- Email: [email protected]
Improving Patient Safety with Technology
International Journal of Medical Informatics (2004) 73, 543—546
EDITORIAL
Improving Patient Safety with Technology The International Medical Informatics Association–— Nursing Informatics Special Interest Group (IMIA NI SIG) traditionally host every 3 years a worldwide conference followed by an invitational post conference workshop. In 2003, the Conference (NI2003–—the Eighth International Conference in Nursing Informatics) was held in Rio de Janeiro, Brazil, under the legend ‘‘e-Health for All: Designing the Nursing Agenda for the Future.’’ Following the main conference, recognized experts in health informatics were invited to discuss the theme of the Nursing Informatics Post Conference Workshop that was ‘‘Improving Patient Safety with Technology’’. The format of the workshop included individual presentations and working group discussion. The groups were to discuss and prepare a report according to selected subjects: (1) technology as an infrastructure to enhance patient safety; (2) safety in practice: future directions; (3) patient safety: what does it mean for education; (4) management issues in patient safety; (5) research directions in patient safety; and (6) cognitive aspects in patient safety. In total, there were 39 participants from 14 countries, covering five continents. For each working group, a chairman and a rapporteur were appointed by the organizers to guide the discussions. The final report originated from the working group discussions were printed in the proceedings and made available to all participants, including those participants of the main conference. We selected some reports and also selected some of presented papers at the main conference for this special issue of the International Journal of Medical Informatics. The authors of these papers have presented many important issues concerning patient safety and quality of care. This editorial summarizes some of these key points and serves as an introduction to this special issue. This special issue congregates 15 papers covering different aspects and different points of view related to the use of technology to facilitate or assure the quality of care and patient safety, most of them under the nursing lens.
Patient safety can be considered as one of the most important aspect of healthcare. Nothing is more contrary to the healthcare philosophy and mission than causing injury or harm to the individuals who search for care. However, procedures or care treatments are not free of risk. Since the release of the Institute of Medicine Report ‘‘To Err is Human’’ in 1999 [1], public and professional attention have been dedicated to this aspect with the objective to eliminate or reduce risk and assure quality of care. While there are many potential approaches to improving patient safety, most observers agree that information technology (IT) applications have the potential to support the delivery of care and promote quality. It also has the potential to transform health care work environment by streamlining processes, making procedures more accurate and efficient, and reducing the risk of human errors [2]. In addition, several studies have demonstrated that the lack of access to information during decision making and ineffective communication among patient care team members are proximal causes of medical errors and other adverse events in patient care [3,4]. The papers presented in this special issue shows that applications, research and educational aspects of health informatics often address very broad user needs and embrace a wide range of perspectives. At the same time, there are also papers included that explore specific aspects of patient safety or share the experience in develop and implement an application of information technology. Among the 15 papers, two explore educational aspects of patient safety. Considering information a key element to assure patient safety, technology resources can be used to document patient clinical data and retrieve patient information at the point of care. However, provision of information tools and resources are insufficient to influence patient safety. Students and faculty must also possess the necessary competencies to use these tools and
1386-5056/$ — see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2004.05.006
544 resources. Consequently, introducing health and nursing informatics in the curriculum is necessary to enhance competencies of the next generation of providers [5]. Enhfors and Grobe [6] pointed out that a critical element for nursing education curricula is the inclusion of learning opportunities for the student nurse to understand the importance of authentic dialogues–—or true encounters–—with patients, in which the patient and the nurse learn to reflect together on the care situation. There are two papers that also introduce international aspects of patient of safety under the nursing lens. The theme is an international concern and several countries are establishing organizations and methods to control adversity and enhance patient safety. Castle et al. [7] emphasize the nursing responsibilities for the patient safety, describing examples of activities taken by different countries organizations. The examples provided by the authors show that patient safety is indeed an international problem. Many occurrences can be prevented and detected by nurses. Having information technology resources to support nursing activities safety improvement can also be achieved more successfully. For that reason, nurses need to be closely involved with the development and application of IT. Medication errors are frequent and caused by multifaceted factors in nature, including calculation errors, preparation and administration phases. The prevention of medication errors at the point of care is a challenge in nursing practice. Developing countries face this problem more frequently due to the insufficient numbers of registered nurses to attend the high demand of nursing care [8]. In addition, the bulk of health professionals, such as nurse assistants and aides, that comprise the ‘‘nursing staff’’ in developing countries may be less well trained. This level of training does not enable them to deliver and document nursing care appropriately in a safer manner [9]. In practice, education, administration, or research, documentation and information communication are the essential ingredient for health care services. It is expected that the use of the electronic patient record simplify the exchange of information between agencies and improve the quality and continuity of care. To identify what information nurses need to provide patient care and to assure the continuity of care is a frequent question for researching around the world. Issues to be considered include the accessibility to information and the appropriateness of information as a communication tool [10].
H.F. Marin Furthermore, instruments to document patient care should be consistent, integrate and facilitate information retrieval. A variety of patient care documents can be identified in health care. They receive many names such protocols, procedure notes, standardized care plans, standards of care, care map, and others. Analyzing several types of documentation tools, Hougaard [11] conducted a project to develop a consistent interdisciplinary document model that could assure the user acceptance and implementation, including standards of care across the continuum of patient care. The model also includes a number of error-reducing strategies. It is recommends standardization of tasks wherever possible as a mean of reducing errors. Mendonça et al. [12] reported an experience of introducing new information technology into in-patient care settings in an attempt to improve access to information and communication (proximal causes of medical errors). They believe that these improvements will ultimately reduce proximal causes of medical errors and adverse events, and plan to perform an evaluation of these applications in clinical settings in order to determine their impact. At the clinical setting, an error of commission can also occurs when two or more orders are not identified as overlapping orders, and one or more of the orders are performed more often than necessary. To reduce and avoid these types of errors, Roemer et al. [13] developed a strategy to determine the frequency of redundant orders and consolidate order list removing duplicate orders before displaying the order list to the nurse. Considering the importance of orders and its impact on patient safety, we included a paper that explores a terminology model for nursing orders developed using empirical data. The model was validated against nursing research and standards literature, and evaluated using 609 nursing orders that were successfully mapped to the structure [14]. The paper explores indeed the attributes that should be included in complete nursing order concepts and how the attributes of a nursing order concept can be compared to defined nursing actions. It is assume that technology can create better conditions to deliver patient care. Newbold et al. [15] describes the process utilized to create research questions to promote technology as an infrastructure to enable safe nursing practice. Beginning with scenarios of safety problems related to nursing practice, the team identified technology including hardware, software, and organizational and operational components to help improve the
Editorial safety aspects addressed in the scenarios. Further discussed are characteristics of technology necessary at each step in the nursing care process and finally the authors include some recommendations for various research questions that would be needed to enable research on the use of the proposed technologies. In nursing practice, managing IT is a function of managing people who use it. Getting nurses to use systems and IT resources and use them correctly is the job of nursing managers. Simspson [16] emphasizes the importance of people, processes and computer programs to better promote infrastructure to enhance patient safety. However, the whole process of designing computer programs and establishing committee to assure patient safety must take into consideration the central element of health care services–—the patient. Frequently, most initiatives on patient safety focus on devices, procedures, professionals training and education, development and selection of computerized programs, and evaluation of delivered care. In fact, patient safety initiatives center on the patient, not only on the care providing system or the provider, will result in care deemed safe by all interested parties. Consequently, patient safety initiatives must be also informed by the patient values, beliefs and willingness to act. Active engagement of the patient in all aspects of patient safety strategies is a key for the success [17]. Nevertheless, even when the patient is already the central key of health care programs, decisions about care treatment can be difficult, particularly under circumstances where outcomes are uncertain and the clinical evidence regarding the effectiveness of treatment do not indicate the best action. Informatics tools such as preference elicitation techniques and knowledge on risk communication can support shared decision-making and risk communication helping patients to better understand their treatment options. These tools can combine advantages of computer technology, particularly its capacity to search, process, structure, integrate and individualize information with knowledge from cognitive science and research on risk communication [18]. This special issue also comprises two research papers that explores the patient privacy related to the disclosures of data in disseminated diseases and the use of the logic of the fuzzy logic to develop system that take into consideration the quality of well being of individuals and populations [19,20]. Both studies demonstrates how important is to consider the patient privacy and get patient involvement on his/her treatment.
545 In conclusion, we would like to emphasize that this volume is not conclusive. Many aspects of patient safety are still to be explored and there is a lot to be learned and implemented before patient can be free of risk in any health treatment or care. However, we hope that you find the papers presented on this special issue very stimulating and useful to your practice.
References [1] To Err is Human. Building a Safer Health System, Institute of Medicine, National Academy Press, Washington, DC, 1999. [2] M.J. Ball, C. Weaver, P.A. Abbott, Enabling technologies promise to revitalize the role of nursing in an era of patient safety, Int. J. Med. Inform. 69 (2003) 29—38. [3] L.L. Leape, Error in medicine, JAMA 272 (1994) 1851— 1857. [4] J.T. Reason, Human Error, Cambridge University Press, Cambridge, 1990. [5] S. Bakken, S.S. Cook, L. Curtis, K. Desjardins, S. Hyun, M. Jenkins, R. John, W.T. Klein, J. Paguntalan, W.D. Roberts, M. Soupios, Promoting patient safety through informatics-based nursing education, Int. J. Med. Inform. 73 (2004) 581—589. [6] M. Enhfors, S.J. Grobe, Nursing curriculum and continuous education: future directions, Int. J. Med. Inform. 73 (2004) 591—598. [7] B.V. Castle, J. Kim, M.L.G. Pedreira, A. Paiva, W. Goossen, D.W. Bates, Information technology and patient safety in nursing practice: an international perspective. Int. J. Med. Inform. 73 (2004) 607—614. [8] M. Pedreira, H.F. Marin, Patient safety in Brazil: a nursing perspective. Int. J. Med. Inform. 73 (2004) 563—567. [9] H.F. Marin, R.R. Rodrigues, C. Delaney, G.H. Nielsen, J. Yan, Building Standard-based Nursing Information Systems, Pan American Health Organization, Washington, DC, 2001, 141 p. [10] R. Helleso, M. Lorensen, L. Sorensen, Challenging the information gap—the patient transfer from hospital to home health care, Int. J. Med. Inform. 73 (2004) 569—580. [11] J. Hougaard, Developing evidence-based interdisciplinary care standards and implication for providing patient safety, Int. J. Med. Inform. 73 (2004) 615—624. [12] E.A. Mendonça, E.S. Chen, P.D. Stetson, L.K. McKnight, J. Lei, J.J. Cimino, Approach to mobile information and communication for health care, Int. J. Med. Inform. 73 (2004) 631—638. [13] L.K. Roemer, A.J. Richardson, R.A. Rocha, G. Del Fiol, R.L. Bradshaw, Exploratory case method to determine the frequency of redundant orders within manually consolidated order lists, Int. J. Med. Inform. 73 (2004) 639—645. [14] S. Matney, C. Dent, R.A. Rocha, Development of a compositional terminology model for nursing orders, Int. J. Med. Inform. 73 (2004) 625—630. [15] S.K. Newbold, G.J. Kuperman, S. Bakken, P.F. Brennan, E. Mendonca, H. Park, A. Radenovic, Information technology infrastructure for patient safety: nursing care requirements and knowledge gaps, Int. J. Med. Inform. 73 (2004) 657—662. [16] R.L. Simspson, Managing the three ‘P’ to improve patient safety: nursing administration’s role in managing infor-
546
[17] [18] [19]
[20]
H.F. Marin mation technology, Int. J. Med. Inform. 73 (2004) 559— 561. P.F. Brennan, C. Safran, Patient Safety—remember who it’s really for! Int. J. Med. Inform. 73 (2004) 547—550. C.M. Ruland, Improving patient safety through informatics tools for shared decision making and risk communication, Int. J. Med. Inform. 73 (2004) 551—557. L.O. Machado, P.S.P. Silveira, S. Vinterbo, Protecting patient privacy by quantifiable control of disclosures in disseminated databases, Int. J. Med. Inform. 73 (2004) 599— 606. A.J.L. Costa, E. Massad, N.R.S. Ortega, A.Q.C. Araujo, Perception of disability in a public health perspective: a model based on fuzzy logic, Int. J. Med. Inform. 73 (2004) 647—656.
Heimar F. Marin Associate Professor, Nursing Informatics Group, Federal University of São Paulo; Associate Adjunct Professor, Johns Hopkins University School of Nursing; Associate Adjunct Professor, The Iowa University College of Nursing; IMIA NI SIG Secretary Nucleo de Informatica em Enfermagem, Federal University of São Paulo, Rua Napoleao de Barros 754, Vila Clemention, 04024-002 São Paulo, Brazil Tel.: +55 11 55764430; fax: +55 11 55733371 E-mail address: [email protected] (H.F. Marin)
EDITORIAL
Improving Patient Safety with Technology The International Medical Informatics Association–— Nursing Informatics Special Interest Group (IMIA NI SIG) traditionally host every 3 years a worldwide conference followed by an invitational post conference workshop. In 2003, the Conference (NI2003–—the Eighth International Conference in Nursing Informatics) was held in Rio de Janeiro, Brazil, under the legend ‘‘e-Health for All: Designing the Nursing Agenda for the Future.’’ Following the main conference, recognized experts in health informatics were invited to discuss the theme of the Nursing Informatics Post Conference Workshop that was ‘‘Improving Patient Safety with Technology’’. The format of the workshop included individual presentations and working group discussion. The groups were to discuss and prepare a report according to selected subjects: (1) technology as an infrastructure to enhance patient safety; (2) safety in practice: future directions; (3) patient safety: what does it mean for education; (4) management issues in patient safety; (5) research directions in patient safety; and (6) cognitive aspects in patient safety. In total, there were 39 participants from 14 countries, covering five continents. For each working group, a chairman and a rapporteur were appointed by the organizers to guide the discussions. The final report originated from the working group discussions were printed in the proceedings and made available to all participants, including those participants of the main conference. We selected some reports and also selected some of presented papers at the main conference for this special issue of the International Journal of Medical Informatics. The authors of these papers have presented many important issues concerning patient safety and quality of care. This editorial summarizes some of these key points and serves as an introduction to this special issue. This special issue congregates 15 papers covering different aspects and different points of view related to the use of technology to facilitate or assure the quality of care and patient safety, most of them under the nursing lens.
Patient safety can be considered as one of the most important aspect of healthcare. Nothing is more contrary to the healthcare philosophy and mission than causing injury or harm to the individuals who search for care. However, procedures or care treatments are not free of risk. Since the release of the Institute of Medicine Report ‘‘To Err is Human’’ in 1999 [1], public and professional attention have been dedicated to this aspect with the objective to eliminate or reduce risk and assure quality of care. While there are many potential approaches to improving patient safety, most observers agree that information technology (IT) applications have the potential to support the delivery of care and promote quality. It also has the potential to transform health care work environment by streamlining processes, making procedures more accurate and efficient, and reducing the risk of human errors [2]. In addition, several studies have demonstrated that the lack of access to information during decision making and ineffective communication among patient care team members are proximal causes of medical errors and other adverse events in patient care [3,4]. The papers presented in this special issue shows that applications, research and educational aspects of health informatics often address very broad user needs and embrace a wide range of perspectives. At the same time, there are also papers included that explore specific aspects of patient safety or share the experience in develop and implement an application of information technology. Among the 15 papers, two explore educational aspects of patient safety. Considering information a key element to assure patient safety, technology resources can be used to document patient clinical data and retrieve patient information at the point of care. However, provision of information tools and resources are insufficient to influence patient safety. Students and faculty must also possess the necessary competencies to use these tools and
1386-5056/$ — see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2004.05.006
544 resources. Consequently, introducing health and nursing informatics in the curriculum is necessary to enhance competencies of the next generation of providers [5]. Enhfors and Grobe [6] pointed out that a critical element for nursing education curricula is the inclusion of learning opportunities for the student nurse to understand the importance of authentic dialogues–—or true encounters–—with patients, in which the patient and the nurse learn to reflect together on the care situation. There are two papers that also introduce international aspects of patient of safety under the nursing lens. The theme is an international concern and several countries are establishing organizations and methods to control adversity and enhance patient safety. Castle et al. [7] emphasize the nursing responsibilities for the patient safety, describing examples of activities taken by different countries organizations. The examples provided by the authors show that patient safety is indeed an international problem. Many occurrences can be prevented and detected by nurses. Having information technology resources to support nursing activities safety improvement can also be achieved more successfully. For that reason, nurses need to be closely involved with the development and application of IT. Medication errors are frequent and caused by multifaceted factors in nature, including calculation errors, preparation and administration phases. The prevention of medication errors at the point of care is a challenge in nursing practice. Developing countries face this problem more frequently due to the insufficient numbers of registered nurses to attend the high demand of nursing care [8]. In addition, the bulk of health professionals, such as nurse assistants and aides, that comprise the ‘‘nursing staff’’ in developing countries may be less well trained. This level of training does not enable them to deliver and document nursing care appropriately in a safer manner [9]. In practice, education, administration, or research, documentation and information communication are the essential ingredient for health care services. It is expected that the use of the electronic patient record simplify the exchange of information between agencies and improve the quality and continuity of care. To identify what information nurses need to provide patient care and to assure the continuity of care is a frequent question for researching around the world. Issues to be considered include the accessibility to information and the appropriateness of information as a communication tool [10].
H.F. Marin Furthermore, instruments to document patient care should be consistent, integrate and facilitate information retrieval. A variety of patient care documents can be identified in health care. They receive many names such protocols, procedure notes, standardized care plans, standards of care, care map, and others. Analyzing several types of documentation tools, Hougaard [11] conducted a project to develop a consistent interdisciplinary document model that could assure the user acceptance and implementation, including standards of care across the continuum of patient care. The model also includes a number of error-reducing strategies. It is recommends standardization of tasks wherever possible as a mean of reducing errors. Mendonça et al. [12] reported an experience of introducing new information technology into in-patient care settings in an attempt to improve access to information and communication (proximal causes of medical errors). They believe that these improvements will ultimately reduce proximal causes of medical errors and adverse events, and plan to perform an evaluation of these applications in clinical settings in order to determine their impact. At the clinical setting, an error of commission can also occurs when two or more orders are not identified as overlapping orders, and one or more of the orders are performed more often than necessary. To reduce and avoid these types of errors, Roemer et al. [13] developed a strategy to determine the frequency of redundant orders and consolidate order list removing duplicate orders before displaying the order list to the nurse. Considering the importance of orders and its impact on patient safety, we included a paper that explores a terminology model for nursing orders developed using empirical data. The model was validated against nursing research and standards literature, and evaluated using 609 nursing orders that were successfully mapped to the structure [14]. The paper explores indeed the attributes that should be included in complete nursing order concepts and how the attributes of a nursing order concept can be compared to defined nursing actions. It is assume that technology can create better conditions to deliver patient care. Newbold et al. [15] describes the process utilized to create research questions to promote technology as an infrastructure to enable safe nursing practice. Beginning with scenarios of safety problems related to nursing practice, the team identified technology including hardware, software, and organizational and operational components to help improve the
Editorial safety aspects addressed in the scenarios. Further discussed are characteristics of technology necessary at each step in the nursing care process and finally the authors include some recommendations for various research questions that would be needed to enable research on the use of the proposed technologies. In nursing practice, managing IT is a function of managing people who use it. Getting nurses to use systems and IT resources and use them correctly is the job of nursing managers. Simspson [16] emphasizes the importance of people, processes and computer programs to better promote infrastructure to enhance patient safety. However, the whole process of designing computer programs and establishing committee to assure patient safety must take into consideration the central element of health care services–—the patient. Frequently, most initiatives on patient safety focus on devices, procedures, professionals training and education, development and selection of computerized programs, and evaluation of delivered care. In fact, patient safety initiatives center on the patient, not only on the care providing system or the provider, will result in care deemed safe by all interested parties. Consequently, patient safety initiatives must be also informed by the patient values, beliefs and willingness to act. Active engagement of the patient in all aspects of patient safety strategies is a key for the success [17]. Nevertheless, even when the patient is already the central key of health care programs, decisions about care treatment can be difficult, particularly under circumstances where outcomes are uncertain and the clinical evidence regarding the effectiveness of treatment do not indicate the best action. Informatics tools such as preference elicitation techniques and knowledge on risk communication can support shared decision-making and risk communication helping patients to better understand their treatment options. These tools can combine advantages of computer technology, particularly its capacity to search, process, structure, integrate and individualize information with knowledge from cognitive science and research on risk communication [18]. This special issue also comprises two research papers that explores the patient privacy related to the disclosures of data in disseminated diseases and the use of the logic of the fuzzy logic to develop system that take into consideration the quality of well being of individuals and populations [19,20]. Both studies demonstrates how important is to consider the patient privacy and get patient involvement on his/her treatment.
545 In conclusion, we would like to emphasize that this volume is not conclusive. Many aspects of patient safety are still to be explored and there is a lot to be learned and implemented before patient can be free of risk in any health treatment or care. However, we hope that you find the papers presented on this special issue very stimulating and useful to your practice.
References [1] To Err is Human. Building a Safer Health System, Institute of Medicine, National Academy Press, Washington, DC, 1999. [2] M.J. Ball, C. Weaver, P.A. Abbott, Enabling technologies promise to revitalize the role of nursing in an era of patient safety, Int. J. Med. Inform. 69 (2003) 29—38. [3] L.L. Leape, Error in medicine, JAMA 272 (1994) 1851— 1857. [4] J.T. Reason, Human Error, Cambridge University Press, Cambridge, 1990. [5] S. Bakken, S.S. Cook, L. Curtis, K. Desjardins, S. Hyun, M. Jenkins, R. John, W.T. Klein, J. Paguntalan, W.D. Roberts, M. Soupios, Promoting patient safety through informatics-based nursing education, Int. J. Med. Inform. 73 (2004) 581—589. [6] M. Enhfors, S.J. Grobe, Nursing curriculum and continuous education: future directions, Int. J. Med. Inform. 73 (2004) 591—598. [7] B.V. Castle, J. Kim, M.L.G. Pedreira, A. Paiva, W. Goossen, D.W. Bates, Information technology and patient safety in nursing practice: an international perspective. Int. J. Med. Inform. 73 (2004) 607—614. [8] M. Pedreira, H.F. Marin, Patient safety in Brazil: a nursing perspective. Int. J. Med. Inform. 73 (2004) 563—567. [9] H.F. Marin, R.R. Rodrigues, C. Delaney, G.H. Nielsen, J. Yan, Building Standard-based Nursing Information Systems, Pan American Health Organization, Washington, DC, 2001, 141 p. [10] R. Helleso, M. Lorensen, L. Sorensen, Challenging the information gap—the patient transfer from hospital to home health care, Int. J. Med. Inform. 73 (2004) 569—580. [11] J. Hougaard, Developing evidence-based interdisciplinary care standards and implication for providing patient safety, Int. J. Med. Inform. 73 (2004) 615—624. [12] E.A. Mendonça, E.S. Chen, P.D. Stetson, L.K. McKnight, J. Lei, J.J. Cimino, Approach to mobile information and communication for health care, Int. J. Med. Inform. 73 (2004) 631—638. [13] L.K. Roemer, A.J. Richardson, R.A. Rocha, G. Del Fiol, R.L. Bradshaw, Exploratory case method to determine the frequency of redundant orders within manually consolidated order lists, Int. J. Med. Inform. 73 (2004) 639—645. [14] S. Matney, C. Dent, R.A. Rocha, Development of a compositional terminology model for nursing orders, Int. J. Med. Inform. 73 (2004) 625—630. [15] S.K. Newbold, G.J. Kuperman, S. Bakken, P.F. Brennan, E. Mendonca, H. Park, A. Radenovic, Information technology infrastructure for patient safety: nursing care requirements and knowledge gaps, Int. J. Med. Inform. 73 (2004) 657—662. [16] R.L. Simspson, Managing the three ‘P’ to improve patient safety: nursing administration’s role in managing infor-
546
[17] [18] [19]
[20]
H.F. Marin mation technology, Int. J. Med. Inform. 73 (2004) 559— 561. P.F. Brennan, C. Safran, Patient Safety—remember who it’s really for! Int. J. Med. Inform. 73 (2004) 547—550. C.M. Ruland, Improving patient safety through informatics tools for shared decision making and risk communication, Int. J. Med. Inform. 73 (2004) 551—557. L.O. Machado, P.S.P. Silveira, S. Vinterbo, Protecting patient privacy by quantifiable control of disclosures in disseminated databases, Int. J. Med. Inform. 73 (2004) 599— 606. A.J.L. Costa, E. Massad, N.R.S. Ortega, A.Q.C. Araujo, Perception of disability in a public health perspective: a model based on fuzzy logic, Int. J. Med. Inform. 73 (2004) 647—656.
Heimar F. Marin Associate Professor, Nursing Informatics Group, Federal University of São Paulo; Associate Adjunct Professor, Johns Hopkins University School of Nursing; Associate Adjunct Professor, The Iowa University College of Nursing; IMIA NI SIG Secretary Nucleo de Informatica em Enfermagem, Federal University of São Paulo, Rua Napoleao de Barros 754, Vila Clemention, 04024-002 São Paulo, Brazil Tel.: +55 11 55764430; fax: +55 11 55733371 E-mail address: [email protected] (H.F. Marin)