Healthcare: Health Insurance and Fraud E. Ethical

Fraud, Waste and Abuse in the Medicare System: A Proactive Approach Course Project Outline Team A: The Prairie State Bulls Julie GIldemeister Elena Hallars Teresa O’Brien Latia Phelps Laura Wimberley HSM 546 Health Insurance and Managed Care Vernice Johnson-Warren Keller Graduate School of Business Management March 17, 2013 Synopsis We propose to discuss the problem of fraud, waste and abuse in Medicare and Medicaid from the viewpoint of a board of directors of a community healthcare system.We agree that a proactive course of action, while initially more expensive, will result in a far better outcome for the system, its providers, and its patients. It will lead to better relations not only with the government but also with our commercial MCO plans. This issue will be addressed on several fronts: legislative loopholes, weaknesses in electronic technology, ethical lapses on the part of providers, and enforcement failures. I. Executive Summary A. Environment B. Rules and regulati ons of Medicare and Medicaid C.Healthcare Reform Legislation D. Problems with Fraud E. Ethical Considerations of Fraud II. Problem Statement A. Fraud, waste and abuse in the Medicare and Medicaid system B. Legislative loopholes C. Weaknesses in electronic medical records D. Ethical lapses in providers E. Common errors in billing and coding F. Enforcement failures III. Literature Review A. Course text B. Fraud, waste and abuse of Medicare/Medicaid funds C. IT and EMR issues D. Ethical training of providers E. Enforcement failures IV. Problem Analysis A.Identification of opportunities for fraud in a healthcare system B. Enforcement of Medicare/Medicaid claims reporting regulations C. Counteracting or preventing a climate of fraud waste and abuse V. Solutions and Implementation A. Streamlining enforcement efforts B. Tightening IT loopholes C. Creating provider incentives for responsible behavior in coding and billing D. Pattern review and claims review to catch trends indicative of fra ud, waste or abuse VI. Justification A. Cost of fraud, waste and abuse, especially in Medicare claims reclamation processesB. Cost of failure to comply with rules and regulations C. Improvement in facility/provider/payer relations D. Improvement in cash flow and claims payment E. Improvement in patient and community relations VII. Conclusion VIII. References Aldhizer III, G. R. (2009). Medicare and Medicaid Fraud and Errors: A Ticking Time Bomb That Must be Defused. Journal Of Government Financial Management, 58(4), 12-20. Boerner, C. M. (2010). 60 Minutes Story on Medicare Fraud. Journal Of Health Care Compliance, 12(1), 29-65. Dietz, D. K. , & Snyder, H. 2007). Internal control differences between community health centers that did or did not experience fraud. Research In Healthcare Financial Management, 11(1), 91-102. Evans, R. D. , & Porche, D. A. (2005). The nature and frequency of medicare/medicaid fraud and neutralization techniques among speech, occupational, and physical the rapists. Deviant Behavior, 26(3), 253-270. doi:10. 1080/01639620590915167. Hambleton, M. (2011). Los Angeles Health Care Fraud Prevention Summit: Moving from a Sickness to Wellness Model of Compliance.Journal Of Health Care Compliance,13(1), 19-24. Hoppel, A. M. (2012). Career Code Red. (Cover story). Clinician Reviews, 22(10), 1-8. Kongstvedt, P. R. (2007). Essentials of Managed Health Care (5th ed). Sudbury, MA: Jones & Bartlett. Moses, R. E. , & Jones, D. (2011). Physician Assistants in Health Care Fraud: Vicarious Liability. Journal Of Health Care Compliance, 13(2), 51-75. Robin, D. W. , & Gershwin, R. J. (2010). RAC Attack—Medicare Recovery Audit Contractors: What Geriatricians Need to Know. Journal Of The American Geriatrics Society, 58(8), 1576-1578. oi:10. 1111/j. 1532-5415. 2010. 02974. x Sparrow, M. K. (2008). Fraud in the U. S. Health-Care System: Exposing the Vulnerabilities of Automated Payments Systems. Social Research, 75(4), 1151-1180. Steinhoff, J. C. (2008). FORENSIC AUDITING: A Window to Identifying and Combating Fraud, Waste and Abuse. Journal Of Government Financial Management, 57(2), 10-15. Thorpe, N. , Deslich, S. , Sikula, S. , & Coustasse, A. (2012). Combating Medicare Fraud: A Struggling Work In Progress. Franklin Business & Law Journal, 2012(4), 95-107.

Lushoto

Lushoto Helen Kejo Form 1 m 2012 TABLE OF CONTENTS TAFORI—————————-pg 3-5 Sakarani Vine yard——————-pg 6 Irente Biodiversity Reserve—————pg 7-8 Irente Biodiversity Reserve’s History—– pg 9-10 Irente children’s home——— pg 11-12 Irente School for the blind——– pg 13-14 Hiking Mount Usambara—– pg 15-19 The experience——- pg 20 In town—– 21-23 Soni falls——–24-25 TAFORI Lushoto Silviculture Research Centre (LSRC)The Centre is in Lushoto District, Tanga Region. It carries out forestry research in four departments namely; Forest Plantation Management and Agro forestry, Forest Ecology, Forest Genetics and Forest Protection. Forest Plantation Management and Agro forestry is responsible for conducting research related to plantat ion forestry and agro forestry. Forest Ecology mainly deals with research in Botany, Herbarium and Natural Forests. The forest Forest Genetics has two sections namely: Seed and Nursery and Tree Breeding.Seed and Nursery section is responsible for seed establishment of trials (species and provenances selection), collection, extraction, storage, and distribution and rising of seedlings while Tree Breeding is responsible for trials maintenance, data collection and evaluation of trials. Forest protection deals with research and consultancies on Entomology, Pathology and Fire Protection. Left: A forest in Lushoto. Right: Tree breeding. The Centre also has established a Desktop publishing unit with the objective of providing services related to typesetting, printing, and binding of documents.The unit provides services to TAFORI itself, Government institutions and other private institutions including individuals. TAFORI’S HISTORY TAFORI- Tanzania Forest Institute. TAFORI started by the Germans in 1902. A number of experimental plots established at that time can be seen today. In 1928, the British renamed the Amani Research Station to the East African Agricultural Research Station. In 1948 the Amani station was moved to Muguga – Kenya, to form the East African Agricultural and Forestry Research Organization (EAAFRO).The organization catered for research activities common to the three partner states. Research problems unique to the individual countries were attended to a national basis. This led to the establishment of the Silvicultural Research Station in Lushoto in 1951 and the Timber Utilization Research Station in Moshi at the same time. Following the collapse of the East African Community in February 1977, an immediate need to fill the vacuum became the apparent, as the two stations established in the early 1950’s were not well placed to act in EEAFRO’s stand. Sakarani VineyardTropical vineyard This one-acre vineyard is part of the St. Benedict's Religious House Sakarani near Soni in the Usambara Mountains in northern Tanzania. It's one of very few tropical vineyards at approximately 5 degrees south. Problems with growing wine grapes in the tropics include too short days and an unfavorable climate overall (too hot). This being in the mountains, at least the heat hurdle is partially overcome. They grow Chenin Blanc, which is the most commonly used white grape in South Africa, as well as a hybrid grape variety for their â€Å"port†.They plant grapes here and later on the grapes are used for wine. They make both sweet and white wine. Irente Biodiversity Reserve Irente Biodiversity Reserve is a nature reserve with a difference. Owned and managed by North-Eastern Diocese of the Lutheran Church in Tanzania, it incorporates both environmental conservation and sustainable organic agriculture. The Usambaras are one of Conservation International’s World Biodiversity Hotspots – that is, they are recogniz ed as an area with exceptional diversity of species.There is a project here to restore this biodiversity by replanting trees, shrubs and climbers native to the Western Usambaras. This in turn will attract more birds, butterflies, reptiles and small mammals. MORE INFORMATION: | Irente Biodiversity Reserve (former Irente Farm) is situated in the western Usambara Mountains, 5 km from Lushoto. It belongs to the north-eastern diocese of the Lutheran church in Tanzania. On the property there is an orphanage (Irente children’s home), a school for the blind (Irente school for the blind), and Rainbow school (a school for mentally retarded and autistic children). The farm is 200 ha with plantations of pines, eucalyptus, wattle and silver oak, interspersed with pastures and plots of maize and beans. There is a dairy herd, which supplies milk to a small-scale cheese, butter and quark production. Goat cheese is also produced. In addition rye bread, an assortment of jams and juices bring a n income. | The farm has a policy of biodiversity restoration that is to replant the rainforest that once existed here. | The climate is mild since the farm lies at 1400 m with a rainfall between 1000 and 1200 mm. The Irente viewpoint with a view over the Maasai Steppe is only 2 km away. | The foods produced at Irente Biodiversity Reserve IRENTE BIODIVERSITY RESERVE’S HISTORY The origin of the name Irente is obscure. Irente was one of the experimental coffee estates established in 1896 by the German colonial government? s plantation company (Deutsche-Ostafrikanische Plantagengeschellschaft). Other estates established in the same year were Gare, Maweni, Sakharani, and Mazumbai. The aim was to test coffee as a crop, but due to soil infertility, coffee as a plantation crop was abandoned by 1914.The Germans lost the colony to the British in 1918, and it was probably after this that Irente coffee estate came into the hands of a Greek farmer, Mr. W. J. Tame. By all accounts Mr Tame was a diligent farmer; he had 60 acres of coffee trees, a bacon factory and a dairy producing cream. With the coming of independence for Tanganyika in 1961 Mr. Tame sold up to the DKMS (Lutheran Church) for ? 25,000. The Lutheran church of Tanganyika converted the bacon factory into the Irente Mental Hospital and these patients worked on the farm in order to produce food in support of the hospital.Over the years different managers developed the farming infrastructure, and milk production started with the introduction of Fresian-type cows. However, farming never really showed a consistent profit, the excuse being drought or too much rain, diseases of crops and cattle, and low prices for produce. In 2004 all foreign assistance to Irente was stopped, but the reserve (as it is now called) had found its niche relying on four pillars †¢ Nature based tourism †¢ Food processing †¢ Biodiversity protection †¢ Farming The cows at Irente Farm; they are used for dairy produc ts.The enterprise has become more profit-oriented and conservation-centred, as it is indeed an income generating enterprise of the North Eastern Diocese of the Evangelical Lutheran Church of Tanzania (Ned ELCT). On the property there are now 3 institutions, Irente School for the Blind, Irente Children? s home, Rainbow school and Irente church. Irente Biodiversity Reserve seeks to integrate conservation, production and rural development by a mix of activities, taking into account the importance of both people and biodiversity. AREA: 200 hectaresHEIGHT: 1450 metres above sea level RAINFALL: 800 to 1280 millimetres (average 1060mm) TEMPERATURES: minimum 10 degrees (July- August) maximum 30 degrees (January-February) Irente Children’s Home Irente Children’s Home (hereafter abbreviated ICH) is an orphanage that has been operating for more than four decades in north eastern Tanzania. The orphanage is run by the Evangelical Lutheran Church in Tanzania; North-Eastern Diocese ( hereafter abbreviated ELCT-NED). ICH is one among nine institutions with a social service orientation run by the ELCT-NED.The diocese is acknowledged for having a long tradition of diaconic work, both in institutional form and in congregations. The first photo shows where the children live. The last photo shows one of the children. Other institutions with a social service orientation include: Irente School for the Blind, Kwemhafa and Hekalungu homes for Lepers, Bangala Lutheran Junior Seminary, Lwandai Secondary School, Bumbuli Hospital, Lutindi Mental Hospital and Agricultural Training at Irente Farm. Moreover, seven parishes within the diocese are running dispensaries. ICH has the capacity of receiving 35 children.They live in a u-shaped building where they are divided in 4 rooms according to age. Other people living at ICH are girls who attend a 2-year pre-nursing course. The ICH staff consists of nurses, nurse attendants, a cook, a laundry man, gardeners, watchmen, a secretary, an accountant and a driver. Often there are girls from abroad (mostly Germany) who stay at the ICH for around 3 months and work as volunteers. IRENTE SCHOOL FOR THE BLIND When someone comes in contact with a blind person, many thoughts run through their head as to how blind people get their daily lives. You might be wondering, how that can be true.But the answer to that is that through blindness, people have come to the realization that even though physical eyes don't see, one can still see with eyes of his/her heart. When it comes to the challenges and struggles of being blind, there have been many, but one way or another they have been able to overcome them. All through primary school years people assumed that being blind would hinder from getting a good education, much less going to the Universities. | Irente School for the Blind| There is a growing awareness among communities that the education which blind children are receiving is helping them.They are receiving a quality educa tion which can prepare them to compete in the high demanding techno-economy and society of the 21st Century. Children demonstrate their skills North Eastern Diocese- ELCT through Irente School for the Blind insures that blind children have the opportunity to become capable in the alternative techniques coping with blindness; they should develop constructive attitudes, and be given a quality education. Through efforts undertaken there are some problems which we wished to address as follows to compete successfully.Irente School for the Blind needs, Renovation of Dormitories and Staff houses, cultivation of 10 acres out of the 50 for food crops, computers installed with dolphin pin, Academic books and teaching aids, Boys Dormitory and Secondary for inclusive education from class 1 to class 4. Finally, we were all too aware of the appalling failure of the teacher training programs to sufficiently prepare their students to teach blind children; even more important in preparing student te achers to work with blind children in the classroom.However availability of quality field placements for students in training is a truly serious problem but now Sebastian Kolowa University College (SEKUCo) has such training is available. It will not fate these students to go into the classroom and deliver the same miserable educational services that blind children where receiving. HIKING†¦. Mount Usambara The Usambara Mountains are a mountain range in North-East Tanzania, approximately 70 miles (110  km) long and ranging from 20 to 40 miles (64  km) in width.Mountains in the range rise as high as 8,000  ft (2,440 m). They are part of the Eastern Arc Mountains, which stretch from Kenya through Tanzania, and are one of the world’s Biodiversity hotspots. The range is accessible from the towns of Lushoto in the West, and Amani in the East. The Usambaras are commonly split into two sub-ranges, the West Usambara and the East Usambara. The East Usambara is closer to the c oast, receives more rainfall, and is significantly smaller than the West Usambara.The Usambaras Geology and ecology The Usambaras are fairly unique in that, being in East Africa, their unspoiled regions are covered in the tropical forest, which today remains mainly in the West of the continent. The mountain range was formed nearly two billion years ago and due to a lack of glaciations and a relatively consistent climate, the rainforest has gone through a long term and unique evolution resulting in an impressive amount of endemism and an old growth cloud rain forest (Lovett 1993[1]).West and East Usambaras are large ranges of Precambrian metamorphic geologic formations of acid-gneisses, pyroxenes and amphiboles. These mountains were formed by faulting and uplifting creating the drainage system of troughs that form many watersheds, which provide water to a majority of the population of northeast Tanzania (Lundgren 1980). Considered tremendously significant ecologically, there are many protected zones throughout the range, which are being expanded and contributed to by the Tanzanian government, associated NGO's and research teams, and donor countries such as Norway.Several species are endemic to the Usambara forests, including the Usambara Eagle-owl, the Usambara Akalat, the Usambara Weaver and the tree Calodendrum eickii. Human history Historically the Usambara Mountains have been inhabited by the Bantu, Sambaa, and Maasai people who were a mix of agriculturalists and pastoralists. In the late 18th century, German colonialists came to the area bringing with them a mix of cash crops like lumber trees, coffee, tea, and quinine, and also designated forests as reserves for either water conservation or timber use (Rogers 2009).They also brought a slew of new, western ideas which were, in many ways, diametrically opposed to traditional beliefs such as coexistence with the forest versus forest as a â€Å"separate wilderness†. The result of colonialism was a mass ive change in the way forests were perceived in the community, and conversion of traditional agriculture to cultivating cash crops such as quinine, pine trees, bananas, maize, tea, and coffee. The people in Lushoto Development and tourism Today, the population of the Usambaras has one of the highest growth rates (about 4% compared to the national average of 2. %), a staggering amount of poverty and highest densities of people in all of Tanzania. Most of the inhabitants are subsistence farmers who rely heavily on the forests around them for timber, medicinal plants, clearing for agriculture, and fuel wood. Furthermore 70% of the original forests cover of the West and East Usambaras has been lost. Major land and forest degradation remain a pressing issue. However, there are still many places that attract tourists looking for an adventure off the beaten path.These include the bustling trade town of Lushoto, the once popular German resort Amani Nature Reserve and farm, and Mazumbai Univ ersity Forest, which is considered the last example of a pristine forest in the East Usambaras. The experience To say the truth most of were tired on the first few minutes because the hill was steep. I was one of the people in the front but found myself one of the last ones to reach the peak. It was a long walk and very tiring. We stopped like three times to take a rest and we were stopped once by these scary people.They said that they told Fredericka and her other friends but they wouldn’t stop and also something about scaring monkeys off. After the mess was cleared, continued with our walk. We took pictures when we reached our last checkpoint. We finally reached the peak. Some of us engraved our names on the hut’s floor. I wrote: â€Å"Helen was here!!! † The walk down was longer than the walk up, which is not supposed to happen. We walked around the mountain and when we finally reached our destination, we found out that we walked to the football pitch where w e played football a day ago.We were exhausted! Bhoke, Ms. Sandra, Marco and Nancy were the last ones to reach the football pitch. IN TOWN After the hike, we dropped of the boys at the place they were staying (Tumaini) and we girls were dropped off at our hotel (Lawns). We cleaned because we were all so sweaty! Later the bus came with the guys in it and we headed for town. We were going to interview local people about their jobs and what profit they get. Lushoto town When we were in town, we paired ourselves into groups that didn’t exceed three people.I paired myself with Amanda since she talks a lot and she was perfect material for interviewing people†¦ We first interviewed a middle aged woman with a baby who was selling charcoal. She did not look like she was in good state. It was raining and the charcoal was getting wet since it’s not good for charcoal to be wet not any customers wear buying her product. I could see that she had influenza. I asked her how she go t it and she said, â€Å"Mkaa unatimua vumbi tukiwa tunachota. † Meaning: â€Å"Charcoal dust rises when being drawn. †She also told as that she only makes 500 tz shillings in a day, which isn’t enough to support her family. She has five children and no husband. We then proceeded and went to a salon that up a hill. The ladies in there, at first didn’t want to give us information but when we introduced ourselves she felt more secure. I didn’t really feel sorry for her because she made 100,000 tz shillings, which was enough since she had no family to support. After that Amanda, Cynthia, Tracey and I became a group. We went to interview bartenders. They went making any money at all since there has been no customer since they opened.We then went to a bar and met up with four bartenders. We interviewed them and they said that there has not been a customer since morning and they have not made any money. After six interviews we called it a day and went ba ck to our hotels. The lawns hotel SONI FALLS The Soni Falls is a waterfall in the Usambara Mountains of northeastern Tanzania, near the village of Soni, to the northeast of Kitunda. The falls lie at the end of the Mkuzu River where it joins the Bangala River. The falls lie in the southern part of the West Usambaras Lushoto Mountain Reserve.Soni falls is a beautiful and calming place. I enjoyed sitting on the rocks and watching the water pour. Some of the rocks were slippery and at a point Asymwe was stuck because she was scared to move due to the slipperiness of the rocks. We also took pictures here and we even drew the waterfall. It was a pretty way to end the trip but kind of sad because we will never be here again as a class. The boys were dropped off at Tumaini Hostel and we went to Lawns. It was our last day in Lushoto and we partied!!! We ate and drunk and danced and laughed! We had so much fun. BYE -BYE LUSHOTO

Electronic Medical Records

Electronic Medical Records Essay Cynthia Jones Grand Canyon University: HCA 450 November 11, 2012 Electronic Medical Records Essay Medical record keeping has change in the last couple of decades. In the past patients records were kept in a file on paper taking up excessive room. In the past, paper charts were the only means of keeping a patient’s medical diagnoses documented. Some of these charts are still used today in healthcare facilities, however they are slowly being replaced with a more advance method; electronic medical records (EMR’s).This virtual data–information center can serve as a vehicle to promote and to disseminate standardized data definitions and best practices to providers, consumers, and others interested in quality improvement efforts nationally and internationally (Varkey, 2010). The Electronic Medical Records is an advance computerizes medical record system that delivers medical data for physician’s office and hospitals within a matt er of seconds while offering care. This system allows the healthcare staff and physicians to modified, store and retrieves patient’s medical records.Electronic medical records are legible and organized. The Electronic Medical Record (EMR) has been around since the late 1960‘s, when Larry Weed introduced the concept of the Problem Oriented Medical Record into medical practice (NASBHC, 2012). Weeds innovation introduces the concept of the Problem Oriented Medical Record into the medical practice, which verifies the diagnosis (NASBHC, 2012). However, it wasn’t until 1972 when the Regenstreif Institute developed the first medical records system. Although it was a great invention, physicians didn’t seek to use it right away.This new system would help physicians improve patients care. Although, $19 billion in stimulus funds have been invested into the Electronic health record (EHRs) another name for EMRs; the Obama administration highly suggested that health car e and hospitals facilities start to digitize patient data and start making better use of the advance technology(Greenemeier, 2010). The health care industry has been slow to adapt to this new system. Although the EMR system is intended to make patients records more accessible for the physicians and staff, still many have not implemented it yet.Given the lack of EMR adoption throughout the health care industry, less than 10 percent of U. S. hospitals have adopted electronic medical records. Cost is the primary reason many have resisted or are unwilling to adopt the EMR system and shortage on staff as well. In a recent interview on November 9, Jessica in human resource at Vineville Internal Medicine, with Dr. Mary Bell Vaughn presiding as the physician over the practice. The practice has been using electronic medical records systems since the practice open in 2002. Dr.Vaughn thought patients and staff needed easy access to their records when needed. Some of her other reasons are as fo llow: †¢ Paperless, Less storage †¢ No physician running around ( Patient info available at finger tips) †¢ Saves time spent with patient †¢ Good for tracking information †¢ Financial Good This system is web based and uses an E-Clinical program through a portal. This system also allows prescriptions to be sent to the local pharmacy as well. Blood work results are also put into the patients charts as well.Recently, the practice took on new patients with paper charts, because their physician retired. In this cause their most recent charts were converted over to EMRs. However those paper charts still exist in a small storage area if further information is needed on the patient. Though the practice implements the EMRs system from the very beginning, the physician and staff are very happy with the system. Most patient information is put into the system via computer on the spot while the patient is telling the nurse or physician what is ailing them.Although there system is a web based system, it has two backup systems in two different locations just in case the systems go down or power outage. The EMR system has had great quality impact on the practice. The patients care has been improve by the system. It allows the physician to track and effectively treat the patient. In some cases if the patient is located at another healthcare facility this system allows them to send information to multiply people for care, no matter where they are. Dr.Vaughn’s practice is already looking into the future to implement sending out text message to patients to inform them of appointments. Patients have access to their care anytime. EMR adoption is slow to be implemented into some practices. Although there is some disapproval of the electronic medical records today, it is merely a digitized version of paper chart. This system will reduce medical errors and help put information in front of researchers This new form of technology is here to stay and the s ooner healthcare facilities start using it the more efficient results they will receive.References Prathibha Varkey (2010). Medical Quality Management, Sudbury, Massachusetts: Jones and Bartlett Publishers. History of the Electronic Medical Record system (2012) Retrieved November 8, 2012 www. nasbhc. org Will Electronic Medical Records Improve Health Care? (2009) Retrieved November 8 2012 http://www. scientificamerican. com/article. cfm? id=electronic-health-records Electronic Medical Records Engineering Management Field Project Electronic Medical Records: A Case Study to Improve Patient Safety at Royal Victoria Teaching Hospital By Annie Bittaye Spring Semester, 2009 An EMGT Field Project report submitted to the Engineering Management Program and the Faculty of the Graduate School of The University ofK. ansas in partial fulfillment of the requirements for the degree of Master's of Science )= †¢ , , Tom Bowlin Cotntnittee Member ‘~k Committee Member Date accepted: _ _&-4–_':'†/~,,,,,,†1_-. -Q:;,,.. r5c—-_ _ Table of ContentsTable of Contents †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 2 List of Figures †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 3 List of Tables †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 3 Acknowledgments†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ Executive Summary †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 5 1. 1. 1. 2. 3. 3. 1. 3. 2. 3. 3. 3. 4. 4. 4. 1. 4. 2. 5. 6. 7. Introduction†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 Background of Royal Victoria Teaching Hospital †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 Literature Review †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 0 Procedure and Methodology †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 17 Exp erimental Design †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 17 Survey Procedure †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 18 Data Analysis †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 9 Limitations of the study †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 19 Resultsâ⠂¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 20 Reasons why EMR is not being used at RVTH †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 23 Benefits and challenges of EMR†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 24 Summary†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 0 Conclusion †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã ¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 30 Suggestions for Additional Work †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 32 References †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 34 Glossary †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 5 Appendix †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 36 2 List of Figures Figure 1: Sources of funding, RVTH 2008 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 22 Figure 2: Averages ofEMR functions in order of relevance to work at RVTH †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 29 List of Tables Table 1: Number of patients seen at RVTH in 2008 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 Table 2: List of Professionals, RVTH 2009 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 0 Table 3: Computer ownership and previous computer training received by the respondents at RVTH †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 28 Acknowledgments My journey towards my Master's degree was a long and fruitful one. The Engineering Management (EMGT) program has not just exposed me to much information and ideas but also opened a way towards my career path. Thank you to my parents, Ebrima and Lucy who have always been a source of great inspiration and strength to me. They taught me the value ofeducation and their prayers has always been with me.Thanks to my brother, Baboucar who encouraged me to pursue my Master's degree and the never ending support I receive from him. Special thanks to my six year old son, Ebrima for his understanding that I'm at school when I'm not home to read him a bedtime story. I also want to thank all my EMGT instructors especially Professor Herb Tuttle, Dr Tom Bowlin and Ray Dick who worked with me recently, for the wonderful information and feedback they provided on this project. Thanks to Parveen Mozaffar for her extreme support and encouragement during the course of my studies.Thanks to the staff at Royal Victoria Teaching hospital for providing me with all the needed information for this project. Last but not least, my gratitude goes out to Dr Don Anthony Woods. It is because of his influence that brought me where I am today. He always had my best interest at heart and I want to thank him for that. May God bless you! Executive Summary Most countries in Europe and the USA are increasingly using an electronic medical record (EMR) system to help improve healthcare quality. Unfortunately, The Gambia government faces a series of health crises including but not limited to HIVIAIDS, malaria, diabetes and tuberculosis.These diseases threaten the lives of thousands of people. Lack of infrastructure and trained, experienced staff are considered important barriers to scaling up treatment for these diseases. The contribution of this field proj ect outlines the benefits of an EMR system at Royal Victoria Teaching Hospital (RVTH) and how it will improve patient safety. This is a descriptive study using interview questionnaires from officials at the Royal Victoria Teaching Hospital. The study also looks into other facilities in similar developing countries with advanced systems, but not so advanced as to be at the level of state-of-the ­ art facilities in the U.S. Results from this study indicates the importance of an EMR system at RVTH to facilitate effective and efficient data collection, data entry, information retrieval and report generation. As a catalyst for development, the implementation of an EMR system at RVTH may make it one on the best hospitals in the West African region. 5 1. Introduction According to Dick and Steen, Electronic Medical Record (EMR) is the compilation of patient medical information in a computer-based format that allows the collection, storage, retrieval, and communication of this data.An electronic medical record replicates a paper chart and contains both clinical information (diagnoses, allergies, drug resistance and treatments) and demographic information about a patient; it provides a comprehensive medical picture and can be used by clinicians as a tool to determine appropriate treatment for patients. EMR is not only being welcomed by healthcare providers as a way to improve care delivery but also serves as a catalyst and gold standard for development (porter, Kohane, & Goldman; Reifsteck, Swanson, & Dallas).Unfortunately, Africa, a continent faced with many challenges ranging from epidemics, civil wars, and disasters, lacks robust healthcare infrastructure in the form of computerized h ealth care systems. For instance, Ghana has one the best health institutions in the region, Korle-Bu Teaching Hospital. This Hospital, for example, is currently the only institution in the West African sub-region which performs surgery. Due to the quality of outcome, it now receives referrals from most parts of the continent namely the Gambia, Sierra Leone, Liberia, Togo Benin, Tanzania, Nigeria, Cameroon, Cote d' Ivoire, and Ethiopia.Despite its exemplary performance, the hospital has no computerized information system which can help improve care delivery in the region. Therefore, the purpose of this study is to examine the potential benefits of EMR and its ultimate contribution to improving healthcare delivery development in less developed countries like The Gambia. 6 1. 1. Background of Royal Victoria Teaching Hospital The Gambia is a small country in West Africa, with a population of approximately 1. 5 million. RVTH has been in existence for over 100 years in The Gambia's capita l, Banjul.It used to be called Royal Victoria Hospital until in the late 1990s, when its name was changed to RVTH. The Gambian Government decided that it had to reduce its dependency on foreign doctors by establishing a medical school in the University of The Gambia (UTG). The UTG now uses RVTH to teach its clinical students. In recent years, The Gambia has been doing much on its own initiative to take to improve the healthcare of the nation. There are 540 beds in the hospital and the two largest Departments are Pediatrics and Maternity.The biggest â€Å"killer† disease in The Gambia is malaria, with young children and pregnant women being particularly vulnerable to this disease. Diabetes, high blood pressure, pneumonia and eye problems such as trachoma and cataracts are also major health problems. The following table provides an estimation of how many patients were seen at RVTH in the year 2008. Procedure Inpatient Admissions Children admitted to Pediatrics Patients treated in the Eye Center Out-Patient Appointments Out-Patients in the ER Number of Patients 25,281 9,352 986 over 184,365 24,334 Table 1: Number of patients seen at RVTH in 2008 7Unfortunately, RVTH does not have any EMR system in place to facilitate patient safety. As noted by participants, â€Å"EMR software is not used at RVTH because administration keeps complaining of money. It looks expensive to them and also they are more used to the paper folder†. Currently, information is very fragmented and therefore does very little to help patient safety and consistency in care. Another important issue here is that a large number of these patients are illiterates. To ensure they receive the appropriate treatment, they will have to explain to the physician current medications they are taking etc.This can be a very challenging and fatal to the patient sometimes. The typical paper medical record contains sections including information on demographics, admissions, discharge summaries, progre ss notes, protocols, laboratory results, radiology results, surgical and pathology reports, orders for, treatment and nursing notes. Most documentation regarding treatment of a patient is written directly in the patient's medical chart. On a given day a patient arrives at the hospital for care, sign in his name and waits anywhere from 30 minutes to six hours o get their records pulled depending on the day. Physicians, nurses, medical residents who need access the information in the medical record must wait till it's available. Typically, medical records are transported to the outpatient clinic where the patient would be seen, and then returned to storage center to be filed again. It is necessary for the medical record to follow the patient throughout their visit. If the patient was seen in one clinic where orders were written, it was necessary to physically transport the record when the patient moved to the medicine room for treatment. The purpose of this field project is to examine the potential benefits of an EMR system and its ultimate contribution to improving patient safety at the Royal Victoria Teaching Hospital in The Gambia. 9 2. Literature Review The first generation of EMRs was extensions of medical billing systems in large US hospitals. Over the last four decades, they have been used as tools to organize and store medical data. EMRs are widely accepted as important tools to support high quality health care in the US, Europe and other developed countries.Evidence shows that using EMRs that include decision support systems improves quality of care and both reduce medical errors and unnecessary medical investigations (Partners in Health), Experience with the use of EMRs in developing countries, if available, is much more limited than it is in the US and Europe. Now there is considerable interest in using medical information systems to support the treatment of HIV and TB in Africa, Latin America, and Asia. In most African countries, healthcare informati on systems have been driven mainly by the need to report aggregate statistics for government or funding agencies.Such data collection can be performed with simple paper forms at the clinic level, with all electronic data entry done centrally, but that approach tends to be difficult and time ­ consuming and may provide little or no feedback to the staff collecting data. Individual patient data that are collected and accessible at the point of care can support clinical management. Clinicians can easily access previous records, and simple tools can be incorporated to warn of potential problems such as incompatible drugs.Physicians or nurses can check on the outcomes of individuals or groups of patients and perform research studies. Many of these functions will work well on paper or with simple spreadsheets for up to 100 patients but become very time-consuming and potentially unreliable with more than 1,000 records, and virtually impossible with 10,000 or more. 10 Experience with the use ofEMRs in developing countries is much more limited than it is in the US and Europe, but there is now considerable interest in using medical information systems to support the treatment of HIV and TB in Africa.Some examples of EMR use in Africa include: †¢ The Regenstrief Institute in collaboration with Moi University in Kenya developed an EMR for general patient visits to clinics in western Kenya. This system was subsequently modified to support the care of several thousand HIV patients. †¢ Baobab Health Partnership in Malawi has developed an EMR system using innovative, low-power touch-screen PCs for data entry and display. This system is now used to support the care of more than 7,000 HIV patients in the Lighthouse clinic in Lilongwe and has been chosen by the national HIV program for use throughout the country. [email  protected], an HIV medical information system developed for US patients, has now been deployed in Uganda and is planned for use in other African c ountries and in Latin America. (Partners In Health) A wide-ranging literature review of electronic medical record implementation over the past decade reveals that clinical, workflow, administrative, and revenue enhancement benefits of the EMR outweigh barriers and challenges. Among other key efforts, organizations must train and motivate users to navigate EMR systems, as well as develop a common structured language.Clinicians who used CPRs found that electronic 11 access to clinical infonnation saves time and provides a thorough and efficient way to manage patient information To reap the full benefits of an EMR, organizations must redesign current workflows and practices to evolve into efficient providers of care. EMR systems are developed to meet the following goals: improve quality of care, reduce organizational expense, and produce a data stream for electronic billing. (Dassenko and Slowinski).The EMR meets these goals through workflow automation, connectivity, and data mining. ( Gaillour) The Computer-based Patient Record Institute's (CPRI) definition concurred with the other researchers, but added that the EMR provides protection of patient and provider confidentiality, has a defined vocabulary and standardized coding, produces documentation as a by-product of patient care, connects local and remote systems and provides electronic support for secondary users (payers, policymakers, researchers). Fromberg and Arnatayakul) Unfortunately, most EMR systems are unable to offer all of the components defined by the CPRI because †the technology is too complex and too expensive, doctors won't use computers, and standards don't exist. â€Å"(Gaillour) The advantages associated with implementing EMRs are well documented and are straightforward. The difficulty comes with placing a dollar figure to these advantages; consequently, few organizations have published studies describing the actual costs and benefits attained from implementing EMRs. Bingham) The benefit s associated with CPRs are organized into four categories: clinical, workflow, administrative, and revenue enhancement. Renner, states that measuring all the benefits associated with EMRs is 12 virtually impossible, and that it is probably safe to select those that can make the greatest financial difference, and incorporate them into a financial model.Clinical benefits seen after implementing an EMR include: better access to the chart, improved clinical decision making and disease management, enhanced documentation, simplified patient education, and increased free time to spend with patients, accompanied by improved perception of care and quality of work life. These benefits ultimately result in better delivery ofpatient care and safety. Despite all of these benefits, EMRs are not a standard in today's healthcare systems. It is evident that EMR technology is still a hot topic for discussion when browsing through current healthcare technology and management journals.The following bar riers have kept healthcare leaders discussing EMR technology instead of adopting it: cost, leadership, ROI, vendors keeping up with users' needs, and deficits in the following categories: public policy, standards, security, and a true definition. First of all, cost has kept organizations from implementing EMR systems. These costs can be organized into the following categories: software, hardware, infrastructure development and maintenance, implementation, education, planning, and administration.Software costs include development or purchase, maintenance, and upgrades over time, while hardware costs include purchase of workstations. (Mohr) Infrastructure development and maintenance costs include servers, interfaces, workstations, network cables, network maintenance, and help desk operations. Planning costs include development of an implementation plan, identifying measurable outcomes, and choosing meaningful metrics and goals, while implementation costs include training, overtime 13 ssociated with entering patient data, business disruption during transition, employee resistance to change, and lost productivity. Drazen, suggested that leadership was probably a more significant barrier than cost because, in the past, healthcare leaders have raised capital for essential business initiatives such as major building programs, acquiring a physician network, or starting up a managed care organization. This amount of capital is on the same scale as an EMR. Next, Drazen stated that a lack of government support is a major issue holding up EMR implementation.Unfortunately, the federal government does not contribute fmancially to EMR implementation projects. Without standards and structured data definitions, computer systems are not guaranteed to interface easily with each other, and databases are not easily developed. Most individual departments within a healthcare system have already invested in computerized patient information systems; however, these systems are isolated and do not communicate well with one another. Getting these systems to interface is one challenge facing EMRs. Data security continues to be an ongoing challenge.Bergman, found that politicians, consumer advocates, and the general public have voiced concerns about risks to the privacy and confidentiality of patient information. However, when compared with the security of the paper chart, the EMR's electronic audit trails and passwords actually improves internal security. The EMR may be more secure for internal breeches of confidentiality, but must also be protected from external breeches such as hackers, who could potentially enter the EMR from an off-site location and download volumes of 4 confidential information. Firewalls and encryption software are methods used to protect patient data from these violators. Clinicians who use EMRs recognize two benefits: First, electronic access to clinical information saves time. Second, electronic access provides a thorough and efficient way to manage patient information. With EMR systems, comprehensive information can be located and presented in a way that is relevant to the task at hand. Dassengko and Slowinski) The obstacles identified have thus far been insurmountable, but the considerable achievements identified in the benefits section of this discussion suggest that the advantages are well worth the effort. As Lenhart et al state, â€Å"Success comes at the price of considerable effort, persistence and optimism, as well as dedicated leadership. † (p. 114) some organizations that invested in early EMR systems are struggling to show the qualitative benefits promised by vendors because an electronic version of current work processes is not cost effective. Sandrick) â€Å"If the ROI were a function of the information tool itself, the financial benefits would be experienced universally. † (ROI: The White Paper. A Business Case for Electronic Medical Records) To get the most value out of an EMR, healthcare organizations must reengineer the following work processes to make full use of the system: Healthcare organizations must first train and motivate their users on how to navigate and operate the EMR tools. To optimally use the EMR, it must be implemented from registration through billing, thus allowing the organization to realize full potential benefits across the delivery system.These benefits include clear, concise, and comprehensive documentation, greater efficiency, care consistent with best practice guidelines and improved claims processing. 15 It is difficult to measure the economic value associated with less tangible benefits such as higher quality of care, patient service, provider and employee satisfaction, and competitive advantage. It is even more difficult to allocate necessary resources and commit to institutional change when the paper chart is â€Å"getting the job done,† even if it is not in the most efficient style.However, Carlon, suggests that all providers s hould embmce the EMR to deliver safe medical care. The information in the EMR can reduce medical errors to avoid dangerous, sometimes lethal, mistakes. If organizations can't show that EMRs have a positive ROI, they may decide that the EMR is just another expense of running a business. The expense is to improve patient safety and reduce medical errors. This review of literature emphasizes that the use of EMR systems contributes to the ultimate goal of delivering effective care while improving patient safety. 16 3.Procedure and Methodology The study is an exploratory study conducted in Banjul, The Gambia, to examine the potential benefits ofEMR and its contribution to improving patient safety. For the most part, this study is descriptive and categorized as a non-experimental qualitative study. Initial contacts were made with the Chief Medical Director, Development Officer and the Head of Medical Records at the RVTH to solicit participants for the study. 3. 1. Experimental Design Surv ey approach was used to gather data from healthcare professionals who are considered potential users of EMR.Copies of the questionnaires were sent through e-mail to participants. A total of 50 surveys containing 15 questions were sent out and 30 of them were returned. The content of the survey designed was open-ended questions based on the following areas: knowledge of EMR, benefits and challenges of EMR, transition from paper-based system to EMR, security issues associated with EMR use and assistance given to developing countries by developed nations to implement or use EMR. Other areas include, demographic details of respondents based on profession, length of practice, age and sex.The survey questions can be found in the Appendix. Participants were selected based on their level of healthcare training. The population set for the study was healthcare professionals from the RVTH, which includes physician consultants, surgeons, pharmacists, nurses, midwives, pathologists, radiologists , and laboratory technicians. Study participants were limited to these previously mentioned health professionals, since they would be the principle users of an EMRsystem. 17 RVTH has a total population of about 500 professionals and a sample size of 50 was chosen for the study.Since this was the first time such a study was being conducted in the country, there was limited knowledge of professionals on the subject as well as difficulty in getting volunteers to participate. 3. 2. Survey Procedure Survey questionnaires were converted into a PDF file and mailed electronically to all 50 participants on February 2, 2009. Unfortunately, five medical professionals who were initially contacted to participate in the study later declined to take part due to lack of understanding of the survey questions. As a result, different participants were contacted to replace the five individuals to make up the sample size.Since the researcher could not travel to Gambia to facilitate the survey, one of th e administrative officers at the hospital was contacted and helped to distribute hard copies of the questionnaire to all participants. Participants were requested to fill out the attached survey and return it in a sealed envelope to this person or the chief administrator. After three weeks, on February 23, 2009, a first reminder was mailed asking for their cooperation and the importance of returning the survey. A final reminder was sent out on March 9, 2009, to those who might have forgotten to return the survey. 8 3. 3. Data Analysis The 30 completed surveys were coded, sorted, and organized into themes. A spreadsheet was created in MS-Excel to enter all data for analysis. All responses were placed into themes and summarized. The survey responses and themes generated were used to determine result interpretation, recommendation, and future research direction. Despite initial difficulties to get volunteers to participate in the study, 30 out of the 50 surveys mailed were returned on March 16,2009, thus representing 60% response rate. 3. 4. Limitations of the studyDue to the difficulty of getting other hospitals in the area involved, the study was limited to RVTH only_ The findings represent views ofthat hospital alone. However, the research would have been more interesting and challenging if more professionals from other hospitals were involved in the study. Secondly, due to cost of air travel between the United States and Gambia, the researcher was not able to travel to Gambia to collect the necessary data for the study. The inability of participants to respond to some important questions on the survey skewed the data.Finally, due to the six hour time difference between Kansas and Gambia, it was hard to reach the participants at during business hours. Lack of high speed internet or sometimes no connection at all caused the delay in receiving all the responses on time. It was also really difficult to get people to cooperate because the survey was not on their l ist of priorities. 19 4. Results Based on the methodology, surveys were mailed to 50 participants at the RVTH in Banjul, The Gambia. Thirty completed surveys were received which included 15 questions.The results from all participants are as follows: The 30 respondents consisted of 17 males, 11 females and two people who did not indicate their gender. The age range of the group was 25-56. Table 2 presents the professional distribution of participants. No Response represents people who did not include their profession. The five students, however, included final year medical and dentistry students, as well as nursing, and medical laboratory students. Professional experience ranged between 1 and 20 years.Profession Surgeon Pharmacist Physician Radiologist Midwife Nurse Laboratory Technician Student No Response Total Table 2: List of Professiona is, RVTH 2009 Number 3 2 3 2 5 6 2 5 2 30 20 To analyze this result, key words such as computerized, storage and retrieval, were used to determi ne respondents' understanding of the concept of an EMR system. Subsequently, one-third of respondents (33. 3%) who included these three key words were marked as right. While nine people representing 20% who said it is a mechanism for storing patient medical record on a computer were classified as partially right and approximately half respondents (46. %) who just said the use of machine to keep patient medical data were classified as having an idea or understanding of the system. In addition, implementing and running a successful EMR system requires a number of key elements. Accordingly, 15 people identified technical elements such as (electricity, hardware, software, etc. ), 10 stated patient data, while four said adequate trained personnel, and one person indicated the need for money to train staff on EMR. Also availability of adequate infrastructure such as experts to support and train care providers on EMR is very crucial when implementing EMR system.However, more than half resp ondents agreed that enough infrastructures are not available in Gambia to support EMR implementation. On the other hand, 10 people believed that infrastructures are available, while four said available infrastructures are only few. Despite unavailability of infrastructures, 16 respondents reported there are enough computer experts in Gambia to train healthcare providers to use EMR. Seven reported experts are not available; six stated experts are available but too few to meet the demand and needed training requirement of the healthcare sector.Lastly, one person indicated he has no idea of the subject. Responses concerning how much developed nations are assisting less developed countries like Gambia with Health Information Management (HIM) system infrastructure 21 implementation showed diverse opinions. Nine people said developed countries are helping, 15 responded no. However, six indicated that â€Å"the help given from developed nations are not enough and sometimes electronic devi ces sent to less developed countries like the Gambia are inferior and lack quality†.Still others think â€Å"some form of assistance comes in to support the country on information management systems but not much is channeled towards the health sector†. Lastly, seven people reported they have no idea â€Å"if developed nations are helping† and one person did not respond to this question at all. This pie chart below shows the sources of funding and the amounts received for the year 2008. Sources of Funding 2% †¢ Gambia Government †¢ Patient User Charges †¢ Donation Fund †¢ Internally Generated Fund †¢ Global Fund Severe Malaria in African Children FundFigure 1: Sources of funding, RVTH 2008 22 The majority of funds come from the Gambia Government in the fonn of subvention received monthly or quarterly in advance. However, about 70% of the amount goes towards payment of salaries and allowances to approximately 1,200 staff. Other donations re ceived are in the fonn of drugs, equipment, supplies and services which made considerable contribution to the hospital. (RVTH) 4. 1. Reasons why EMR is not being used at RVTH Paper records are bulky and can take up costly space.Filing, retrieval of files, and the re-filing of paper records are very labor-intensive methods with which to store patient infonnation. Plus if a record is checked out for one department, another department cannot access the chart. The impact of not having immediate access to key infonnation in emergency situations can be serious. Paper medical charts also cannot be effectively searched and used to track, analyze, and/or chart voluminous clinical medical infonnation and processes. They cannot be easily copied or saved off-site.Also physician's orders and the corresponding results such as medications and labs can be issued and saved in a comprehensive EMR system. Our literature review and results have proven that paper records are costly, cumbersome, misinter preted, easily misplaced and cannot be used for any meaningful decision analysis. Unfortunately, RVTH does not have any EMR system in place to improve patient safety. As noted-by participants, â€Å"EMR software is not used at RVTH because administration keeps complaining of the lack of money. It looks expensive to them and also they are more used to the paper folder†.Nevertheless, four key issues were identified by participants as the main reasons why RVTH does not have an EMR system in use. 23 Overall, 36% of respondents attributed the problem to lack of resources in terms of personnel and infrastructure, 29% blamed it on lack ofleadership initiative and priority. While 18% reported cost in terms of equipment and training personnel, 15%, however, stated lack ofEMR importance or awareness and fear to change. Lastly, 2% respondents did not give any reason. 4. 2. Benefits and challenges of EMR There are both benefits and challenges to EMRs.Many argue that positive aspects of u sing an EMR system outweigh the challenges. Even though the investments in EMR systems are costly, most argue that over time this outset cost will result in greater savmgs. As well as cost saving, many agree that one advantage of EMR system is that they save space. Instead of keeping huge paper files on patients, all records are kept on computer files. Though someone must store these records in computers, this still represents a small percentage ofthe space required to store physical records. Along with saved space is reduction of paper used by hospitals.Although EMR systems do not render paper obsolete, but they certainly do reduce needed paper significantly. Another advantage of electronic medical records is the ability for all in a health care team to coordinate care in terms of monitoring and treating diseases. This helps avoid duplication of testing, prescribing medicines that in combination might be dangerous and the ability for anyone on the medical team to understand the app roaches taken to a condition. A person with complex health issues may see several specialists, and can easily become confused by overlapping or contrary advice.When specialists and primary care doctors use the same system for electronic medical records, then everyone on the team would be aware of all the other team members' actions and recommendations. Electronic medical records may save time as well. Though faxing and email may assist one doctor to get information from another doctor or a laboratory, there is generally a wait time to receive this information. When a doctor has instant access to all of a patient's information, including things like x-rays, lab tests, and information about prescriptions or allergies, he or she is ready to act right away, thus saving time.This may be particularly helpful in emergency situations where a patient cannot answer questions about medical history or allergies due to extreme illness or injury. Generally, doctors are often considered to have th e worst handwriting, though this is just a generalization, unclear writing can lead to misinterpretations and mistakes. Typed notes and prescriptions are more legible and less likely to create misunderstandings. However, electronic medical records do not rule out the occasional typo. One of the main disadvantages to EMR system is that start up costs is enormous.Not only must you buy equipment to record and store patient charts (much more expensive than paper and file cabinets), but efforts must be taken to convert all charts to electronic form. Patients may be in the transitional stage where old records haven't yet been converted and doctors don't always know this. Further, training on EMR software adds additional expense in paying people to take training, and in paying trainers to teach practitioners. In fact, one concern about the use of electronic medical records is that doctors may have a significant learning curve when these programs are first implemented.A poor 25 typist may a ctually take a long time to input information. Doctors often have to be their own medical clerks especially during an office visit, and a doctor distracted by confusing technology may not be as alert to a patient's symptoms or needs. There is no single electronic medical records source or system, so different hospitals and individual clinicians may not all be using the same program. This negates the possibility of instant information for all on the medical team, since one program may not communicate with another.Another concern is that electronic medical record systems might be hacked and exploited by others. Since one of the first considerations of medical treatment is confidentiality, it may remain a concern about how many people may have access to other medical records which they are not authorized to do so. Misuse of private medical information could create problems for people who have conditions they wish to keep private. Despite these concerns, it appears many hospitals are no w attempting to use EMR systems.It remains unclear how long it will take for hospitals to transition completely from the traditional paper-based systems to a complete paperless environment. As shown from the survey results, it is clear that many participants believe that implementation ofEMR will tremendously improve upon patient in the country. For instance, as noted by one respondent, â€Å"availability of patient past history in electronic format will enable health care workers have information about patients in seconds and with ease which will facilitate quick diagnosis and treatment hence reducing the rate of mortality. 26There is always some level of fear and resistance to change, especially in the healthcare industry. A question concerning the level of acceptability from the traditional paper-based system to EMR system shows that such change will be met with some difficulties. More than half of respondents said the process would be challenging initially, but eventually care providers will accept the system because it will improve patient safety and work performance. Although the majority may still prefer the paper-based system, â€Å"they will change when they see the importance or need for EMR† stated a participant.Others also believe it would be a â€Å"welcome idea†. The adequate protection of patient health record requires limitations at all levels, such as: collection, use, access, and disclosure. Therefore, development of privacy, confidentiality, and security principles is necessary to protect patients' interests against inappropriate access to their health data. Unfortunately, 14 respondents (47%) did not respond to this important question regarding measures necessary to maintain patients' privacy, security, and confidentiality at RVTH.However, 16 people representing (53%), did state that all health records must be securely protected by use of password, data encryption, and access restrictions to users. It is obvious from the surv ey results that effective implementation and utilization ofEMR can improve patient safety in developing countries. Considering training as one of the key elements to EMR success, a question was asked to determine length of time required to train care providers in Gambia on EMR.Almost 50% of respondents indicated it might take 6-18 months depending on â€Å"practitioners' ability to understand the concepts ofEMR as well as the user friendliness of the software†. Others believe â€Å"for 27 current medical students who are already computer literate may take about two weeks, but the older practitioners will take longer time (approximately over a year)†. Table 3, below shows the number of respondents that own a computer or has had some form of computer training in the past. Computer Training Profession Own a Computer 1 1 1 0 1 2 1 2 I Yes 1 1 1 0 2 3 1 7 16

Critically evaluate the impact of social media on the business world Essay - 2

Critically evaluate the impact of social media on the business world and our life - Essay Example es users to interact between each other and exchanging details of their lives such as personal information, biographical data and professional information. The emergence of social media from web 2.0 has created a huge impact on the current scenario of commercial environment. The utilization of social media has changed the way people communicate and human relationship dynamics has taken a new perspective. The history of internet has changed drastically due to the revolution of social media and made internet technologies inclusive. Social media has become largest web presence for many businesses which overtakes email and company websites. It is really hard to find any people who does not exercise any forms of social media which can be application and websites. This essay will follow the statement about the emergence of social media has huge impact on human lives and businesses. Social media has provided people a platform that encourage them to share their views, news and opinions that are happening around the globe. Factor that enables to the growth of this technology is due to their ability of producing user-generated content. At an unprecedented level, social media allows users to connect with each other. It has become inevitable part of human lives. Social media has created a global reach for human beings via internet. The benefit of social media on human lives is enormous as it helps users to share knowledge, information and communicate. Advantages of social media are discussed below: Social media enrich human lives by helping them to communicate effectively and regularly with other people. In earlier days, technology used to be more intensive and it required experts to handle it. But over the period, development of technology and platforms helped users to actively use the services without requirement of any expertise in technological background. Social media acts as a wonderful communication tool for people to interact with each other at any place and time.

Explain how the Emissions Trading Scheme impacts flaring of gas on the Essay

Explain how the Emissions Trading Scheme impacts flaring of gas on the United Kingdom Continental Shelf(UKCS) and comment on the effectiveness of this scheme - Essay Example asingly and progressively upholding measures aimed at controlling these emissions even as industry players have realised the economic benefits of preserving the vented gas (Gerner and Svensson, 8). Countries and organisations have are obliged to adhere to regulations governing emissions and which are based on Kyoto Protocol of 1997. In Europe the European Union (EU) has promoted the EU Emissions Trading Scheme (EU ETS) as variable model for its member countries that especially enhances CO2 preservation and the greenhouse effect. The oil and gas industry faces a number of challenges as it struggled to curb emissions within the United Kingdom Continental Shelf (UKCS) offshore industry. This includes fire, gas explosions, gas venting, and structural infrastructure collapse in its aging structures. Some of these calamities have had some fatalities on human life like the 1988 Piper Alpha disaster. Active legislative measures have been undertaken to curb this episodes within the industry with some noted success, however the nature of the rapid evolving industry and technology mitigate against some of these tactics. In the UKCS, the Health and Safety Executive (HSE) is mandated to regulate the sector2. The HSE has set up an Offshore Division in a Hazardous Installations Directorate who is tasked as preventing major catastrophes and consequences while ensuring more stable working environment for the firms (HSE, 1). 1. World Bank Report estimates that this is adequate fuel to supply all of Germany and France consumption. In Africa the wasted energy can provide 50 percent of the continent’s electricity requirements. 2. The HSE is a UK agency more concerned about the safety of the more than 20,000 employees in the offshore oil and gas industry. The aging infrastructure still pose potential health hazard to the workers and environment. The United Kingdom Emissions Trading Scheme (UK ETS) was the precursor as the first world bid in a trade-wide greenhouse gas emission

Leasing and Buying Essay Example | Topics and Well Written Essays - 1500 words

Leasing and Buying - Essay Example This incident Mr. Walton couldn't forget till his grave. It also pictures the dilemma in everybody's mind when it comes to taking a place on rent. So, why would anybody rent Definitely, it feels great to own something. Unless you own something, you can't be happy having it because you always fear that it could be taken away. Every man dreams of owning the world. But, how much can you own and can you handle the hassle of owning everything. Sometimes you have to have a logical thought about what is more important - owning things or just being able to use them. Let us analyze from the point of view of a small business what is good for them. All new small businesses generally start from a relatively even smaller scale. Until the business is not set, the risk factor associated with it is high. So, initially the focus is on keeping investments in the business to what ever is essential only. The owner has to keep a backdoor for himself so that in case things don't work out fine, he has a way of exiting with minimum losses. Because, when the time comes to "Establish the liquidation value of your assets" (Cavanaugh, step 4) you rarely get a fair price. According to the U.S. Small Business Administration, "Generally this amount is at least 20% less than its retail value." Also, initially most of the liquidity is sucked up by the core activities of the business. As such, even if the owner of the business wants to own his premise, he cannot afford it. He is forced to rent. So, as long as the location of the business is not all that important (like in the case of small factories or offices) it makes more sense to rent, since even if they have to relocate, it's not very difficult and it doesn't affect their customers much. According to Dratch "Taking your company from Point A to Point B may seem at first to be a simple matter of "get up and go," but if you plan ahead, you will get it done without too much trouble." (Dratch, par. 1) But as the business grows old (as in the case of most mom and pop businesses), it becomes more stable. Or even initially, if the location of the business is very important, like in the case of a small shop, re-location becomes a hassle. So, it makes sense to buy your own property instead of paying rent. If you own your space, it also gives a sense of belonging. You know that it is yours and no one is going to ask you to leave from there. You take more efforts in planning it, furnishing it, decorating it and incase you need to change anything, like even pulling down a wall to make more room, it's totally upon you. It gives both, mental as well as physical stability. Large Businesses: Large businesses have their own way of doing things. Being usually tied down with their bureaucratic inertia, they have to fix their policy once and once fixed, they have to follow it. Either they buy the space or they rent it. They usually do not prefer to rent in the beginning and buy later. They usually will just follow their policy. The concerns of big companies are not very different when it comes to premises. Usually big industries and corporations will prefer to own their premises. This is because relocating a big industry is not easy. Finding a similar huge place, with all the necessary approvals and facilities is most difficult. Since most of the equipment or machinery is tailor made and huge, it's impossible to relocate. And even if they try, the cost is exorbitant and the

Feminism in Iran Essay Example | Topics and Well Written Essays - 2000 words

Feminism in Iran - Essay Example Such a rejection in Islamic societies is often associated with the fact that it is seen as being part of western, middle class ideology and a very negative aspect of modernization. Modern day Iran is a strongly fundamentalist Islamic nation, at least as far as those who control it are concerned, with only 2% of the population being non-Islamic. Of the Muslims 89% are Sunnis and the rest are Shia. Despite all the elderly clerics who the media seem to concentrate upon Iran is a relatively young country with a median age of 28.6 years and only 5% of people living beyond retirement age.( World Fact Book, undated) Both sexes average the same length of schooling, but men out do women as far as literacy rates go – a difference of 13.1% in 2002. (World Fact Book) . The women have comparatively few children compared with many other countries – an average of 1.88 each. This is in part explained by an infant mortality rate running at almost 10 times that of the United Kingdom (World Fact Book), but also be the easy availability of contraception. What the figures do not show is how a society that was privately patriarchal has now become publicly patriarchal. Has women’s position really been changed as the post revolutionary state put in place a strongly patriarchal system of legislation – or is it just that the control over women has become more public – as the picture at the head of this piece seems to show? Less than 4 weeks after the downfall of the ruling family and the exit of the Shah, Khomeini was launching an attack on female Iranians. His timing was important - the eve of International Women’s Day - this was when he demanded a strict observance of Islamic dress codes.(Shahidian 2002, page 112) In June 2009 there were elections in Iran. The two main contenders were Mahmoud Ahmadinejad, the pro- polygamy incumbant, and Mir-Hossein Mousavi, a more liberal thinker who had vowed to remove laws which were oppressing women . However he did not win the election . In the period immediately followin g the Second World War many Islamic nations embraced modern , Western inspired ideas. ( Haddad and Esposito 1998, page ix) .These ideas included such things as educational patterns, legislation and social codes. Mnay women stopped wearing the veil and became increasing involved in public activities, and to a certain extent barriers between the sexes were

America's Post-Civil War Growing Pains Essay Example | Topics and Well Written Essays - 750 words - 1

America's Post-Civil War Growing Pains - Essay Example During this major era of the US history, the major events that lead to the turning of the entire society were the emancipation of slavery and the passing of two amendments i.e., thirteenth and fourteenth. The Civil War provided the African Americans freedom from their masters by outlawing slavery within the country. They now had more control over their own lives. Many wanted to buy land so they could continue on with the planting life. This freedom allowed blacks to control their own lives in their own ways. They were used to cultivate lands and hence started to buy land of their own to continue their cultivation life. Yet following the Emancipation Proclamation, war of two more years, served by African American groups, and the crush of the Confederacy, people were even unwary to address the question of complete citizenship for its freshly released black population (Guelzo, 2006). The passing of the 14th and 15th amendment was prominent. The fourteenth amendment assured all citizens that they can experience the â€Å"due process† in case if any of their constitutional rights are breeched. So due to this, an individual was provided the right to explain his/ her part of the tale before the formation of a decision. The fifteenth amendment allowed voting rights to every male citizen irrespective of their color, race or former condition of slavery. Thus the black males were able to vote and be a part of the electoral process to elect the government of their choice. The affect of the above mentioned turning points on the present America is that nowadays there is no discrimination in the whites and non whites within America and the biggest example of the level of equality is the Victory of President Obama who himself is non white. The cultural change is that today inter marriages among the two are common. The economy booms due to efforts from all corners of society and the overall society has developed the concept of equal rights for all humans. These Reconstru ction Period amendments constituted the rights that, thru extensive proceedings, extended to rulings of the Supreme Court initiating in the early 20th century that outlawed state laws based on discrimination. The Civil Rights Movement proved to be a second reconstruction as it headed to civil rights laws in the year 1964 and 1965. These laws enforced and protected complete civic rights of Afro-Americans. The reconstruction period might have been different if President Lincoln had not been assassinated because he would not have let the radicals to gain position within the government. Moreover the regain of white rule on the South at the end would not have resulted in depriving the non-whites from their civil rights that were formerly provided by amending the constitution (Rife, 2002). The rapid industrialization and urbanization resulted in the development of more jobs and the freed slaves were now ready to be used for the work in industrial processes. Overall the economy boomed and the average man life enhanced due to increased employment and more available products. After the passing of the amendments to ensure the civil rights of non-whites various attempts were made from the law enforcing agencies to continue the discrimination. The Southern Democratic force to continue blacks in their "previous status"

The culture and social impact of YOU TUBE Essay Example | Topics and Well Written Essays - 500 words

The culture and social impact of YOU TUBE - Essay Example They watch it for their knowledge as well as informational expansion. YouTube has recordings from different sources. It keeps one glued to its aura. YouTube has the power to change perceptions by showing all the sides of a concept or story. The world of Internet has helped YouTube to expand in an exponential way. It has viewers from all over the world. YouTube has made available all past recordings of TV programs, short films and documentaries. It has in its archives the historical content too. The amateur videos are also present within YouTube. It makes YouTube a very fun-loving experience. Viewers enjoy spending time on YouTube. Writers and directors watch it to understand different cultural divides. Some watch clippings on YouTube to plagiarize which is a wrongful deed. However the incentives and drawbacks are there when one talks of YouTube. YouTube has cut through barriers. It has invited creative content to be available in a free flowing way. YouTube is interesting as it paves way for creative expansion. It gives the youngsters a feel that they are closely associated with each other. The societal aspects are also given significance. The people-to-people linkage on the Web is made possible. The cultural exchanges come into the play as well. There is interaction within the different cultures. Mass media has suffered due to the presence of YouTube. The media fraternity believes it is a direct attack on their content. However proponents of free speech think the exact opposite. There are a number of different viewpoints in entirety. Some see it as a cultural and social bonding phenomenon. Others view it as a place where ideas get stolen. There could be a host of options for the viewers. This makes them remain glued to YouTube for a number of reasons. In addition, mass media has issues in the name of copyrights. There are infringement issues as well. The need is to balance all these aspects. The end user must benefit at the end. He should not be made to pay

How Authentic And Religious Are Virtual Rituals Essay

How Authentic And Religious Are Virtual Rituals - Essay Example The accessibility of information online has drawn more people to virtual religious places, thus pulling them further away from offline, real-life religion. Connelly attests to this observation when he states that the lack of Buddhist teachers and learning centers, among other factors, has facilitated the growth of an online Buddhist ritual â€Å"Second Life†. Helland views a ritual as an individual or communal engagement undertaken for sacred reasons, which allows a person to have contact with the supernatural. A ritual can also be performed as a form of expressing social cohesion and preserving culture. In terms of social cohesion, Connelly states that through Second Life, feel like they belong to a community in which there are expressive involvements. The problem with online rituals as Helland states is that a person may decide to develop individual religiosity and deviate from what their traditional religious authority prescribes. These cyber rituals allow for some form of religious freedom that some strict religions are not comfortable with. According to Helland this raises the question of authenticity and authority of the people carrying out the rituals and the rituals themselves. Judging by this form of evaluation, Second Life would seem legitimate because, as Connelly states, most of the facilitators are ordained priest in real-life, who lead meditation rituals at Buddha centers.7. That aside, many questions are asked about the authenticity of the symbols found online and the sacredness of online space. The seriousness or level of religiousness of these symbols and the rituals they are used in is what bothers many religious observers. Although many people who are involved in online rituals claim that these rituals are as valid as real-life physical rituals, this issue remains to be a subject of debate. According to Connelly the symbols used in Second Life include donation boxes, statue of Buddha, incense, and meditation cushions8. These symbols, a mong others are a representation of the actual artifacts found at the Buddha Center. Virtual pilgrimages according to Helland are one of the most common points of disagreement between participants and observers9. The fact that such pilgrimages are called â€Å"virtual pilgrimages† makes observers hold the view that they are unreal. Here, it appears that observers measure the authenticity of pilgrimages using physical presence. In essence, this argument holds that a pilgrimage could only be valid if a person went physically to a place that is recognized as sacred by their religion. On the other hand, believers and practitioners of online religion believe that a spiritual journey does not have to bet physical, it can be metaphorical. For example, in addressing silent meditation in Second Life, Connelly states that while participants are meditating online, they are represented by avatars10. These avatars sit cross-legged in a room and they form a semicircle facing the statue of Buddha. Participants in Second Life even prostrate three times before entering the temple, in addition to using such words as â€Å"Namaste† at the final chime, in order to thank the facilitator. Yet, the availability of exceptionally good images and sounds that allows someone to make an electronic pilgrimage inside their head is real to those who believe. Helland states that there are those web developers who take the virtual sacred travels more real by, for example, connect with the actual places. This way, these developers can place sacred words or prayer items that can be read to the online audience during the virtual pilgrimage. In silent meditation, according to Connell

Stereotyping Black People Essay Example for Free

Stereotyping Black People Essay Stereotyping is when something is believed about a group of people that is untrue or only partly true. When someone stereotypes against a group of people they tend to not understand that group or do not want to understand them. Black people, to me, are the most stereotyped race. They are stereotyped as being lazy, loud, they steal, love chicken and watermelon, the women get pregnant and the men are well-endowed. As humans we tend to allow negative stereotyping to determine our thoughts, feelings, and our lives in general. People start to believe things that are not true and teach others that it is acceptable and tolerable to do so. According to April Kemick, from the University of Toronto, it has been proven that stereotyping has a lasting effect on people’s lives. Black people are stereotyped and have to deal with what others think in their daily life. There is a negative stereotype that all black people love to eat chicken and watermelon. I want to challenge this. Looking at its backgrounds, the stereotype that all blacks eat chicken and watermelon came from the south as blacks were claiming their freedom and independence from slavery and Jim Crow laws. As blacks transitioned from slavery to freedom, many black families lived in unfortunate and unaffordable situations. Eating chicken and watermelon was less expensive, convenient and economical for poor black families. Black families could raise their own chickens and plant their own watermelon providing food for their families. They used these sources of food for survival not to be stereotyped. When I think about this stereotype, I image it to be as foolish as saying all Chinese people love to eat fish and oranges. What is so negative about that exactly? Fish and oranges have a lot of nutritional value, just as chicken and watermelon do. Chicken, when skinned, baked or grilled, is a great source of lean ample protein. It is rich in trace minerals like zinc, cooper, manganese and selenium. Eating chicken helps to slow down the aging process, no wonder black people look so young, and it is easy to digest. Some studies have proven that eating chicken legs and feet can contribute in the reduction of high blood pressure. Watermelon also has nutritional benefits being as it is full of vitamins like Vitamin A, C and B6. It is very low in calories and rich in potassium, even the seeds provide iron and fiber. Watermelon also aids in the anti-inflammation of arthritic joints. It is an antioxidant proven to help prevent heart attacks and cancer. Chicken and watermelon have plenty of wonderful qualities to keep a person healthy! There is a great deal of jokes and humility towards black people about this stereotype. There is a photo of a black man looking shocked and horrified because a watermelon is being chucked at him. On the bottom of the photo in bold letters it says â€Å"Flying watermelons if they only came with fried chicken this guy would shit himself. † There is also a white man standing behind him and another white person ready to catch the watermelon. In another photo there is an old white man holding KFC with two black men trying to beat him up to take his KFC. In the back ground there is a crowed of black people staring in awe of what is going on. In bold letters at the bottom of the photo it says â€Å"Bravery at its finest. † These photos represent what others think about black people. It is not right to only classify black people who love chicken and watermelon. Being a middle eastern I love to eat chicken and watermelon. Chicken and watermelon are so good! I would say that eating chicken and watermelon is not a negative stereotype at all. Maybe eating more chicken and watermelon is the solution to our obesity epidemic here in America. There is nothing wrong with eating chicken and watermelon. The stereotype is ridiculous being as it is a food that everyone enjoys regardless of race or culture. The chicken and watermelon experience surpasses all racial and ethnic appearances. If people say that it is funny or weird that black people eat chicken and watermelon maybe they should look at themselves first. Chicken and watermelon are two great and healthy food sources. This is the most ridiculous, immature and uncalled stereotype to be judging black people by. It does not make sense to me why others would do that. Just leave them be and let them eat what they want, it is their own dictions to make. They are not affecting others by eating what they please. It sucks that people are judged by the way certain people act in their race, not all act like their stereotypes. To change a person’s view of a stereotype, be regularly different from it. Beware of your own stereotypes that people think of your race and show them wrong. Stereotyping can be reduced by bringing people together. When they discover that other people are not as the stereotypes are believed to be, the instant evidence creates conflict that leads to changing thoughts about the other group. Stereotypes are true to a certain extent. It may be true to some of the people in the race but it should not be a general impression of the race. Everyone is their own person and has a unique touch to them. People are not mindful to other races or even try to know the race well. Stereotyping is hard to break but people should try and make an adjustment so others can see that stereotyping are judgments people make because we do not know how to interact with one another.

Technology and modern enterprise Essay Example for Free

Technology and modern enterprise Essay Today billions in advertising dollars flee old media and are pouring into digital efforts, and this shift is reshaping industries and redefining skills needed to reach today’s consumers. Firms are harnessing social media for new product ideas and for millions in sales. Many of the world’s most successful technology firms—organizations that have had tremendous impact on consumers and businesses across industries—were created by young people. Today, tech knowledge can be a key differentiator for the job seeker. It’s the worker without tech skills that needs to be concerned. The aspiring investment banker who doesn’t understand the role of technology in firms and industries can’t possibly provide an accurate guess at how much a company is worth. Lecture 2 Chapter 2-4 Strategy and technology, case of Zara and Netflix Sustainable competitive advantage: financial performance that consistently outperforms their industry peers. According to Porter, the reason so many firms suffer aggressive, margin-eroding competition is because they’ve defined themselves according to operational effectiveness rather than strategic positioning. Operational effectiveness refers to performing the same tasks better than rivals perform them. Everyone wants to be better, but the danger in operational effectiveness is â€Å"sameness.† The fast follower problem exists when savvy rivals watch a pioneer’s efforts, learn from their successes and missteps, then enter the market quickly with a comparable or superior product at a lower cost. Operational effectiveness is critical. Firms must invest in techniques to improve quality, lower cost, and design efficient customer experiences. But for the most part, these efforts can be matched. Because of this, operational effectiveness is usually not sufficient enough to yield sustainable dominance over the competition. In contrast to operational effectiveness, strategic positioning refers to performing different activities from those of rivals, or the same activities in a different way. Technology itself is often very easy to replicate, and those assuming advantage lies in technology alone may find themselves in a profit-eroding arms race with rivals able to match their moves step by step. But while technology can be copied, technology can also play a critical role in creating and strengthening strategic differences—advantages that rivals will struggle to match. Higher inventory turns mean the firm is selling product faster, so it collects money quicker than its rivals do. Resource based view of competitive advantage can help: if a firm is to maintain sustainable competitive advantage, it must control a set of exploitable resources that have four critical characteristics. These resources must be (1) valuable, (2) rare, (3) imperfectly imitable (tough to imitate), and (4) non-substitutable. Dense wave division multiplexing (DWDM) enabled existing fiber to carry more transmissions than ever before. The end result—these new assets weren’t rare and each day they seemed to be less valuable. Firms that craft an imitation-resistant value chain have developed a way of doing business that others will struggle to replicate, and in nearly every successful effort of this kind, technology plays a key enabling role. Sources of switching costs: learning costs, information and data, financial commitment, contractual commitments, search costs, loyalty programs. In order to win customers from an established incumbent, a late-entering rival must offer a product or service that not only exceeds the value offered by the incumbent but also exceeds the incumbent’s value and any customer switching costs. Commodities are products or services that are nearly identically offered from multiple vendors. Consumers buying commodities are highly price-focused since they have so many similar choices. In order to break the commodity trap, many firms leverage technology to differentiate their goods and services. Data is not only a switching cost, it also plays a critical role in differentiation. Network effects (sometimes called network externalities or Metcalfe’s Law) exist when a product or service becomes more valuable as more people use it. Switching costs also play a role in determining the strength of network effects. Tech user investments often go far beyond simply the cost of acquiring a technology. Nothing lasts forever, and shifting technologies and market conditions can render once strong assets as obsolete. It doesn’t matter if it’s easy for new firms to enter a market if these newcomers can’t create and leverage the assets needed to challenge incumbents. Beware of those who say, â€Å"IT doesn’t matter† or refer to the â€Å"myth† of the first mover. This thinking is overly simplistic. It’s not a time or technology lead that provides sustainable competitive advantage; it’s what a firm does with its time and technology lead. If a firm can use a time and technology lead to create valuable assets that others cannot match, it may be able to sustain its advantage. But if the work done in this time and technology lead can be easily matched, then no advantage can be achieved, and a firm may be threatened by new entrants. Industry competition and attractiveness can be described by considering the following five forces: (1) the intensity of rivalry among existing competitors, (2) the potential for new entrants to challenge incumbents, (3) the threat posed by substitute products or services, (4) the power of buyers, and (5) the power of suppliers.