CCC System concepts and<br />
components to the student.<br />
Summary<br />
The Clinical Care Classification System Manual is a comprehensive tool for<br />
understanding and implementing the use of structured clinical vocabulary – a goal<br />
for every <strong>Informatics</strong> Nurse! It serves as both a reference for the background and<br />
benefits of structured vocabularies, as well as a manual for implementing the CCC<br />
System for the benefit of nursing care and nursing science.<br />
*Reviewer’s Note: The many benefits of the identification and quantification of<br />
nursing care will be accomplished by integrating the CCC System into<br />
commercial automated care planning and clinical documentation software. Figure<br />
1 provides an example of how CCC could be use in a traditional care planning<br />
setting. Figure 2 depicts how CCC concepts may appear using a clinical<br />
documentation methodology, such as PIE or APIE (Assessment, Problem,<br />
Figure 1<br />
Care Planning Example for a poorly controlled diabetic patient to manage<br />
prescribed oral hypoglycemics coded using the CCC System<br />
Coded <strong>Nursing</strong><br />
Diagnosis<br />
G20.4<br />
Coded Expected<br />
Outcome<br />
G20.4.1<br />
Coded Intervention<br />
H24.4.3<br />
Coded Actual Outcome<br />
G20.4.1<br />
CCC Component<br />
CCC <strong>Nursing</strong> Diagnoses<br />
CCC Expected Outcome<br />
CCC <strong>Nursing</strong> Intervention<br />
CCC <strong>Nursing</strong> Actions<br />
CCC Actual Outcome<br />
G. Health Behavior Component<br />
18. Health-Seeking Behavior Alteration<br />
19. Home Maintenance alteration<br />
20. Noncompliance<br />
20.1 Noncompliance of Diagnostic Test<br />
20.2 Noncompliance of Dietary Regimen<br />
20.3 Noncompliance of Fluid Volume<br />
20.4 Noncompliance of Medication Regimen<br />
G20.4 Compliance with prescribed course of<br />
medicinal substances.<br />
Pt’s HbA1C level will improve<br />
H. Medication Component<br />
24.4 Medication Treatment – actions performed<br />
to administer drugs or remedies<br />
regardless of route<br />
1. Assess/Monitor<br />
2. Care/Direct or Perform<br />
3. Teach or Instruct Medication Regimen<br />
4. Manage or Refer<br />
G20.4 Compliance with prescribed course of<br />
medicinal substances.<br />
1. Improve<br />
2. Stabilize<br />
3. Deteriorate<br />
More Member News<br />
Project Management Professional<br />
(PMP) Credential<br />
Charles Boicey, Mission Viejo, CA,<br />
November 4, 2006. He is also working<br />
on a Masters in Project Management at<br />
Stevens in Hoboken.<br />
Margaret Cox, Glenn Dale, MD,<br />
January 2007.<br />
Awards and Honors<br />
Martha Dewey Bergren, Chicago, IL,<br />
was accepted for the Omada Board<br />
Leadership development program sponsored<br />
by Sigma Theta Tau. The program<br />
begins in March 2007 and ends in<br />
February 2009.She will be assigned a<br />
mentor and attend the Omada Institute,<br />
held at the organization’s headquarters<br />
in Indianapolis, from June 7-10, 2007.<br />
http://www.nursingsociety.org/<br />
programs/omada_main.html<br />
Judy Murphy, West Allis, WI, was elected<br />
to the AMIA Board of Directors for<br />
another term from January 1, 2007<br />
through December 31, 2009. Judy also<br />
won the 2006 HIMSS <strong>Nursing</strong><br />
<strong>Informatics</strong> Leadership Award.<br />
Carol Romano, Columbia, MD, was<br />
honored during the University of<br />
Maryland, Baltimore Founders week as<br />
an “Illustrious Alumni.” See<br />
http://founders.umaryland.edu/<br />
alumni/romano.html<br />
Robin Raiford, Coppell, TX, was honored<br />
with the October 2006 “Spirit of<br />
HIMSS” Award. She is Chair of the<br />
Patient Safety and Quality Outcomes<br />
Steering Committee, a liaison to the<br />
HIMSS Advocacy and Public Policy<br />
Steering Committee, and an exam<br />
question writer for the CPHIMS certification<br />
program. She also participates in<br />
the Advocacy Legislation/Regulation<br />
Review Work Group and the HIMSS<br />
Electronic Health Record Vendors<br />
<strong>Association</strong>. Robin will speak at<br />
HIMSS07 as a CCHIT panelist discussing<br />
“What It Means to the<br />
Clinician at the Point of Care – Patient<br />
Safety, Medication Management and<br />
ePrescibing.”<br />
continued on page 4<br />
Page 3 • 4th Quarter 2006<br />
continued on page 4
More Member News<br />
Bobbie Stone, Freehold, NJ, was nominated<br />
for Garden State Woman of the<br />
Year for Garden State Woman<br />
Magazine in the categories of<br />
Healthcare and Women Owned<br />
Business.<br />
Betsy Weiner, Brentwood, TN, received<br />
an Alumnae Award for Excellence in<br />
<strong>Nursing</strong> Education from the University<br />
of Kentucky and numerous other<br />
awards for multimedia projects.<br />
Presentations<br />
2006 National League for <strong>Nursing</strong><br />
Technology Conference, (November 3,<br />
2006). Online Teaching - Basic by<br />
Jennifer Couvillon, New Orleans, LA,<br />
Deana Molinari, and Susan K.<br />
Newbold, Columbia, MD, University<br />
of Maryland School of <strong>Nursing</strong>,<br />
Baltimore, MD.<br />
Publications<br />
Nam-Ju Lee, New York, NY.<br />
Bakken, S., Grullon-Figueroa, L.,<br />
Izquierdo, R., Lee, N., Morin, P.,<br />
Palmas, W., Teresi, J., Weinstock, R.<br />
S., Shea, S. & Starren, J. (2006).<br />
Research paper: development, validation,<br />
and use of English and Spanish<br />
versions of telemedicine satisfaction<br />
and usefulness questionnaire. JAMIA,<br />
13(6), 660-667.<br />
Susan K. Newbold, Columbia, MD.<br />
Newbold, S. K. and Dykes, P. (2006).<br />
NI2006: The 9th international conference<br />
on nursing informatics. CIN:<br />
Computer, <strong>Informatics</strong>, <strong>Nursing</strong>, Vol.<br />
24(6), 354-355.<br />
Kathleen McCormick, Connie Delaney,<br />
Patricia Brennan, Judith Effken,<br />
Kendrick, Judy Murphy, Diane<br />
Skiba, Judy Warren, Charlotte<br />
Weaver, Betsy Weiner, and Bonnie<br />
Westra. (2007). Guideposts to the<br />
future - An agenda for nursing informatics.<br />
JAMIA, 14(1), 19-24.<br />
<strong>Nursing</strong> and <strong>Informatics</strong> for the 21st<br />
Century won the HIMSS 2006 Book of<br />
the Year Award. Editors are: Charlotte<br />
Weaver (Kansas City, MO), Connie<br />
White Delaney, Patrick Weber, and<br />
Robyn L. Carr, (Auckland, NZ).<br />
Clinical Care Classification (CCC) System Manual:<br />
A Guide to <strong>Nursing</strong> Documentation [Book Review]<br />
continued from Page 3<br />
Intervention, Evaluation). Such integration must support the notion of ‘automagic’<br />
for the end user. The ‘auto-magic’ terms refers to the thoughtful<br />
profiling/configuring of a system by informatics nurses allowing computerization<br />
of care data and its resulting outcomes for evidenced based practice and statistical<br />
analysis while simultaneously supporting rapid online care planning and/or<br />
documentation by clinicians. From the clinician’s perspective, the data and<br />
statistics of the care they have provided are available from the computer as if by<br />
magic.<br />
Figure 2<br />
Phrase Constructed Documentation with CCC<br />
Potential snippets of ‘point & click’ clinical<br />
documentation screens<br />
Assessment<br />
Neuro<br />
GI<br />
GU<br />
CV<br />
√ Endocrine -<br />
Integument<br />
Diabetes I<br />
Diabetes II<br />
Problem –<br />
Hemoglobin A1C WNL<br />
√ Hemoglobin A1C > normal<br />
Hemoglobin A1C < normal<br />
Intervention<br />
√ Medication Treatment – provide teaching<br />
Evaluation*<br />
√ Hemoglobin A1C WNL<br />
Hemoglobin A1C > normal<br />
Hemoglobin A1C < normal<br />
√<br />
*Assumes there is improvement following teaching<br />
CCC Coding within the configuration<br />
files and tables of a Clinical<br />
Documentation System<br />
Assessment<br />
G20 Health Behavior Component<br />
Problem<br />
G20.4 Non compliance w/ Medication Regimen<br />
Intervention<br />
H24.4 Medication Treatment - Instruct<br />
Evaluation<br />
G20.4.4 Non compliance w/ Medication Regimen<br />
Improved<br />
Editor’s Note: The Springer Publishing Company is offering a 10% discount on this book if you place your order directly from the publisher’s<br />
customer service, identifying yourself as a CARING Newsletter subscriber. Discount code: CARING<br />
(Disclaimer: A book review published in the CARING Newsletter does not convey endorsement or disapproval of the book or its contents<br />
by CARING.)<br />
Upcoming Events<br />
March 9, 2007 2-4 pm<br />
Central Florida CARING meeting at Florida Hospital i-Extend in Orlando, FL. For more<br />
details, contact Amy Walker, (awalker625@aol.com).<br />
March 16, 2007 4-7 pm<br />
CARING meeting at the Embassy Suites Phoenix-Tempe Hotel, Phoenix, AZ.<br />
Susan Newbold will speak on the topic of ‘Technology and the <strong>Nursing</strong> Shortage’. For<br />
more details, contact Susan Newbold, (snewbold@umaryland.edu).<br />
April 26 – 28, 2007<br />
ANIA CARING Annual Conference, Las Vegas, Nevada. A collaborative event on the topic<br />
of “Transforming the Future of Healthcare: <strong>Nursing</strong> <strong>Informatics</strong> 2007,” Earn up to 16.55<br />
contact hours. See special ad this issue. Also check the CARING website<br />
(www.caringonline.org) more details as they become available.<br />
continued on page 5<br />
CARING • Page 4
Photo courtesy of Karl Oyri<br />
One Size Does Not Fit All: An Initiative to Improve Pediatric<br />
Patient Safety at Children’s National Medical Center<br />
By Susan Stanley, MSN, RN<br />
Long ago in the land of babes, a techno-savvy group of nurses began<br />
questioning the lack of well fitting armbands for the children. “Why do I have to<br />
tape this giant band on my 3 kilogram baby? It always falls off anyway. I’ll just<br />
tape it to the crib – that will work.”<br />
his may sound like a fairy tale, but in reality, properly fitting identification (ID)<br />
Tbands for pediatric patients is a challenge. In order to provide an age-specific<br />
ID band, a team of clinicians at Children’s National Medical Center (CNMC) in<br />
Washington, D.C. developed a task force to develop and implement point of care<br />
access for pediatric ID bands. Sounds simple enough, right? Three arduous years<br />
after the task force began its work, the staff at CNMC is on the verge of the actual<br />
implementation. This article will outline the journey of the CNMC task force to<br />
identify the desired elements and develop a concept of age-specific ID bands, and<br />
the challenges encountered in this process. In a future article, the process of<br />
implementation of the plan as well as lessons learned will be discussed.<br />
Review of Current ID Band Processes<br />
“To help reduce patient identification errors, most hospitals use patient ID<br />
bands that can either be worn on the wrist or ankle” (“Technology in patient<br />
safety,” 2005). At CNMC, the admissions department staff prints a “one size fits<br />
all” ID band during patient registration, and in most cases, applies it to the child’s<br />
wrist. In the Neonatal Intensive Care Unit (NICU), this band is unsuitable, forcing<br />
the nurse or clerk to create a patient ID band by trimming the patient name,<br />
medical record number, and account number from a pre-printed label and affixing<br />
it to a soft band used for neonates. This soft band is then applied to the baby’s<br />
extremity. In the presence of skin fragility, the ID band is secured to the bed. If,<br />
for any reason, the ID band is removed, a new band is requested from admissions<br />
via phone or fax and delivered to the unit with an expected time delay. Temporary<br />
ID bands are available on the inpatient units that require trimming of a pre-printed<br />
patient label to fit on the band. A frequent problem necessitating application of a<br />
replacement band is contact with moisture from the patient directly or from<br />
patient care activities that denigrate the visibility of the patient information on the<br />
band needed for proper identification.<br />
A series of interviews and scheduled demonstrations for band printers and ID<br />
band designs led to selection of a vendor, Zebra Technologies. Our important<br />
selection criteria included:<br />
• Appropriate ID band size choices for pediatric patients<br />
• ID band reprint capability at the point of care<br />
• Ability to upgrade ID bands in the future to include Radio Frequency<br />
Identification (RFID) without need to purchase brand new equipment.<br />
• Thermal printing to maintain water proof integrity of printed ID Band<br />
information<br />
Designing the ID Band Elements<br />
The design of the new band was one of the unexpected challenges for the task<br />
force. Initially, the task force thought it wise to limit the information on the ID<br />
band to patient name, medical record number, and encounter/account number<br />
because a new band would not need to be generated if the patient’s attending<br />
physician changed, or if the patient transferred to another<br />
Page 5 • 4th Quarter 2006<br />
continued on page 6<br />
More Member News<br />
Bytes of Interest<br />
Debbie Harris, Columbia, MD, was featured<br />
in the Howard County General<br />
Hospital publication, Wellness Matters,<br />
Vol.10, No. 4, Winter 2007 in an article<br />
called, “Helping Hand gives a Head<br />
Start.” Debbie is a volunteer for the<br />
Community Action Council of Howard<br />
County serving those in need.<br />
Focus on Military members: CARING<br />
has 38 members currently servicing in<br />
the US Military service. Lori Frank<br />
(Navy) and Angela Stone (Army) are<br />
currently in Iraq. Saturnino “Tony”<br />
Chavez (Army) is stationed in<br />
Wurzburg, Germany. Margaret<br />
Beaubein (Navy) is in Okinawa. We<br />
thank our troops for serving within and<br />
outside of the United States.<br />
Karen S. Martin, Omaha, NE, reports<br />
that an international conference, The<br />
Omaha System: A Key to Practice,<br />
Documentation, and Information<br />
Management, will be held April 12-14,<br />
2007 in Minneapolis-St. Paul, MN.<br />
Details are posted on www.omaha<br />
system.org, The Conference is cosponsored<br />
by Martin Associates and the<br />
University of Minnesota School of<br />
<strong>Nursing</strong>.<br />
Michael J. Sutter, Champaign, IL, was<br />
interviewed and featured in a Health<br />
Management Technology article,<br />
“Clinical Systems are a ‘Go’ in Real<br />
Life.” See http://www.healthmgt<br />
tech.com and select the article from<br />
the January 2007 issue.<br />
Pauline Ellis, MPA, BSN, RN, COHN-S,<br />
CLCP, Lake Ridge, VA died January<br />
2007. She was an active member of<br />
CARING from about 1998 to 2005.<br />
She attended many meetings. In the<br />
2002, Vol. 17 No, 2, CARING<br />
Newsletter, Pauline penned a fascinating<br />
account of Anthrax and the US<br />
Postal service (USPS). She was an<br />
Occupational Health Nurse at the<br />
USPS in Washington, DC and used<br />
information management tools to help<br />
solve healthcare problems - a true<br />
informatics nurse. She also presented<br />
her story at a CARING meeting. Our<br />
condolences go to her family.<br />
Please send items for future newsletters<br />
to: Susan K. Newbold,<br />
snewbold@umaryland.edu
One Size Does Not Fit All:<br />
An Initiative to Improve Pediatric Patient Safety at Children’s National Medical Center<br />
continued from Page 5<br />
room. This set of data would require<br />
3 lines of text on the band. Next,<br />
feedback was solicited from several<br />
hospital departments to determine<br />
any other required elements.<br />
Additional requirements and<br />
considerations were discovered<br />
during this design phase:<br />
• The Radiology and Imaging<br />
department and the Operating<br />
Room required the date of birth<br />
(DOB) as an identifier to<br />
differentiate same name and<br />
similar name patients.<br />
• Hospital administration required<br />
inclusion of the CNMC Bear<br />
logo<br />
• Patient’s hyphenated names<br />
would not fit on one line with<br />
current limited print characters.<br />
• Adding DOB and separating the<br />
first and last names on 2<br />
separate lines increased lines of<br />
text on the band from 3 lines to<br />
5 lines<br />
• Barcodes for future use and<br />
current technology<br />
Barcode Technology<br />
In order to prepare for future<br />
barcode technology envisioned at<br />
CNMC, the task force team realized<br />
that addition of a barcode to the ID<br />
band was needed. They proceeded to<br />
learn more about barcode technology<br />
than they ever expected. First<br />
consideration was given to using a 2<br />
dimensional barcode that would<br />
contain the required patient data<br />
elements. However, the equipment<br />
currently used in Laboratory<br />
Medicine department cannot read a 2<br />
dimensional barcode. They use<br />
barcode scanning of a linear, onedimensional<br />
barcode on the received<br />
specimen label. Because barcode<br />
scanning for nursing and patient care<br />
activities is not yet in use at CNMC, the team decided to begin with a linear, one<br />
dimensional barcode that only captures the patient’s medical record number. In the<br />
future, use of either 2-dimensional barcoding or RFID is anticipated and<br />
Laboratory Medicine expects to upgrade their system accordingly.<br />
Pilot Testing<br />
Before advancing further in the project, a pilot test of proposed ID bands was<br />
implemented for one week on an inpatient psychiatry unit, a surgical care unit,<br />
and the NICU, to determine the integrity of the material, security of the adhesive<br />
used, and ease of use by staff. The bands were pre-printed with “TEST BAND”<br />
and were applied to the patient along with the official ID band in current use.<br />
Informational letters were given to the parents to explain the project.<br />
Next, a survey was conducted to elicit feedback on the piloted bands from<br />
parents, staff, and patients. The feedback results included the following:<br />
• The majority of the staff responses indicated approval of the new band. They<br />
found it easy to use and apply. All staff responses showed preference of the<br />
band to display the patient’s last name on the first line in bold font and that<br />
the pediatric and adult bands be the same width. Three of the staff responses<br />
suggested a bigger font size. One response suggested addition of a data<br />
element - medical service.<br />
• The adhesive area of the band was less secure for older children because<br />
they could pick at the seam.<br />
• Parent responses indicated the desire for a band that would fit their child<br />
appropriately instead of attaching it to a crib or bed.<br />
This feedback led to a modification of the design of the adhesive area by the<br />
Figure 1<br />
Serrated Slits in the<br />
Band<br />
Adhesive Overlap Area<br />
vendor to replace the smooth<br />
even seam with a serrated seam.<br />
This seam format strengthens<br />
adhesion as well deters a child<br />
from lifting the entire edge. The<br />
serrated seam in a jagged format<br />
adheres more easily and will be<br />
more difficult for the child to<br />
lift. If the child picks at the<br />
edges and lifts a seam, the<br />
serrated portion will shred but<br />
not lift the whole edge. See<br />
Figure 1. The team also elected<br />
to standardize the width of the<br />
ID bands for neonatal, pediatric,<br />
and adult as well as a band format to print the last name on the first line in bold<br />
font. Figure 2 shows the new ID band design.<br />
Figure 2<br />
continued on page 7<br />
CARING • Page 6
One Size Does Not Fit All:<br />
An Initiative to Improve Pediatric Patient Safety at Children’s National Medical Center<br />
continued from Page 6<br />
Printing Logic<br />
Over several months, the team worked with another vendor, Optio, to design<br />
the software logic for printing the correct size band using data entered during the<br />
registration process in admissions. Although using patient weight information<br />
might be preferred for determining band size, the majority of the patients have not<br />
been weighed prior to admission. Therefore, patient age was selected for use in<br />
printing the initial ID band. Of course, the possibility exists a band based on age<br />
will not fit the patient. Thus, the availability of printing a replacement ID band on<br />
the unit at the discretion of the nursing staff was very important to the task force<br />
charter. Three replacement ID band sizes were chosen for availability on the units:<br />
SIZE LENGTH WIDTH AGE PARAMETER<br />
Neonatal Band 6 inches 3/4 inch 0-30 days<br />
Pediatric Band 7 inches 3/4 inch >30 days < 7 years<br />
Adult Band 11 inches 3/4 inch > 7 years<br />
The concept of reprinting patient care labels and face sheets on the inpatient<br />
units from a clinical registration system is already established. With assistance<br />
from the software vendor and CNMC’s information technology services (ITS)<br />
staff, three additional files were<br />
Figure 3<br />
created in the clinical<br />
registration system to represent<br />
a neonatal, pediatric and adult<br />
ID band. When needed, the new<br />
ID band process will allow the<br />
nurse to access the clinical<br />
system on the unit, select the<br />
patient, and request a reprint file<br />
for the appropriate size ID band<br />
plan after the patient is assessed<br />
for the appropriate size.<br />
Dedicated Zebra printers for the<br />
ID bands will be located on<br />
each inpatient care unit, as<br />
shown in Figures 3 and 4.<br />
Network Preparation<br />
In order to implement the new ID<br />
band process, preparation for printer<br />
installation was required. This included<br />
use of the local area network to retrieve<br />
clinical information to formulate an ID<br />
band, but an internal technology survey<br />
revealed insufficient availability of data<br />
cables and data jacks to connect to the<br />
printers. With support from the ITS<br />
Figure 4<br />
department, the team developed a<br />
plan for the location of each printer<br />
and worked with a consulting<br />
technology company to install the<br />
data lines and drops. Each data jack<br />
was activated and tested. The jacks<br />
were clearly labeled for patient ID<br />
printer and a road map of data jack<br />
locations was provided as a resource<br />
for the ITS department. In addition to<br />
the need for additional cabling and<br />
jacks, all ID band printers required an<br />
IP address and description in order<br />
for the network to locate the correct<br />
printer. In a similar way, the printers<br />
were added to a table in the clinical<br />
registration system which identified<br />
the location of the patient care unit<br />
for point of care reprinting. The<br />
network preparation phase of the<br />
project used most of CNMC’s<br />
technology personnel resources and<br />
required more time than expected to<br />
complete.<br />
Next Steps<br />
To prepare for implementation of<br />
the new ID band process, the task<br />
force will develop and execute an<br />
educational plan for <strong>Nursing</strong> and<br />
support staff to use the new software<br />
and printers, begin actual use of the<br />
new patient ID band process, and<br />
evaluate its success. A follow up<br />
discussion of these next steps and<br />
lessons learned is planned for a future<br />
issue of the CARING newsletter.<br />
Reference:<br />
Technology in patient safety: Using identification bands to<br />
reduce patient identification errors. (2005, April). Joint<br />
Commission Perspectives on Patient Safety, 5(4), 1-10.<br />
Additional Reading:<br />
Use of Color-Coded Patient Wristbands Creates Unnecessary<br />
Risk. (2005, December). Patient Safety Authority, Vol 2,<br />
Supplement 2. Retrieved February 15, 2007, from<br />
http://www.psa.state.pa.us/psa/lib/psa/advisories/v2_s2_sup<br />
__advisory_dec_14_2005.pdf<br />
Page 7 • 4th Quarter 2006
Natural Language Processing and Understanding<br />
‘Just because<br />
it is free text<br />
doesn’t mean<br />
it has no<br />
value.’<br />
CARING educational event took<br />
Aplace on October 3, 2006 at the<br />
Skyline Complex in Falls Church,<br />
VA. Participation was available via<br />
Webex. Fifteen people registered to<br />
attend in person, and 40 registered for<br />
the Webex, including one from<br />
Canada and one from Finland. The<br />
session was titled “Introduction to<br />
Natural Language Processing and<br />
Understanding: Enter Clinical Data<br />
the Way You Want, Capture<br />
Clinical Data the Way You Need.”<br />
Natural Language Processing” (NLP)<br />
and Natural Language Understanding<br />
(NLU) are emerging technologies that<br />
continue to show promise for<br />
extracting data from free text<br />
documents.<br />
CARING member Karen Doyle<br />
with Dave Hellman and Dr.<br />
James Flanagan from Language<br />
and Computing developed this<br />
session to explain some of the<br />
basics of NLP and NLU<br />
technologies. Definitions of the<br />
associated terms include:<br />
• Natural language: Any<br />
language naturally used by<br />
people – for example,<br />
English, Spanish, or<br />
Arabic; not a<br />
programming language<br />
such as BASIC, C ++, or<br />
XML<br />
• Natural Language<br />
“Processing” (NLP): the<br />
process of building<br />
computational models for<br />
understanding natural<br />
language that is Machine<br />
Dave Hellman<br />
Readable<br />
Input: natural language<br />
text<br />
Output: representation of the meaning of text<br />
• Natural Language “Understanding” language (NLU): means knowing<br />
what concepts a word or phrase stands for and how to link those concepts<br />
together and is Machine Understandable<br />
Input: natural language text<br />
Output: interpretation of the infinite ways a human can express a concept<br />
Use cases helped to demonstrate using NLP and NLU to transform the free text<br />
from History and Physicals, Discharge Summaries, and other clinical notes into<br />
discreet data elements that can:<br />
• Improve patient safety and decision support applications<br />
• Implement HL7 Clinical Document Architecture (CDA) representation.<br />
• Populate a clinical data warehouse<br />
• Support the billing and reimbursement process<br />
The hour long session was very informative and provided a basic premise for<br />
using an application that can capture and interpret data from free text entries.<br />
This recorded Webinar is available for free viewing or downloading by<br />
registering with your name and email address by using this link:<br />
https://landc-events.webex.com/landc-events/onstage/g.php?<br />
AT=VR&RecordingID=297314027<br />
For more information, please contact Karen Doyle at karen@landcglobal.com.<br />
Karen Doyle<br />
CARING • Page 8
Page 9 • 4th Quarter 2006
Report on the TIGER Summit<br />
IGER (Technology <strong>Informatics</strong><br />
TGuiding Educational Reform)<br />
conducted an invitation-only summit<br />
last October in Bethesda, Maryland.<br />
The purpose of the summit was to<br />
bring together leaders from the<br />
nation’s nursing practice, education,<br />
and informatics/technology<br />
organizations, government agencies,<br />
and other key stakeholders to develop<br />
a 10-year vision, to articulate 3-year<br />
local and global action plans, and to<br />
affirm commitment by the participants<br />
to carry out these action plans for<br />
“transforming nursing practice and<br />
education to better prepare nurses to<br />
practice in an increasingly automated,<br />
informatics-rich, and consumer-driven<br />
health care environment.” (T.I.G.E.R.<br />
Press Release, 2006). This<br />
commitment means an effort towards<br />
achieving 85% of their goals by Year<br />
1 and 100% of their goals by Year 3<br />
(T.I.G.E.R. Summary Report, 2006).<br />
As planned, several documents were<br />
produced to provide a report of the<br />
summit work:<br />
• The TIGER Press Release<br />
• The TIGER Gallery Walk<br />
Brochure<br />
• The TIGER Final Report<br />
• The 10-Year TIGER Vision with<br />
Key Actions<br />
The following link will allow you<br />
access these documents after you<br />
register on the TIGER summit<br />
website. Registration will allow<br />
TIGER to track the distribution of the<br />
reports, and will provide email<br />
updates on progress of the TIGER<br />
initiative if you opt for this function.<br />
http://app.quicksizzle.com//<br />
Survey.aspx?SFID=26174<br />
7 Key Pillars<br />
At the summit, participants used<br />
these seven focus areas or pillars to<br />
inform their discussions around key<br />
actions and success factors for each<br />
pillar (T.I.G.E.R., 2006-2007):<br />
1. Communication and Collaboration<br />
• Communication Techniques and Methodologies<br />
• Interdisciplinary Care<br />
• Therapeutic Relationships and Technology<br />
2. Education<br />
• Integration of <strong>Informatics</strong> and Education<br />
• <strong>Informatics</strong> Core Competencies<br />
• Faculty Readiness (Barriers and Strengths)<br />
• Generational Considerations<br />
3. <strong>Informatics</strong> Design<br />
• Intentionally Designed <strong>Informatics</strong><br />
• Ease of Use in Professional Workflow<br />
• Design Considerations for Education and Learning Enhancement<br />
4. Information Technology<br />
• Electronic Health Record (EHR)<br />
• Personal Health Record (PHR)<br />
• System Interoperability<br />
• Standards and Frameworks<br />
• Technology Partners<br />
5. Culture<br />
• Culture Transformation<br />
• Journey Milestones—steps on the journey of culture change<br />
• Change Theory/Management<br />
6. Management and Leadership<br />
• Creating Shared Vision<br />
• Courageous Leadership<br />
• Direction and Support<br />
7. Policy<br />
• Organizational Policy (Local and Global)<br />
• Governmental Policy (Local and Global)<br />
Susan Newbold was CARING’s representative to the TIGER summit. She noted<br />
that out of approximately 120 attendees, 30 were CARING members, who were<br />
attending the summit as representatives from other groups. She will be keeping<br />
CARING members informed about TIGER activities and how CARING will be<br />
moving forward with an action plan.<br />
Please visit http://www.umbc.edu/tiger and https://www.tigersummit.com for<br />
more information about the TIGER Initiative and the TIGER Summit.<br />
References:<br />
T.I.G.E.R. Technology <strong>Informatics</strong> Guiding Educational Reform (TIGER), (2006-2007). 7 Key Pillars. Retrieved January 28, 2007, from<br />
https://www.tigersummit.com/Pillars.html<br />
T.I.G.E.R. Technology <strong>Informatics</strong> Guiding Educational Reform, (2006). TIGER SUMMIT, Summary Report: Evidence and informatics<br />
transforming nursing, p 50.<br />
T.I.G.E.R. Technology <strong>Informatics</strong> Guiding Educational Reform, (2006). 2006 TIGER SUMMIT, Press Release: Nation’s nursing and<br />
informatics leaders gathering to create an actionable plan for bridging the quality chasm with information technology, p1.<br />
CARING • Page 10
Central Florida CARING November Meeting Report<br />
By Amy Walker, MS, RN<br />
he Central Florida CARING group has grown to almost 30 members in the<br />
Tshort 9 months since the first meeting. The November 10, 2006 meeting which<br />
was held at South Seminole Community Hospital, welcomed 7 new attendees<br />
along with 10 current members. A goal for 2007 is to meet every other month at<br />
different locations. A meeting was scheduled for January 12 at Health First, and<br />
another is scheduled for March 9 in Orlando. An announcement was made of the<br />
upcoming Orlando WINI, Feb 16-18, 2007, sponsored by OptimizeIT Consulting<br />
and Orlando Regional Healthcare System.<br />
Link to registration: http://optimizeITconsulting.com/WINI.html.<br />
Central Florida CARING members Cindy Kolombo RN,BC Senior Application<br />
Analyst and Theresa Skinner RN,BC Application Analyst of Wuesthoff Health<br />
System provided the educational session for this meeting titled “Multidisciplinary<br />
Clinical Documentation of Plan of Care Using NIC/NOC.”<br />
Wuesthoff Health System uses Meditech as the enterprise-wide software. The<br />
presentation demonstrated the electronic, multidisciplinary use of <strong>Nursing</strong><br />
Interventions Classification (NIC) and <strong>Nursing</strong> Outcomes Classification (NOC) in<br />
a stroke patient that entered the system through the emergency department and the<br />
subsequent admission to the Acute Stroke Unit at a Wuesthoff Medical Center.<br />
The NIC/NOC care plans are set up with patient specific Problems, Outcomes,<br />
and Interventions. Patient outcomes are assessed on admission, once a shift and at<br />
discharge. The patient response to<br />
interventions can be trended by the<br />
outcome score received during the<br />
specified time points.<br />
David Barnhart, Wuesthoff CIO<br />
states, “Cindy and Theresa are an<br />
integral part to our Process<br />
Improvement processes and<br />
instrumental in implementing the<br />
clinical documentation improvements<br />
and developments.”<br />
Wuesthoff Health System is located in Brevard County and is<br />
the county’s leading comprehensive healthcare provider.<br />
Wuesthoff Medical Center-Rockledge and Wuesthoff<br />
Medical Center-Melbourne, both full service acute care<br />
hospitals, and a full complement of health service affiliates,<br />
comprise the system. Both Wuesthoff facilities received the<br />
Joint Commission and Accreditation of Healthcare<br />
Organizations (JCAHO) Certification in Disease<br />
Management for Stroke. Wuesthoff Medical Center-<br />
Rockledge was the first hospital in Florida and second in<br />
the nation to receive a dual certification Gold Seal of<br />
Approval from JCAHO for coronary artery disease care<br />
and management for stroke.<br />
CARING-AMIA Luncheon<br />
ARING co-sponsored a<br />
Cnetworking and educational<br />
event during the <strong>American</strong> Medical<br />
<strong>Informatics</strong> <strong>Association</strong> (AMIA)<br />
conference in Washington, D.C. on<br />
November 13, 2006. Two<br />
prominent informatics nurses were<br />
the featured presenters. Bonnie L.<br />
Westra, PhD, RN, presented<br />
“Wisdom From the Pioneers to<br />
Create the Future.” She briefed<br />
the audience about a current<br />
project by the AMIA <strong>Nursing</strong><br />
<strong>Informatics</strong> Working Group to<br />
document the pioneering efforts<br />
and progress of nursing<br />
informatics in the United States.<br />
Many of these informatics nurse<br />
pioneers have already been<br />
interviewed and recorded on video and many more<br />
interviews are planned. A book and video series are the<br />
desired end product of this project. Virginia K. Saba,<br />
EdD, RN, FAAN, FACMI, one of several true pioneers,<br />
presented “Historical Perspectives of <strong>Nursing</strong> and the<br />
Computer.” Her presentation was sprinkled with several<br />
trips down memory lane, shared stories, and prompts to<br />
bring a few other notable informatics nurse pioneers in<br />
Dr. Bonnie Westra<br />
Dr. Virginia Saba<br />
the audience to come to the podium for<br />
a few shared memories. Susan K.<br />
Newbold, PhD, RN-BC, FANN,<br />
FHIMSS, introduced the speakers as<br />
well as provided a diversion for the<br />
audience to participate in filling out a<br />
quiz about nursing informatics,<br />
CARING, and AMIA for the chance to<br />
win a one-year subscription to<br />
CARING.<br />
Page 11 • 4th Quarter 2006
A Look into the New CARING Website<br />
by Stephen W. Prouse MS, RN-BC<br />
CARING Contacts<br />
Newsletter<br />
Debra Derickson, MS, RN<br />
3774 Gunston Road<br />
Alexandria, VA 22302<br />
H: 703/578-0415<br />
E-Mail: DebraDerickson@comcast.net<br />
.<br />
Membership<br />
Susan K. Newbold, MS, RNBC, FAAN<br />
6460 South Wind Circle<br />
Columbia, MD 21044<br />
H: 410/531-9244<br />
E-Mail: snewbold@umaryland.edu<br />
.<br />
CARING Board of Directors:<br />
Jerry Chamberlain<br />
President<br />
Patrick Shannon<br />
Vice President, Program Planning<br />
Amy Jacobs<br />
Treasurer<br />
Placidia Clark<br />
Secretary<br />
Debra Derickson<br />
Newsletter Editor<br />
Jason Windsor<br />
Marketing Liaison<br />
Susan Newbold<br />
Membership, ANI Representative, E-list<br />
Liberty Rovira<br />
Web Committee Liaison<br />
Stephen Prouse<br />
CARING Webmaster<br />
n mid 2006, the CARING web team completed the enhancement conversion of<br />
Ithe CARING website at www.caringonline.org, allowing achievement of two<br />
major goals:<br />
1. Transform CARING’s web presence from a collection of flat files<br />
manageable by one overarching administrator to a decentralized model<br />
allowing for content components or modules to be managed by various<br />
users.<br />
2. Provide a real-time, searchable, and integrated membership directory.<br />
The integrated membership database is the core component that drives access to<br />
all other website features. In addition to serving as access control, it also enables<br />
members to manage their own online profile, pay membership dues, subscribe or<br />
unsubscribe from the e-list, and query other member profiles using the contact<br />
center. Having members manage their own information and preferences also<br />
improves the overall management and administration of the database online.<br />
Other major content areas of the website include:<br />
• Event Calendar – displays informatics-related events ranging from<br />
networking dinners and meetings to the latest Weekend Immersion in<br />
<strong>Nursing</strong> <strong>Informatics</strong>. It also provides other features such as online event<br />
registration and functionality for exporting events to a personal calendar.<br />
• Mobile Link – available only to current members actively logged into the<br />
website, provides on-the-go access to the integrated members’ directory from<br />
a web-enabled Personal Digital Assistant or Smart Phone.<br />
• Bulletin Board – used to host a wide range of member submitted documents.<br />
The goal of this content area is to create a collaborative repository of<br />
documentation and discussions to support common projects and issues<br />
within the disciplines of informatics. Members are encouraged to upload<br />
non-proprietary content to any of the topical categories and are welcomed to<br />
provide suggestions for additional categories. Any CARING member<br />
interested in moderating a category should contact one of the board<br />
members. Topical categories currently include:<br />
– Industry Documents with sample and real-world content ranging from<br />
wireless mobile device guidelines to Request For Proposal templates.<br />
– Role descriptions<br />
– Past meeting presentations.<br />
• CARING Newsletters – current issues made available to members, and older<br />
issues available to any visitor.<br />
• Monthly Health News – a new member-supported section compiled by<br />
CARING member Kathleen Kimmel. This section is a great example for<br />
other members interested in maximizing the value of the website.<br />
Future focus feature areas will include online polls to capture both simple and<br />
complex questionnaires. Other areas considered for implementation include an<br />
integrated e-list, really simple syndication (RSS) feeds, and podcasts. Ideas for a<br />
simple questionnaire are welcome; just contact any CARING board member. In<br />
addition, all visitors to the website are invited to provide feedback or comments<br />
about the site in using the website feedback link under the “Actions” menu.<br />
.<br />
CARING Web site – Homepage<br />
http://www.caringonline.org<br />
CARING • Page 12