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Nursing News & Views

Clinical updates, perspectives, and more.

Thursday, July 30, 2015

 

BY ERIN NOEL, RN, OCN

 

Prior to 2015, the last Oncology Nursing Society Congress I was able to attend was in 2002. To say the least, Congress has grown tremendously, offering many learning opportunities for both the new and the experienced oncology nurse. If I could have cloned myself, I would have attended every session I could at this year’s meeting in Orlando. But, from the sessions I was able to attend, here are some highlights.

 

Opening Ceremony Keynote Address: Transforming our Future

With speaker, Kevin Sowers, RN, MSN, Director, President, and CEO of Duke University Hospital

“Respecting the Past and Visioning the Future.” This statement resonated with me as a 22-year oncology nurse veteran. There are so many things we have learned as oncology nursing has evolved—from safe handling (or lack thereof of in our past) to the first ONS cancer chemotherapy guidelines published in 1986 to new roles with nurse navigation to the use of social media in health care. 

 

Oncology nursing has come a long way from 1975 to 2015, and it will continue to transform over the next 40 years and beyond.

 

ONCC Recognition Breakfast for Oncology Certified Nurses

With speaker Karren Kowalski, PhD, RN, NEA-BC, FAAN, President and CEO of the Colorado Center for Nursing Excellence,

Kowalski was absolutely AMAZING! I was mesmerized. Her wise (and candid) words during her talk at the Oncology Nursing Certification Corporation Breakfast for Oncology Certified Nurses both filled the room with laughter and inspired moments of deep thought.

 

She taught us a new word: “psychosclerosis”—which, according to Kowalski, can be defined as the hardening of the attitude. She drew out more than a few laughs when she used the term to identify some of the nurses we come across in our profession, reminding those of us who do run into this type of nurse (certainly not me—wink, wink), keep smiling and spread your cheer, love, passion, and inspiration for the nursing profession. You never know just how infectious a positive attitude is for new and experienced nurses.

 

Kowalski shared anecdotes from when she served as a labor and delivery nurse, as well as from her days as an Army nurse. She encouraged the nurses in the room to create a vision. In this vision, “know your purpose, it should be clear and well-defined, as well as positive and inspiring.” The advice applies to both novice and expert nurses. A lot of factors make it easy for nurses to burn out on their roles, but creating a vision and focusing on this vision, is a way to help reduce and avoid compassion fatigue and burn out. 

 

She completely rocked the house.

 

Psychosocial Challenges for the Young Adult with Cancer—How Can We Help?

With speaker Anne Katz, RN, PhD, Clinical Nurse Specialist at Cancer Care Manitoba, Editor of the Oncology Nursing Forum, and author

Katz’s presentation was eye opening. She urged nurses to take the lead to address sexuality and fertility with our patients. For so many years, sexuality—for both young adult patients with cancer, as well as older adult patients with cancer—was a difficult conversation to approach. It is a sensitive subject for most patients. And personally, I have found physicians and nurses tend to skip over the topic, too, or barely mention it at all, including issues like preventing pregnancy during treatment and fertility preservation.

 

But Katz really honed in on why it is so important to talk about sexuality during cancer treatment, as well as know what the overall emotional stages of the young adult are. And beyond sexuality, she challenged the nurses listening to think about: are we really meeting the needs of young adults with cancer? Are we truly helping balancing cancer treatment, family, work, and paying bills?

 

There are so many emotional needs that go unfulfilled that we do have resources for. How can we help this population of cancer patients? Katz suggested continuous contact with the oncology team, developing a survivorship care plan, assisting our patients’ reintegration into the community, supportive care, peer support, and surveillance of late affects, to name a few. We need to make the patient aware of the resources available and counsel them throughout the full course of their cancer treatment and beyond.

 

I truly respect Katz’s ability to speak about sexuality and the care of the young adult with cancer. I encourage oncology nurses everywhere not to be shy about talking about these particular needs for these patients and developing a plan of care in your current practice for these patients. They need to know the facts and what options they have.

 

Social Media Mini Workshop,

Led by Carol Bush, BS, RN, Nurse Consultant at Midwest Cancer Alliance; Suzanne M. Mahon, RN, DNSc, AOCN, APNG, Professor at Saint Louis University and Head of the Hereditary Cancer Program at the Cancer Center there; and Joni Watson, MSN, MBA, RN, OCN, Director of the Baylor Scott and White McClinton Cancer Center in Waco, Texas

This social media session was a great interactive session that taught me about online platforms, and introduced me to nurses using them. I learned about appropriate social media tools to develop nurse-nurse relationships, as well as nurse-patient relationships. Whether it’s professional or personal, when creating a social media account, it is important to be mindful of these relationships and be mindful to establish a clear definition between professional and personal relationships.

 

Confession: I had a Twitter account before attending this session, but I never even understood how to use it until attending Congress this year. I even became a “Top Ten Tweeter” at the meeting! Though I’m probably no longer a “Top Ten Tweeter” after leaving Orlando, I still connect and Tweet on a regular basis. Twitter opened up so many opportunities to meet other oncology nurses around the world, to connect and to share information that can help us all grow personally and professionally.

 

If you don’t have a professional social media account—being mindful of your company’s social media policies—I encourage you to create one and start connecting with other professionals.

 

Self-Care of the Oncology Nurse

With speaker Mary Lehett, RN, BSN, OCN, a retired oncology staff nurse

Self-care of the oncology nurse is a topic near and dear to my heart. In my 23 years in the field, I have seen new nurses get burned out in just a few short years, and I have seen compassion fatigue at all stages of their career. I am currently in the process of developing a program to further identify and acknowledge nurses in our system who can benefit from additional self-care resources to avoid these averse outcomes.

 

Nurses are so busy taking care of others, we too often fail to remember our own health. But to be able to take care of others, it needs to first start with taking care of our own body and mind. In her presentation, Lehett showed that mindfulness-based stress reduction programs have been shown to help reduce stress and burnout. Programs such as guided meditation, inner source meditation, yoga, and Reiki, have also been found to be beneficial.

 

But, how to find the time to incorporate stress-reduction training—whether it be Reiki or any other modality—into your routine? Time is a limitation only if you make it one. Lehett shared this helpful reminder to stop and breathe (and take time for yourself!)—a quote from Thich Nhat Hanh:

 

“Breath is the bridge which connects life to consciousness, which unites your body to your thoughts. Whenever your mind becomes scattered, use your breath as the means to take hold of your mind again.”

 

This session reminded me about the importance of taking charge and caring for my own self; energize and empower yourself to be revitalized so that you can better care for others.

 

ERIN NOEL RN, OCN, is the Team Leader in the Infusion Room at Baylor Scott & White McClinton Cancer Center-Hillcrest in Waco, Texas. She has been an oncology nurse for 23 years, and is currently pursuing the RN-BSN program through Texas A&M University—Central Texas with plans to pursue a program for MSN in fall, 2016.  She is a current member of the Heart of Texas ONS Chapter.

Thursday, June 25, 2015

BY GEORGIA J. SMITH, RN, OCN

 

Taking care of your personal health was not treated as a priority when I entered the health care field 30 years ago. During my time as a medic in the U.S. Air Force and as a bedside nurse, the focus—in my experience—was always on the care and well-being of the patient, the troops under your command, or, as a charge nurse, the members of the health care team. The focus was always external, never internal. 

 

But because of the high-stress environments nurses work in, self-awareness and self-care are essential to the well-being of nurses themselves—as well as to the well-being of the patients they serve. One tenet of integrative nursing theory is that in order to help others heal, the caregiver must also be fully nurtured and cared for.1 Put more simply: to support others, the caregiver must also be supported.

 

It is time for oncology nurses to evaluate what each of us needs to do to improve self-care and life balance, and open dialogue with oncology nurse leaders to promote self-care in their subordinates and peers.

 

One excellent tool for nurses to use to assess self-care status is the Healthy Nurse Survey from the American Nurses Association (www.anahra.org). This tool evaluates myriad personal care areas from physical and emotional health to healthy behaviors, looking at home and worksite environmental factors. After completing the survey, nurses can compare their results with national averages and ideal standards, and are directed to resources for wellness.    

 

Oncology nurses also need to be aware of the facets of their work that affect their personal health, as well as the factors they can control. Here are eight important self-care reminders: four aspects of oncology nursing that can make self-care difficult, as well as four best practices for better self-care.  

 

What Makes Self-Care Tough

Work Hours: Oncology nursing in the hospital is shift work with long hours, often including 12-hour shifts. Mandatory overtime also takes a toll on the bedside nurse. In the ambulatory setting, most chemotherapy nurses work from the start of the day until the last chemotherapy protocol concludes. And unlike other inpatient peers, oncology nurses usually work Monday through Friday with little break. Most oncology nurse leaders are frequently salaried and clock 60-plus hours a week. These schedules are not conducive to finding time for exercise, family, or relaxation.

 

Emotional Stress: Oncology nurses care. We become attached to our patients and families, so we are constantly suffering loss when a patient dies. Some of these cases allow for preparatory grieving, but many are unexpected from treatment side effects and are emotionally draining. The stoic nature of oncology nurses can cause us to bury feelings, which then later erupt as physical symptoms.

 

Lack of Daylight: Whether it is shift work, or prolonged work days, oncology nurses rarely find time to be in the sunlight.  This is particularly noticeable in the more northern areas of the country, where winter daylight time is actually shorter than a typical nurse’s shift. By not getting outdoors and having sunlight and green space time, nurses lose an important tool in managing emotional balance.

 

Poor Sleep Patterns: As an oncology nurse, it is hard to let go of the day and fall into seven to eight hours of uninterrupted sleep. How many share the recurring nightmare of the patient, who needs leucovorin rescue, but you can’t find the drug, the room, or the patient? You awake in a cold sweat realizing it is just a dream, but now you can’t fall back asleep. Studies have shown that women who do not get adequate sleep, are poor decision makers in critical situations.2 Lack of restful sleep can lead to medication errors, accidents, and other fatigue-associated problems.

 

Best Practices for Better Self-Care

Maintain a BMI of 25 or less: A healthy body mass index (BMI) can be achieved by increasing dietary fiber and water intake, controlling portion sizes, and increasing physical activity.  Increasing physical activity has the secondary gain of decreasing stress levels, which can release cortisol and inhibit weight loss.3 Weight-control is essential to good health.

 

Increase “green space time” to a minimum of 60 minutes per day: Take 20 minutes of the lunch period to walk around the hospital campus outside and then spend the remaining 10 minutes in quiet reflection before returning to work. Find a way to spend quality time outdoors after work and on days off.

 

Avoid over-committing: The current trend toward 12-hour shifts has been proven to not be as healthy for nurses as eight hours. Despite the longer work day, oncology nurses have a difficult time saying “no” when asked to pick up extra shifts, or stay late.  If you are the nurse who can’t say no, screen your calls and do not respond to calls requesting extra shifts unless you truly feel rested and up to the challenge.

 

Treat yourself as well as you treat your patients: The personality type that pursues nursing as a career is a natural caregiver. We typically put others—patients, family, and friends—first, and look at our own needs last. Give yourself permission to be a little selfish. Whether it is a day of golf, a hike in the mountains, or a pedicure at the spa, make time to do something just for you.

 

In summary, oncology nurses need to be self-aware and enlightened nurses in order to provide better care to both their patients and themselves.4 By assessing personal health needs and behaviors, formulating a self-care plan, and making a commitment to take care of ourselves as well as our patients, each oncology nurse can be a more effective and holistic clinician and person.

 

GEORGIA J. SMITH, RN, OCN, is Director of Cancer Services for HSHS Sacred Heart Hospital in Eau Claire, Wisconsin, where she has led numerous quality and patient-focused initiatives. The hospital currently holds a top decile ranking in patient satisfaction for its oncology service line.

 

Smith was also previously a Senior Airman in the U.S. Air Force, where she served as a medic (in a role similar to a certified nursing assistant) at Wilford Hall Medical Center and Bergstrom Air Force Base in Texas, as well as at Clark Air Force Base Medical Center in the Philippines.

 

REFERENCES

1. Koithan, M. (2014). Concepts and principles of integrative nursing. In M. J. Kreitzer, & M. Koithan (Eds.), Integrative nursing. New York, NY: Oxford University Press.

           

2. Whitney, P., et al. (2014, November 3). Feedback blunting: Total sleep deprivation impairs decision making that requires updating based on feedback. Sleep 2015;38:745-754.         

 

3. Constantinopoulas, P., et al. (2014, October 21). Cortisol in tissue and systemic level as a contributing factor to the development of metabolic syndrome in severely obese patients. European Journal of Endocrinology 2014;172: 69-78.

           

4. Quinn, J. F. (2013). The integrated nurse:  Wholeness, self-discovery, and self-care. In M. J. Kreitzer, & M. Koithan (Eds.), Integrative nursing. New York, NY: Oxford University Press.

Tuesday, April 21, 2015

BY GERMAN RODRIGUEZ, RN, MSN; THELMA NAVARRO, MSN, FNP-BC, OCN; and MARLEEN MEYERS, MD

 

The American Cancer Society estimates that there are nearly 14.5 million people in the United States with a history of cancer—and that number is expected to rise to almost 19 million people by 2024. The overall five-year relative cancer survival rate has increased to 68 percent for 2003 to 2009, up from 49 percent for 1975 to 1977.1

 

With this growing population of cancer survivors, there is a large and growing need for systems and programs to meet the ongoing survivorship care needs of these patients—a distinct phase of the oncology care trajectory—and oncology nurses have a big role to play in such systems and programs. 

           

Key opportunities for oncology nurses in survivorship care include:

  • Disseminating information and coordinating care;
  • Connecting patients with the community and existing resources;
  • Spearheading survivorship activities within their own clinical setting; and
  • Providing public and professional education on survivorship care.2

 

Although there are costs to implementing survivorship programs, such as time and staff resources, there are important benefits to patients. Research has shown that survivorship care programs help patients feel more informed; and that having survivorship care plans encourages patients to share the information and recommendations from those plans with their primary providers. Care plans also help patients make healthier lifestyle choices related to diet and exercise. 

           

The following is an overview of key elements of our plan at New York University Langone Medical Center.

 

An Integrated Model

At the Laura and Isaac Perlmutter Cancer Center at NYU Langone, we chose to develop an Integrated Model Survivorship Program that provides ongoing care in the patients’ existing practice and transitions their care back to primary care using survivorship care-focused visits. After a review of the literature and best practices, the program was designed to address regulatory requirements, work without the need for additional staff, and most importantly, meet patient needs. 

           

The familiar health care team is involved in the survivorship process, including the nurse practitioner or registered nurse who is part of the treating team that follows the patient through treatment and post-treatment. Their knowledge of the patient aids in determining the right time for the patient to transition back to his or her primary care provider. 

           

Patients are identified for the program when they finish treatment—chemotherapy, radiation therapy, or surgery. At that time, a survivorship visit is scheduled, which includes meeting with a nurse or nurse practitioner, a nutritionist, and an integrative practitioner. Nutritional needs and weight control along with general wellness needs are major concerns of cancer survivors. With the expertise of the whole team, we created resources to promote a healthy living lifestyle. The nutritionist and integrative practitioner are integral parts of the program.

           

The program has been developed in a way that each major treatment modality—medical oncology, surgical oncology, and radiation oncology—can refer patients for survivorship visits. However, most often the medical oncology team is the leader. Multidisciplinary team involvement and collaboration are important features of our survivorship program. 

 

Before & at the Visit

The day before the survivorship visit, the nurse or nurse practitioner completes a treatment summary report with the patient. Both patient and staff know one another—and are familiar with the patient’s treatment—making for a smooth transition. Auto-populated data from the electronic health record is used as much as possible to decrease the time commitment for completing the treatment summary. 

           

When the patient arrives for the appointment, he or she completes a self-assessment using an electronic tablet. Information from the assessment is sent via email to the NP or RN, the nutritionist, and the integrative health practitioner, so that everyone on the team has an understanding of what the focus of the clinical interactions were for that survivorship visit.  Common areas addressed include fatigue, cognition, pain, sexuality, infertility, menopause and related symptoms, exercise, weight gain, diet, and smoking cessation. At the time of the visit, the treatment summary and care plan is given to the patient and can also be shared with the primary care physician or referring providers. 

 

Treatment Summary & Care Plan

Treatment summaries and care plans serve as tools to improve communication and coordination of survivorship care. Key components of the treatment summary include the type of cancer, tumor characteristics, cancer stage, and treatment modalities, such as chemotherapy drugs and dosages, radiation fields and doses, and type of surgical procedures (specific to each patient). Other information may include clinical trial enrollment. Because the treatment summary is integrated into the electronic health record, each discipline can add to the summary.

           

The Survivorship Care Plan contains information from treating providers and their recommendations for cancer surveillance, as well as health maintenance recommendations. One aim in the ongoing development of the Survivorship Program at NYU Langone is to work with the disease management groups to standardize general recommendations for surveillance and health maintenance. 

 

Outcomes, Barriers, & Benefits

Using an integrative model for implementing the survivorship has proven positive outcomes. It leverages existing resources in the disease-specific model.  The integrated survivorship care program at NYU Langone allows for individual practices to determine patients’ survivorship program timelines and address specific needs. A decision to transition care to primary care is the decision of the care team, always including the patient and family members.

           

Some providers as well as patients are reluctant to transfer care to primary care providers because of concerns that the recommendations in the survivorship care plan or other national guidelines will not be followed. Decreasing frequency of visits with oncology specialists may be part of this transfer of care to primary care. Another factor to consider is time constraints of existing nurse and nurse practitioner staff in the practice to ensure they are effectively able to manage survivorship visits.

           

While there are obstacles to implementation of survivorship care plans, there are clear benefits to patients. Studies have shown that survivorship care plans help patients. The end of treatment is a time of relief and hope for patients, but also a time of stress. Having a treatment summary and a survivorship care plan helps patients feel more informed and makes it easier for patients to share information with their primary care providers.

 

The care plans also help patients make healthier lifestyle choices in terms of diet and exercise. The post-treatment period is a time for patients to regain health and improve health through healthy behaviors and lifestyle changes.

 

As oncology specialists, we can help patients reach their goals faster and more efficiently by using survivorship care plans.  

 

GERMAN RODRIGUEZ, RN, MSN, is the Associate Director of Clinical Operations at New York University’s Langone’s Laura and Isaac Perlmutter Cancer Center, where he oversees all ambulatory clinical operations for the center and its affiliated sites. He has been a nurse for 28 years, working in oncology for the past 15. His recent work has focused on nursing administration, specifically in process improvement projects, informatics, and innovative activities.

 

THELMA MYERS NAVARRO, MSN, FNP-BC, OCN, is a nurse practitioner at NYU Langone’s Perlmutter Cancer Center. She works collaboratively with medical oncologists to manage care for patients with breast cancer. She holds the following certifications: Oncology Certified Nurse, Clinical Specialist in Medical Surgical Nursing, Family Nurse Practitioner, and Nurse Executive; and she holds the following licensures:  Family Nurse Practitioner and Registered Professional Nurse. She has published research on critical care, human immunodeficiency virus disease, and the psychosocial aspects of end-stage renal disease.

 

MARLEEN MEYERS, MD, is Assistant Professor of Medicine at NYU School of Medicine and Director of Survivorship at NYU Langone’s Perlmutter Cancer Center. Her clinical practice is devoted to medical oncology with a focus on breast cancer and survivorship. She published clinical research in oncology; and she also serves on several hospital committees and speaks at community outreach programs on breast cancer and survivorship.

 

REFERENCES

     1. American Cancer Society:  Cancer treatment and survivorship facts and figures 2014–2015.  Atlanta:  American Cancer Society, 2014.

     2. Grant, M., et al (2010).  Oncology nurse participation in survivorship care.  Clinical Journal of Oncology Nursing, 14(6).  DOI 10.1188/10.  CJON.  709-175

           

 

 

 

Tuesday, March 24, 2015

BY CHRISTA ROE, BS, RN, OCN
 
CHRISTA ROE BS, RN, OCN, is an oncology nurse in the Malignant Hematology Department at H. Lee Moffitt Cancer Center. She is a primary nurse within the lymphoma team. Her clinical and research interests are T cell lymphomas and cutaneous T cell lymphomas. She is pursuing an advanced registered nurse practitioner degree with a concentration in adult gerontology.
 
Just as Da Vinci and Rembrandt practiced their artistic genius with the paintbrush, Hippocrates and Nightingale practiced their art of medicine and nursing through exceptional interpersonal skills. As a primary hematology and oncology nurse working at a National Cancer Institute-designated center, I have discovered that human-to-human interaction is still the most critical component of medical and nursing practice. I currently practice in an academic tertiary setting and consider myself privileged to provide care to patients diagnosed with T-cell lymphomas, leukemias, and other rare hematological diseases.
 
At initial presentation, my patients often exhibit a sense of fear, hopelessness, and disappointment in their previous care. Patients tell me stories that reflect a diminished quality of life after the onset of their illness. After the patient’s first visit, once a human connection has been established, most patients become physically calmer. A trusting relationship begins to grow, which evolves throughout their care.
 
Interpersonal skills, including direct eye contact, face-to-face verbal communication, active listening, and physical touch, are crucial to this relationship. These human skills are the best tools to communicate genuine care with invested interest in the patient’s best outcome.
 
Enter Technology…
Modern day health care is synonymous with technology. A report titled, Crossing the Quality Chasm: A New Health System for the 21st Century, published by the Institute of Medicine, in 2001, made an urgent call for fundamental changes to health care in the U.S. to improve quality, promote evidence-based practice, and strengthen clinical information systems.1

In 2004, President George W. Bush set a goal that electronic health records be implemented for all Americans by 2014. President Barack Obama supported and offered financial incentives for health care institutions to adopt the implementation of electronic health records through both the American Recovery and Reinvestment Act and the Health Information Technology for Economic and Clinical Act.
 
The National Healthcare Information Network (NHIN)—a set of standards, services, and policies that enable the secure exchange of health information over the Internet—was established in 2009 as part of the Health Information Technology for Economic and Clinical Health Act.2 Its intention is for broad implementation of the network to enable the secure exchange of health information using national standards, will help improve the quality and efficiency of health care.3
 
Standardization, Organization, and Efficiency
Medical informatics has helped create standardization of care for patients seen by all health care team members. Based on my experience, electronic clinical information systems do enable more organized and detailed patient charting, which facilitates communication among providers and promotes continuity of care. 
 
Electronic health records allow health care providers to create and systematically store detailed patient histories, as well as physical, medication reconciliation, and demographic records. Institutions use a standardized language for entering patient information into the records and incorporating clinical pathways specific to that institution. Electronic health records are efficient and have received much support from both the government and health insurance agencies.
 
The Paradox
But, I find these systematic technological advances paradoxical. As I interact with patients for most of my waking hours, I realize that every patient is different. Technology allowed Watson and Crick to identify the structure of the DNA. Their findings taught us that every individual is unique right down to the strands of their double helix. When contemplating the future for my patients, my fellow health care professionals, and myself, it seems quite hazy.
 
A system that was created to provide equal care for every individual does not afford the same opportunity for the very sick or high-risk patient populations.  This system forces patients to expect the best services for their money but doesn’t provide the necessary tools to render the best quality of care. Physicians and nurses are forced to spend more time interacting with computers than directly interacting by educating patients and supporting their needs. Shortcuts have been made to bypass the annoyances of the electronic health records.  Ready-made templates that meet all needed documentation requirements are made but never meet the patient’s unique needs and sadly are not patient-specific.
 
I have learned from my experience as a nurse that my patients are not products or goods—and excellence in providing their care is not easy to judge or individualize. For me, the questions grow exponentially every day: Do pay for performance, standardized health care systems, and health care cost reimbursements allow for health care providers to practice the true art of medicine or nursing? Will these standardized systems allow me to practice my calling and mission to humanity?
 
I find myself wondering: with all the advances in technology, why are patients still being misdiagnosed or under diagnosed? At what point does technology interfere with the connection between human interaction and the forming of a trusting provider-patient relationship which is the foundation of health care?
 
The Nurse’s Paint Strokes
As a painter takes the brush and uses strokes unique to his talent, physicians, nurses, and other health care professionals interact with their irreplaceable acquired interpersonal skills. At what point does the click of a mouse, video chat, or an electronic questionnaire replace look, listen, and feel? At what point does human interaction become lost in cyberspace? How will the art of medicine and nursing be affected by technological uniformity and standardization?
 
Over the centuries, artists were not forced to follow the expert opinions of the economist to mass produce their works in a systematic and uniform way. In fact, the quality and rarity of artists is what makes their talent so monumental. I ponder the future advances of technology, and where this leaves the provider of health care. What makes our talents so specialized and needed?  And what does this mean for the patient who presents with a rare or almost unheard of disease?
 
REFERENCES
 1. Institute of Medicine (U.S.) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (U.S.); 2001. 
 2. Hebda T, Czar P Handbook of informatics for nurses & healthcare professionals. 5th ed. 2013; 314.
 3. The Office of the National Coordinator for Health Information Technology: Get the Facts about The Nationwide Health Information Network, Direct Project, and Connect Software. PDF Accessed via
www.healthit.gov/policy-researchers-implementers/nationwide-health-information-network-nwhin