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Critical Analysis of an Information System for Community NursingIztok Bitenc, Robert Leskovar,Vladislav RajkoviE, Mojca BernikUniv. of Maribor, Faculty of Organizational Sciences,Kidriceva 55a, 4000 Kranj, Slovenia

Abstract-The paper presents results of a critical analysis of aninformation system (IS) for community nursing (CN) which hasbeen developed to improve health care in Slovenia. The goal ofIS is to support CN practice and to encourage research anddevelopment in the field. The developed IS will: increase workeff iciency, introduce process-oriented nursing doctrine, supportintegrated treatment of the subjects and enable datacommunication. In the paper main stages of IS development areshown with detailed explanation of functional model, datamodel, user interface, testing phase and implementation. Criticalanalysis is based on SWOT techique.

I. INTRODUCTIONCN is defined as a special form of health care that ensuresan active health and social care of clients (individuals,families and communities) that are, due to their biologicalfeatures or a particular disease, more exposed to harmfuleffects from the environment. Community nurse helps clientsto perform better daily living activities in various healthconditions from birth to death. The role of the communitynurse is to support activities in primary health care,prevention and health education (for example Salvage [ 111).According to the Resolution WHA49.1 (World HealthAssembly) ~nursing/midwifery service development is an

integral part of health development. To maximize thecontribution of nurses and midwives to the achievements inthe field of health country-specific approach must be adopted.Active involvement of nurses at all levels of the health caresystem, together with the recipients of health care,p&icymakers, the public and private sectors, representativesof professional associations and educational institutions, andthose who have responsibility for social and economicdevelopment must be assured

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decomposition is reported in the proposed projectdocumentation (Jereb [4]). The need assessment functionconsists of five subfunctions: information gathering,interpreting, recognizing, ranking and checking. The planninggives detailed CN plan, which includes decision-making,what to do and how to do. The subprocess of planning are:joint goal settings, selecting nursing interventions,preliminary contact with client in order to get confirmation ofthe plan, dissemination of the CN plan to other relevantrecipients (co-workers, relatives). Implementation of plannedinterventions includes nursing and technical procedures.These procedures are adjusted according to the current stateof the client and unpredictable developments. Performedinterventions are recorded in CN plan. Evaluation is the mostimportant phase in CN. It enables process improvement forthe benefit of the client and cost effective treatment. Feedbackinformation can contribute to better need assessment.The analysis of the current practice in two health centerswas performed. It was determined that current practice differsamong health centers and that practice deviates fromproposed theoretical education process. Duplicated,incomplete and inaccurate paper documentation on clients iskept on various locations. Several problems related to datagathering, data updating and data deletion were identified.Personal data security problem was generally inadequatelytreated. Scheduling of the CN process, planning andevaluation were neglected either because of shortage of timeor because of inaccessibility of relevant data. On the otherhand the administrative tasks proposed by theoretical modelwould significantly decrease the time that a nurse devotes to aclient. The )?unified nursing la.n~~ge(< described in(Mortensen [ 91, Wake et al. [ 141, Mortensen [lo]) andproposed by ICNP (International Classification of NursingPractice) is hard to use without computer support.Extensiveness of the language on one side and semanticdeficiency on the other side are identified as serious

unsbuduedinamson,ICNNeed _

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problems. The conclusions made by system analysts were notblack/white (SuSterK et al. [ 131). It was decided to designopen-ended system, to implement theoretical model where itis reasonable, and to support good practice where necessary.B. DATA MODEL

Data model was developed gradually during the researchproject. The first preliminary models were more medicallyoriented (for example Milavec et al [S]) and proposed mainlylogical-semantic approach (SuSterSiE, Rajkovic [ 121). Thelater one included more or less complete data support forCN. Figure 2 presents the core of the current data model,which is described in Leskovar et al [63. Complete datamodel includes more than 30 relational tables and more than50 tables of codes.The most important relational tables are Client, Family,Community and Nurse. Each Family can include manyClients; each family member is a potential Client. The newOrder issued by Order Issuer triggers one or more CNProcesses. Each Process corresponds to one of the states ofthe Client (for example newborn, child, teenager, adult,elderly person). The Process triggers Visit. Each Visit isscheduled by Calendar. The Process links different states ofthe same person while Visit links different activities duringthe visit. Properties are measured and each property has it;own set of agreed values (Domain). Instances of CNdiagnoses are confirmed during the visit. Instances of CNinterventions are executed during the visit. Table Propertystores all nursing anamneses. Additional classification ofproperties enables testing various coding schemes (forexample complete or reduced ICNP, user proposed propertiesetc.). Tables Insurance Company and Instance of Otherintervention will serve to demonstrate the financial aspect ofCN .

Int. class. of1llness Insurance/ company1 dClient Illness ro - Client co . Famy

r- -

Reschedule log - Nurse Q CN Process

Property I IDoman ofPropeW I I CN diagnose

Figure 2. The core of CN data model.Figure 1. System diagram of CN process.

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c. USER INTERFACEBorland Delphi was the chosen implementation tool. Theapplication was designed as multiple document interface(MDI). Main window controls one or more child windows.Standard Windows entry/transition controls are used (dropdown menus, combo boxes, ALT+character, toolbars etc.).

The figure 3 shows the main window of application.

Figure 3. Main window of CN IS with four child windows (two shown).After successful authorization, the application permits the with Apple Newton PDA and cable showed relatively fastconversion and transmission but at present too complicatedfor target users (nurses).user to perform granted functions. Three classes of users cansimultaneously use the program: Administrator, Head Nurseand Nurse. The user interface kept a significant degree ofsimilarity with theoretical model of community nursingdescribed in chapter 2.1. Report section of the application isopened for new tools such as statistical package or e-xptr2system.

D. TESTINGThe most important sof tware assessment criteria areusability (time to learn), functionality (support foroperational, administrative, research and educationalpurposes), maintenance (time to implement change) andreliability (number o f errors per time interval, number ofcrashes per time interval, time to repair error). Black boxtesting at users locations were performed (Leskovar et al.[5]). The learning curves of users were satisfactory. Usersspent approximately 20 hours to become aware of thefunctionality and control mechanisms of the program.Embedded classification of the nursing phenomena tookmuch more time to learn. Suggestions to tested functions of

IS were collected and easily implemented. Acceptance testshowed satisfactory results from nurses and clients.E. IMPLEMENTATION

The information system architecture is schematicallypresented in figure 4. Servers in different municipals areconnected via routers and public or private network.Alternatively, fast modems can be used. It is expected that the

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Workstation Personal digital assistant

Figure 4. Information systemarchitecture for CNlink between servers will support e-mail and client migrationmainly. The proposed minimum configuration of the serveris: processor speed 233MHz, memory 64MB, disk capacity4Gb, DAT backup unit 4/8Gb, Windows NT operationsystem and Access/Paradox/Oracle/MS SQL databasesystem. Workstations and portable PCs are Windows 95/98based systems.The communication between server and client is enabledvia LAN preferably Ethernet. Portable PCs and personaldigital assistants without network interface card will receiveand send data through RS 232 or infrared interface. Personaldigital assistants require data conversion from chosendatabase format to ASCII and vice versa. Preliminary tests

III . CRITICAL ANALYSIS OF ISSWAT analysis was chosen as a tool for the analysis. Itprovides a framework for identifying issues that have themost impact on the situation. Significant strengths,weaknesses, opportunities, and threats that characterize the

situation can be found. The results in the case of communitynursing IS are presented in figure 5.Strengths: close linkage between IS and process approachto CN is recognized as an important strength. CN IS ischaracterized by unified process approach. Data in our IS aretherefore comparable with electronic patient record fromother sources. Community nurses not only work with patientsbut also with their families and other communities, sosupport fo r these activities is included in IS. As a result wegot large amount of well-structured data that enables easyoverseeing of daily workflow for each nurse and to producequality reports and documentation. Nursing anamnesis arebased on daily activities (Henderson [2]) and serve as achecklist what-patient properties should also be examined.Weaknesses:n most cases of practical nursing a processapproach is implemented only partiallv. Increased data entryalso increases workload of a nurse. Testing phase revealedalso a concern of some patients that nurses will pay moreattention to the computer instead to them. This issue willbecome even more important with nurses that lack oncomputer literacy/skills. Another problem is accessibility ofinformation and communication technologv (ICT). Anv up-

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1 STRENGTHS -1Integrated approach toorganization of CN

Better connection amongfinance, statistics andCN

Network and portableICT

enlargedPoor computer literacy(Un)accessibility of ICTresourcesMore rigorous supervisionof nurses activitiesFinancial and statisticalpart not fully implementedFocus of attention shiftsfrom patient to ICT

OPPORTUNITIES IComputerization ofhealth careHolistic patient/clienttreatmentInformationpicture/profile andfeedback informationICNP and nursing as awholeUsage in education ofcommunity nursesR&D in health carePartial automation ofnursing diagnoses andinterventions

/ J

THREATSExistent standards in CNState of medicalinformaticsICT and IS for CN are nota substitute for creativenurse and/or nursing

process

Figure 5: SWOT analysisof CN ISto-date desktop computer could be used as a server orworkstation however in the field-work only portablecomputers can be used and they are priced double comparedto an adequate desktop computer. When designing andimplementing IS we focused primarily on nursing support.Financial and statistical reports were only analyzed to makesure no data were overlooked. At present these reports areimplemented in software of other vendors. The last issue is

also among strengths: with all the data about a patient andvisits a very tight control over work of any nurse can beachieved. In the testing phase nurses expressed a concern ofsuch kind of control being misused.Opportunities: informatization of the nursing processcould contribute to the development of informatics in thefield of health care. Complete alpha version of ICNP isalready built-in in presented IS. With all patients data incomputer a thorough approach to a patient can be affordedbecause computer will search relevant information and willproduce information picture of him. This will also producefeedback information to nurses and other medical staff. Animportant part of IS is evaluation of patients condition.Based on these data quality assurance with all its benefits canbe introduced in process of nursing. Large amount of data oncomputer makes an excellent source for research anddevelopment in nursing. One of research topics could be anexpert system for partial automation of nursing diagnosesand interventions. Because of its theoretically strong sourceand structure IS can be used in education of communitynurses.As threats wed like to expose existing standards andlegislation in CN. Currently they are in process of changesbut IS isnt very compliant with the proposed ones that arebased on paper processing. This issue clearly shows state ofmedical informatics where changing way of work involvesmuch more effort then in other fields. At last we shouldstress that ICT and IS are not a replacement for a nursebecause a computer is only a tool that can work with andoffer existing knowledge. Only a human being can work in anew way, can be creative cand an listen to the patient.

IV. CONCLUSIONThe developed IS for community nursing is a practicalsof tware solution based on modern network, portableinformation and communication technology. The solutionsupports CN as a client/patient oriented process and cansignificantly contribute toward better quality of home healthcare and life of people in the need in general. This approachleads toward better evaluation and quality control in nursingencouraging further research and development in the field.Critical analysis of presented system showed many benefitsfrom using process of CN as the core of IS structure. State-of-the-art approach to a client, family or community with alot of data enables excellent reporting but also involves morework just to enter all the data. This can shift nurses focus of

attention from the patient to the computer. With smallchanges IS can be introduced into other fields of nursing. IScan serve as a tool for R&D in nursing, for evaluation andquality assurance and as an educational toll but only i fcurrent legislation and standards in CN allow that.

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ACKNOWLEDGEMENTThe research was supported by Slovenian ScienceFoundation in cooperation with DG III of theCommission of the European Union and EU projectINCO Copernicus: Co-operative Research in Information

Infrastructure. The authors would like to express theirthanks to other team members from collaborativeinstitutions.REFERENCES

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