Sparks, Susan M. PhD, RN, FAAN
Health professionals concerned with nursing and healthcare administration issues and research are taking advantage of the unique communications opportunities afforded by the Internet, a network of computer networks that exchange and transmit data and information. The Internet is one of several major technologies collectively and popularly referred to as the "Information Superhighway." Up to this time, the Internet has been used by health professionals, including nurse executives, primarily as a means of personal communication (electronic mail [e-mail]) and to disseminate traditional text and graphics electronically. Some are also taking advantage of the Internet for the rapid transmission and distribution of information that includes sounds as well as still and motion images to a variety of constituencies including colleagues, patients, and the public.
The functionality afforded by the Internet is even more useful, perhaps necessary, in this time of rapidly changing health policies, care delivery systems, and nursing administration. The following are examples of existing and potential Internet applications:
* To disseminate any information rapidly to a large group or an individual.
* To disseminate information requiring graphics, images, or sound. For example procedures, including "how-to" images and graphics, could be useful to nurses and patients. Other aspects of patient care such as the informing component of informed consent could be facilitated in a manner not possible before the development of the Internet.
* To facilitate patient assessment; it is possible to transfer images and sounds of patient signs and symptoms to or from anywhere in the Internet-accessible world, affording activities such as telenursing and telediagnosis. Rare nursing expertise can be obtained nearly instantaneously, even in the most remote part of the globe.
* To facilitate collaboration; joint consultations, diagnostic and treatment plans, clinical trials data gathering, and manuscripts for publication (either electronic or printed) are some of the activities that can be accomplished relatively easily using the Internet. Patients might also collaborate with experts, their care providers, and others with the disease in an electronic support group over the Internet.
* To plan, prototype test or simulate, and implement transition to new care delivery models and new technologies to enhance or provide care.
* To provide quick information or consultation, such as clinical or bedside access to MEDLINE, the National Library of Medicine (NLM) database of citations to the journal literature, and other care-relevant resources.
* To provide and document continuing education and staff development via Internet-accessible resources, thus eliminating the expense of travel, subsistence, and, most importantly, the need for replacement staff during an employee's absence.
Just What is the Internet?
The Internet is composed of computers of various sizes connected with each other by high capacity fiberoptics, telephone lines, and satellites. The Internet is global, although many developing nations do not yet have access. However, should access become necessary in a situation such as the recent Ebola outbreak in Kitwit, Zaire, portable satellite phones and cellular technologies can be added to enable connectivity.
Internet connectivity is obtained via an Internet service provider, roughly analogous to a long distance telephone service provider. Many educational and healthcare institutions provide Internet access to faculty, staff, and students. Other Internet service providers are nationally accessible and "value-added" such as CompuServe, America Online, and Prodigy. They provide a wide range of information and products. They also provide some access to the Internet. Other Internet service providers may be national, regional, or local. Their primary purpose is to provide access to the Internet. Detailed information about thousands of Internet service providers and direct access to them is available athttp://www.thelist.com.
Communication Via the Internet
There are at least five types of Internet communication supported by the telecommunications system and software. These are e-mail, file transfer protocol (FTP), telnet, Gopher, and the World Wide Web (WWW). All, except e-mail, require software specific to the communication application.
Everyone who has Internet access has e-mail. This means that to reach the largest number of people around the Internet world, e-mail is the Internet communication mode that should be used. E-mail can be used for memoranda or letter-type communications and short manuscripts. At this time, e-mail supports text but no true graphics. E-mail can be sent to one person or to several individuals at the same time.
There are more formalized applications of e-mail technologies, such as LISTSERVs and newsgroups. LISTSERVs are mailing lists of people who are interested in a specific topic. Some LISTSERVs have a handful of subscribers, others have thousands. One e-mail message sent to a LISTSERV is distributed to the e-mail addresses of all subscribers. It is possible to identify subscribers to a LISTSERV. Newsgroups are e-mail postings, such as to a bulletin board, where interested people connect to share and exchange similar information. Individuals must connect with newsgroups purposely, and, unless a person leaves a message, it is impossible to know who is participating in the newsgroup. Newsgroups are public, meaning that anyone can participate. LISTSERVs may be public or private, allowing only certain people to subscribe, such as only the students in an nursing administration course.
For example, you might be interested in research-funding interests of the the National Institutes of Health (NIH). If so, it could be useful to subscribe to the NIH Guide to Grants and Contracts via LISTSERV. More directly relevant to nurse executives is the Nurse Managers (RNMGR) LISTSERV. Instructions for subscribing to both of these free resources are shown inTables 1 and 2.
File Transfer Protocol
Another type of Internet communication, requiring special software, is FTP. Relatively large text documents may exceed e-mail capacity. To share both these larger text documents and files that run computer programs, such as computer-assisted instruction software, FTP can be used. The file to be transferred is placed in a special computer directory. The intended file recipient(s) are notified of the file-name, directory location, and any special passwords necessary to obtain the file. The intended recipient(s) access the host computer and the directory and electronically retrieve the file.
For example, you might be interested in obtaining Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines, perhaps to prepare clinical programs and pathways for acute and cancer pain management. These guidelines and other reports are in the Health Services/Technology Assessment Text (HSTAT) database. The methods to do so are:
FTP to: ftp://nlmpubs.nlm.nih.gov
When asked for a password, enter the term "anonymous." (Because this site is open to the public and there are no restrictions on it's use, it is in network parlance, referred to as an anonymous FTP site.)
Then choose the /hstat directory.
Transfer both guidelines, Acute Pain Management and Management of Cancer Pain, in versions of your choice, to your computer.
Telnet is another kind of Internet communication. Its popularity seems to be declining with the rapid development of more advanced and functional Internet technologies. A telnet session is an interactive communication session with a host computer. The user connects with a computer and uses the files and programs provided there as though they were a terminal to the host computer. There is a constant electronic connection during a telnet. America Online, CompuServe, etc. use telnet to provide their subscribers access to their proprietary forums and to the Internet.
Maybe you need an instructional program to meet requirements of the Joint Commission on the Accreditation of Health Organizations. Performing a free search of the NLM's AVLINE database, which contains information about more than 25,000 audiovisual items, may meet the need by identifying a suitable computer-assisted instruction program institution.
Telnet to locator.nlm.nih.gov
Enter your login name as "locator."
Gopher, developed by the University of Minnesota and named after its mascot, the Golden Gopher, is an Internet communication technology that supports hypertext. Hypertext allows the user to electronically leap from one text-based computer file to another. Hypertext does this, in networking parlance, relatively transparently (mouse point-and-click), without the user necessarily knowing any but the initial electronic address. Users have special software, a Gopher client, on their computer. The client software executes instantaneous connection with the chosen file on a chosen host computer, the Gopher server, then instantaneously transfers the text file to the client, and then disconnects from the server. The Gopher client also participates in formatting the text displayed.
You may wish to take advantage of the many resources of the National Information Center on Health Services Research and Health Care Technology available from the NLM's Gopher server. The US Taskforce Guide to Clinical Preventive Services, 2nd ed, 1996, is available there. In addition to information about many screening technologies services, there is also a chapter titled Cost-effectiveness and Clinical Preventive Services. To connect, gopher to: gopher.nlm.nih.gov
World Wide Web
The WWW is the technology with the most exciting developments. It has many similarities to Gopher. The major functional advantage currently is that WWW technology is hypermedia. Hypermedia allows the user to electronically access a variety of computers. However, unlike text-based Gopher, the WWW accesses a variety of media, such as sound, still and motion pictures, graphics, and computer programs. The host computer has special server software; the user has special client software, generically referred to as a "browser." The browser participates in the formatting and displaying of digital information and data as text, sound, pictures, etc. World Wide Web technology will also be capable of supporting the incorporation of computer files, such as interactive instruction and data modelling.
There are many brands of browsers including Mosaic (Urbana-Champaign, IL)(the "original"), Netscape, (Mountain View, CA) and others, which all have similar functionality related to the WWW protocols; however, there are differences in the browsers' other functionalities. An important difference is whether the browser can also be configured to allow all the other Internet protocols such as Gopher, telnet, FTP, newsgroups and e-mail. It is the nature of telecommunications and networking technologies to be constantly changing, hopefully advancing, and providing greater functionality. Readers should be aware that the information in this article will soon need to be updated.
Nursing Administration Uses of Selected Internet Resources
The AHCPR has posted its Research Portfolio including Research in Action Fact Sheets: Improving Consumer Choice, Strengthening Managed Care, Improving Health Care for Rural Populations, Examining Long-Term Care, and Using Computers to Advance Health Care. The Research Portfolio is located at:http://www.ahcpr.gov/research/
Another AHCPR resource useful to nurse executives, available on the WWW, is CONQUEST (COmputerized Needs-oriented QUality Measurement Evaluation SysTem). This tool permits users to collect and evaluate healthcare quality measurements to find those suited or adaptable to their needs. There are two interlocking databases: a measure database that summarizes information on approximately 1200 clinical performance measures; a condition database that contains conditions for diagnosed conditions and patient health states, whether diagnosed or not. To obtain access to CONQUEST 1.0, connect with:http://www.ahcpr.gov/research/conquest.htm
Nurse executives need to keep abreast of rapidly changing circumstances in healthcare delivery, development of the electronic nursing/health record, technologies they and their staff can use to improve care or to "work smarter, not harder," etc. The most expeditious way to keep current is to take advantage of high-quality resources via the Internet. MEDLINE and HealthSTAR (the online bibliographic database that provides access to the published literature of health services technology, administration, and research, which focuses on both the clinical and nonclinical aspects of healthcare delivery) cite already published manuscripts. However, the Internet offers access to the most current information. Some of this available information will have been peer reviewed some of it will not have had any review.
HSRProj (Health Services Research Projects in Progress), another database available through the NLM, does provide information about health services research in progress before results are in a published form. HSRProj contains citations to research in progress funded by federal and private grants and contracts for use by policy makers, managers, clinicians, and other decision makers. Nurse executives interested in networking with others researching an aspect of administration would find HRSProj of value. They might also want to review the projects reported as part of the background study of a nursing administration question. For more information on accessing HSRProj contact the MEDLARS Management Section at: firstname.lastname@example.org
Health delivery institutions and services are using the technology of the WWW to make their procedure and policy manuals and care pathways available to those who need them. Most of these only permit access to users within the organization and are not publicly available.
There are many issues involving the Internet and its applications that require astute professional attention. Some of these include:
* The quality of the Internet application or resource. Because the nature of the Internet design allows anyone to post nearly any material, professionals will need to decide how to safely identify the quality of resources to protect those least able to judge for themselves, their students and patients, and the public. Some tips for assessing the technical and functional quality of resources are available (Cybertourtorials athttp://www.oise.on.ca/~jnorris/welcome.html). You are the expert in nursing administration content-its accuracy, its currency, its balance or bias, etc-and you are also the expert in how the content and the functionality of the site interact. Much will depend on your applying your expertise in determining quality.
* Protecting confidentiality and privacy of personal or patient information. Before there can be useful clinical applications of the Internet these security matters must be solved. Having security, via cryptography or password protection, may make what is technically possible, socially and ethically acceptable. Nurse executives working with any clinical information systems must recognize potential problems and participate in the work to develop solutions.
* Development, deployment, and research of the delivery of nursing care via tele-(distance) technologies, (telenursing) needs the vision and support of nurse executives. New, practical, and efficacious technologies to deliver care such as two-way video and remote electronic monitoring already in use in a few places are proving cost effective and acceptable to both the patient and professional. Nurse executives without vision will hamper the development and deployment of appropriate distance care technologies.
* Telenursing, telemedicine, and telehealth raise significant questions about licensure of professional practice on the Internet (some call this"telepractice") and reimbursement of services rendered. Is a professional practicing in the state or country where the patient is located or where the professional is located? Who will pay for what clinical services? How will this infrastructure be maintained?
As creative, innovative, visionary nurse executives exploit the technology in yet unexplored ways, unique issues will no doubt continuously arise.
Search Tools for Finding the Information You Want
Most Internet users have difficulty finding their way on the Information Superhighway until they identify tools to help them identify sites of interest and value. Before that, most are overwhelmed with the amount of information available and the chaos they perceive. Many get frustrated and give up on their pursuits of the Information Superhighway.
The remainder of this article will focus on the wonderful resources available on the WWW component of the Internet for nursing administration or general health professional interests. Rather than "surf" around from someone's favorite WWW site, the most useful starting point is one of the many search tools.
Most browsers have a search tool readily available to users right on the software interface. Some people prefer to use search tools prepared by other sources. Some tools only allow searching, others allow both searching and browsing. There are tools that focus on one database and others that encompass several databases. No one tool or combination of tools searches the entire WWW, much less the Internet.
As of May 2, 1996, according to the WebCrawler Top 25 most popular sites(of all kinds): Yahoo was number 2, WebCrawler was number 4, and Lycos was number 5. In other words, of the top five sites, three of them were search tools. Alta Vista, which is much newer and larger than the others is number 22 on the WebCrawler Top 25.
Each tool searches a different database of sites. Each offers different options. Each tool has a different interface. Before using any search tool, know the parameters of the database, how to use the options furnished, and how to interpret the results. This information is readily available on the interfaces of each search engine. Readers wanting more guidance in the use of search tools can access a Cybertourtorial on these four at the following Uniform Resource Locator (URL=WWW electronic address):http://www.oise.on.ca/∼jnorris/welcome.html
To connect and learn about each tool from the source, connect with any of the URLs shown in Table 3. Once a search is performed, the findings are presented as hyperlinks, or embedded electronic connections to other computers. So, to explore any of findings, all that's needed is a mouse click or two to be connected. A general search term such as infectious disease is likely to generate hundreds of resources (hits). Some relatively rare search terms might not locate any resources.
As you use the search tools and look and learn, think about how these resources can enhance your work, your practice, your education. Think about how they could be used in administering and delivering nursing care. With these ideas and more experience using the Internet, nurse executives will be developing electronic resources and creating new applications for themselves.
If you are not already an Internet user or might want to change your Internet service provider, contact http;//www.thelist.com. Some sites of interest to nurse executives and other health professionals are shown in Table 4.