NCM 110A (Nursing Informatics Laboratory)

Module 2: Advanced hardware and mHealth

INTRODUCTION

Hardware—the silicon, metal, and plastic portion of the

hardware–software–human triangle—exists to support the
activities in which we engage. New care models are
driving a change in the way people think about the use of
advanced hardware in healthcare. One activity that is
pushing the development of and leveraging the existing
advanced hardware is eHealth—the use of information
and communication technology for health services and
information by both healthcare professionals and the public. At the leading edge of eHealth is the
practice of healthcare and public health supported by mobile devices.

The three key synergistic advanced hardware elements enabling mobile health (mHealth) are
(1) physical device size,

(2) wireless network access, and

(3) battery life. mHealth is accelerating due to the convergence of the infrastructure of adequate
processing power and storage available on mobile devices (e.g., smartphones, advanced tablets,
and wearable/implantable/injectable devices); large capacity redundant storage typically available
through cloud computing services; and long-life batteries.

Hardware
Advances in computer hardware continue two trends:

(1) more powerful processing in ever-smaller packages and

(2) more power distributed across many, many machines, most commonly seen in cloud services.

For example, tablets used to be a bridge between a desktop and a smartphone, allowing
mobility but lacking the range of computing capability that a laptop provided.

This distinction is disappearing as tablets evolve to provide the same capability as a laptop. A
smartphone is a powerful hand[1]held computer with an operating system and the ability to access
the Internet. Wearable devices, the size of a piece of jewelry, collect physiological measures and
wirelessly send that data to smartphones or cloud services via the Internet. Implantable devices, such
as an implantable cardioverter-defibrillator, not only monitor physiological responses, they also provide
interventions. Research on injectable microchips continues, and raises many security, privacy, and
ethical issues. Advances in large capacity redundant storage allows rapid access to massive amounts
of data with steadily improving fault tolerance. Redundant arrays of independent disks (RAIDs) for
replicating and sharing data among disks make it possible to store larger chunks of information than a
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single storage device can handle. The combination of accessibility and capacity can be used in
healthcare for storage of large data sets such as genomics data. Making this storage accessible
through the Internet allows mobile devices to overcome local storage limitations. The ability of a mobile
device to access a large number of computers connected through a communication network and
run a program or application on many connected computers at the same time is known as cloud
computing. A common example of mobile device access to cloud services is when the user of a
smartphone takes photos, edits the photos, and shares them, all without having to go back to a
desktop machine in order to edit and share. The length of time a mobile device can work powered by
a rechargeable battery is the limiting factor for mobile computing. The most common complaint about
the limitation of a mobile device is battery life, which becomes problematic when there is a high level
of background activity. For example, running multiple interactive mobile applications (apps) in the
background, each of which drains power, shortens the amount of time the device can be used before
having to recharge the battery. Use of mobile data and video is rapidly expanding (Moore, 2011),
driving research on ways to deliver vastly improved power density (Williams, 2013).

Wireless Communication

The ability of a mobile device to connect with networks in multiple ways is the foundation of
mobile computing and mHealth. Technology used to wirelessly communicate with a mobile device
includes mobile telecommunications technology, Wi-Fi, Bluetooth, and Radio-Frequency IDentification
(RFID). Mobile telecommunications technology continues to evolve (Federal Communications
Commission, 2012).

Fourth-generation (4G) networks that provide faster performance and more capabilities are
replacing third-generation (3G) networks. A 4G network supports all Internet Protocol (IP)
communication and uses new technology to transfer data at very high bit rates, significantly improving
both the speed of transfer and volume of data over that possible with a 3G network. The International
Telecommunications Union Radio (ITU-R) communications sector sets the standards for International
Mobile Telecommunications Advanced (IMT-Advanced) technology. The peak speed requirements
for 4G service are 100 megabits per second for high mobility communication (e.g., communications
while traveling by car or train) and 1 gigabit per second for low mobility communication (e.g.,
communications while walking or standing still).
Technologies that do not fulfill 4G requirements but represent the forerunners to that level of
service by providing wireless broadband access include Worldwide Interoperability for Microwave
Access (Mobile WiMAX) and Long-Term Evolution (LTE), a standard for wireless communication of high-
speed data for mobile phones. (Although the standards-setting body is international, due to different
frequencies and bands used by different countries, only multi-band phones will be able to use LTE in all
countries where LTE is supported.) Wi-Fi is intended for general local network access, called a wireless
local area network (WLAN). Bluetooth is intended for a wireless personal area network (WPAN). Wi-Fi
and Bluetooth are complementary. Wi-Fi is access point-centered, with all traffic routed through the
access point (typically, several computers, tablets, and other devices share a single access point).

Bluetooth is used for symmetrical communication between Bluetooth devices, transferring

information between two and seven devices that are near each other in low-bandwidth situations
(typically, several devices are paired with a single device, such as Bluetooth keyboards, mice, activity
monitors, and cameras paired to a single desktop, tablet, or smartphone). Protocols covering wireless
devices include Wireless Application Environment (WAE), which specifies an application framework,
and Wireless Application Protocol (WAP), which is an open standard providing mobile devices access
to telephony and information services.

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 Wi-Fi is a technology that allows an electronic device to exchange data or connect to the
Internet wirelessly using (in the United States) 2.4GHz Ultra High Frequency (UHF) waves and 5GHz Super
High Frequency (SHF) waves. Advanced hardware makes this connection through a wireless network
access point, or hotspot. Wi-Fi is based on the Institute of Electrical and Electronics Engineers (IEEE)
802.11 standards.

To provide a level of security for the wireless connection, various encryption technologies are
used, such as Wi-Fi Protected Access (WPA) and Wi-Fi Protected Access II (WPA2) security protocols.
To ensure that devices can interoperate with one another, a type of Extensible Authentication Protocol
(EAP) is used. Wi-Fi security concerns are covered in the National Institute of Standards and Technology
(NIST) Guidelines for Securing Wireless Local Area Networks (NIST Special Publication 800-153) (2012b).
Bluetooth is a wireless technology standard for control of and communication between devices,
allowing exchange of data over short distances. Bluetooth is used for wirelessly connecting keyboards,
mice, light-pens, pedometers, sleep monitors, pulse oximeters, etc. The range is application specific.
Bluetooth uses 2.4 to 2.485GHz UHF radio waves, and can connect several devices. The Bluetooth
Special Interest Group (SIG) is responsible for Bluetooth standards.

Bluetooth security concerns are addressed in the NIST Guide to Bluetooth Security (NIST Special
Publication 800-121) (2012a). Radio-Frequency Identification (RFID) is a technology that uses radio-
frequency electromagnetic fields to transfer data, using tags that contain electronically stored
information. Typically, RFID is used for equipment tracking and inventory control. For example, in an
Operating Room, RFID is used to automatically poll equipment in the suite and cross-reference that
equipment with inventories showing the equipment is certified, and the date of the most recent service.
Tags contain an integrated circuit for storing and processing information, and modulating and
demodulating a radio frequency.

Tags also contain an antenna for receiving and transmitting the signal. The tag does not need
to be in the line of sight of the reader, and may be embedded in the object to be identified. The reader
is a two-way radio transmitter-receiver that sends a signal to the tag and reads its response. Advanced
hardware uses increasingly miniaturized RFIDs; some chips are dust-sized. The International
Organization for Standardization (ISO) and the International Electrotechnical Commission (IEC), among
others, set standards for RFID. The standards for information technology telecommunications and
information exchange between systems are ISO/IEC 18092 and ISO/IEC 21481. (Although the standard-
setting bodies are international, frequencies used for UHF RFID in the United States are currently
incompatible with those of Europe or Japan.) Security concerns are addressed by using cryptography.
RFID security concerns are addressed in the NIST Guidelines for Securing Radio Frequency Identification
(RFID) Systems (NIST Special Publication SP 800-98) (2007).

Standards and Protocols

Use of well-established standards and best practices allows global and easy access to networks
and networked information in a standardized way. The networking model and communications
protocols used for the Internet are commonly known as Transmission Control Protocol (TCP) and the
Internet Protocol (IP) or TCP/IP. This suite of standards provides end-to-end connectivity specifying how
data are formatted, addressed, transmitted, routed, and received at the destination. The Internet
Engineering Task Force (IETF) maintains the standards for the TCP/IP suite. Some of the most commonly
used protocols for Internet user-interface services and support services include Simple Mail Transfer
Protocol (SMTP), File Transfer Protocol (FTP), and HyperText Transfer Protocol (HTTP).

Encryption provides confidentiality and integrity for data sent over the Internet. Cryptographic
network protocols to protect data in transport are Secure Sockets Layer (SSL) and Transport Layer
Security (TLS). Protocols for encrypting data at rest include Pretty Good Privacy (PGP) and GNU Privacy

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Guard (GPG). Building on top of network standards, there are standards that ensure health information
is properly identified, transmitted correctly, and complete. Health Level Seven International (HL7)
maintains the framework and standards for the exchange, integration, sharing, and retrieval of
electronic health information. These standards are the most commonly used in the world for packaging
and communicating health information from one party to another using language, structure, and data
types that allow seamless integration between systems.

The HL7 standards support management, delivery, and evaluation of health services and clinical
practice (Health Level Seven International, 2014). Clinical Content Object Workgroup (CCOW) is an
HL7 standard protocol that enables different applications to synchronize at the user-interface level in
real time. This standard allows applications to present information in a unified way. For example, with
CCOW enabled, a provider could bring up a patient record in the inpatient electronic record
application, and then open the outpatient electronic record in a different application, and CCOW
would bring up the same patient in the outpatient application. Evolution and adoption of existing
technologies and standards allow users to benefit from advanced hardware without the need for
deep knowledge or expertise. For example, you can watch a feature film on a smartphone without
knowing how the underlying hardware and software work. These advances in hardware along with
virtualization support new care models.

Drivers of Mobile Healthcare

The 2012 documentary Escape Fire: The Fight to Rescue Healthcare is an urgent call to think
differently about healthcare. Clinicians shifting from a focus on disease management to a focus on
ending lifestyle disease may leverage the use of mobile platforms. For example, during an outpatient
visit, Dr. Natalie Hodge prescribes an app for health self-management in the same way that medicine
or any other intervention would be prescribed (Wicklund, 2014 February 13). According to the mHIMSS
Roadmap, “patients and providers are leveraging mobile devices to seek care, participate in, and
deliver care. Mobile devices represent the opportunity to interact and provide this care beyond the
office walls” (Healthcare Information and Management Systems Society [HIMSS], 2012b).
Advancements in technology, federal healthcare policy, and commitment to deliver high-quality care
in a cost efficient manner have led to new approaches (mHIMSS, 2014b, 2014c).

The Affordable Care Act (ACA) leverages innovative technology to bring about “a stronger,
better integrated, and more accessible healthcare system” (HIMSS, 2012b). For example, mobile apps
allow expansion of telemedicine and telehealth services. The current healthcare focus is on preventive
and primary care to reduce hospital admissions and emergency department utilization. Engaging
patients in management of their chronic diseases helps them maintain their independence and
achieve a high quality of life. Patients may make use of collaborative tools such as Secure Messaging
to communicate with their healthcare team, and may find support through social interactions on a
blog.

Technology in Mobile Healthcare

Under the ACA, innovative technology is seen as an integral component of an integrated,

accessible, outcome driven healthcare system. Mobile technology may be key to providing more
effective preventative care, improving patient outcomes, improving access to specialized medical
services, and driving system-wide cost reduction. Services to patients and families at home will be
personalized and delivered by providers equipped with apps for smartphones, tablets, and laptops
(Powell, Landman, & Bates, 2014). The National Institutes of Health defines mHealth as “the use of
mobile and wireless devices to improve health outcomes, healthcare services, and health research”
(HIMSS, 2012a).

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 A major component of mHealth includes timely access to clinical information such as the data
contained in electronic health records (EHRs), personal health records (PHRs), and patient portals. This
information should be securely accessible by clinicians, patients, and consumers over various wireless
mediums both inside and outside the traditional boundaries of a hospital, clinic, or practice (HIMSS,
2012b). The iPhone and Android operating systems have accelerated the proliferation of mobile data
use. By 2015, mobile data traffic will be some 20 times the 2010 level (Moore, 2011).

The concept of mHealth can be traced to the early 1990s when the first 2G cellular networks
and devices were being introduced to the market. The bulky handset designs and limited bandwidth
deterred growth, lack of communication standards impeded interoperability, and batteries lasted less
than 6 hours. A major standards breakthrough occurred in 1997, enabling Wi-Fi capable barcode
scanners to be used in hospital inventory management. Shortly thereafter, clinicians began to take an
increasing interest in adopting technologies.

At this time, nurses began to use personal digital assistants (PDAs) to run applications like general
nursing and medical reference, drug interactions, and synchronization of schedules and tasks. This
quick rate of adoption was quite notable for clinicians often considered technology adverse.
Increased processing capabilities and onboard memory created an appetite for more advanced
applications. Network manufacturers were beginning to offer Personal Computer Memory Card
International Association (PCMCIA) wireless devices, creating an environment where retrofitted
hospital computers or new laptops allowed nurses to access the Internet without adding network
cabling.

In 2000, the Federal Communications Commission (FCC) dedicated a portion of the radio
spectrum to wireless medical telemetry systems (WMTS), which was widely adopted for remote
monitoring of a patient’s health. As data transmission rates increased, it became feasible for hospitals
to run video or voice applications over the wireless networks. Application-Specific Devices (ASDs) are
often integrated with nurse call systems and medical telemetry so that nurses can receive alerts,
alarms, and text messages. Many vendors are now beginning to offer the same type of nurse call
integration and voice-over Wi-Fi capabilities on popular smartphones (HIMSS, 2012b). Nurses soon
became familiar with Computers on Wheels (COWs), which evolved to workstations on wheels
(WOWs). More wireless devices were integrated into networks and a greater emphasis was placed on
error detection and prevention, medication administration safety, and computerized provider order
entry (CPOE). Parallel to Wi-Fi technology evolution has been the growth in cellular technology. In
many healthcare organizations, seamless roaming between the two systems is a reality. Nurses now
have immediate access to patient data at the bedside.
Infrastructure.

mHealth is a broad, expanding universe that encompasses a wide variety of user stories (use
cases) that range from continuous clinical data access to remote diagnosis and even guest Internet
access. The role of video in healthcare is evolving as quickly as the standards themselves. Telemedicine
carts outfitted with high-resolution cameras include remote translation and interpretation services for
non-native speakers as well as the hearing impaired. In the past, WOWs were mainly used to access
clinical data, but these carts have gained such wide acceptance that they are often found in use by
clinicians on rounds or at change of shift. Hospital systems and ambulatory practices have also started
using products like FaceTime, Skype, Google Hangouts, and other consumer-oriented video-telephony
and voice-over Internet Protocol (VOIP) software applications for patient consults, follow-up, and care
coordination (mHIMSS, 2014a).

Overlay networks for medical devices are becoming obsolete as hospitals seek economies of
scale by utilizing their existing Wi-Fi infrastructure.

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This places a heavy dependency on the Information Technology department (IT) to ensure that the
hospital, clinic, or practice wireless network is secure, designed properly, and robust enough to support
various types of medical devices such as infusion pumps, mobile EKG devices, mobile X-ray devices,
ultrasounds, and blood gas analyzers on a single infrastructure. An important and often overlooked
aspect of mHealth is patient or guest access to the wireless system. Care must be taken to segregate
the guest access wireless network from the health professional networks. Wireless guest access provides
a way for patients and their families to access the Internet; it can be a valuable tool for hospitals to
engage with patients and guests.

In a healthcare setting, organizations generally opt to provide free unencrypted access with a
splash page that outlines terms and conditions. This allows the hospital to address liability for the
patient’s Internet traffic and allows guests and patients to access the network quickly. Real-time
location services (RTLS), a concept dating back to the 1990s, has evolved rapidly over the years. RTLS
can be used for asset location tracking using RFID beacons, temperature/humidity monitoring, distress
alert badges, and hand washing tracking (mHIMSS, 2014e). A properly configured RTLS system can
minimize the task of tracking down medical equipment and show the nurse the status of the
equipment. The wide range of options includes using RFID technology. Biomedical, pharmacy, security,
and other departments in the hospital are using this technology).

Mobile Devices

Smartphones and tablets are ubiquitous in the healthcare setting. What started out as consumer
devices are now in the hands of almost all clinicians. In a short period, mobile device performance has
improved radically, putting them closer and closer in capability to general computing devices such as
laptops and desktops. Battery technology has also improved significantly, with most devices able to
go a shift between charging. Within the palm of a nurse’s hand is a fully capable computing device
able to perform complex and powerful operations. Many mobile devices are using high-resolution
touch screens. When clinical information systems are designed to display well on smartphones and
tablets, these devices will emerge as the primary computing device for all users. These devices already
support text messaging, voice, and video.

Telehealth

One of the latest trends in healthcare IT is the concept of Bring Your Own Device (BYOD).
Products in the market place today, such as the iPhone, iPad, and similar devices from other vendors,
have produced loyal customers who do not want to have multiple communication devices attached
to their waistband or filling the pockets of their lab coat. They prefer one device, the device that they
own. In many hospitals the IT department has already ensured that their devices are secure and able
to meet government regulations. Back-end IT systems are required to ensure that a given device does
not introduce vulnerabilities into the system. Mobile Device Management products provide policy
enforcement on end-user devices, remote wipe capability, and endpoint integrity. To implement
BYOD, owners of the devices must be willing to abide by the hospital’s mobile device policy and allow
their devices to be managed. As the concept of unified communications continues to grow, fed by
the challenge to attain work life balance, BYOD is becoming increasingly attractive in many
organizations.

Future of mHealth Inside Healthcare Facilities

The nation’s healthcare model is on the path toward consolidated, coordinated, value-based
care. Information Technology tools, mobile applications, and clinical information systems provide an
evolving platform for the effective delivery of clinical services, increased operational excellence, and
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cost containment. Wireless networking, specifically Wi-Fi, began to be widely adopted in hospitals
about 10 years ago. In the beginning, few organizations had 100% Wi-Fi coverage, but steadily
increasing demand resulted in the deployment of wallto-wall Wi-Fi coverage in hospitals and often in
adjacent outside areas. Cellular network coverage in hospitals has also grown. Initially, owners of
mobile devices were accustomed to spotty coverage and dropped calls or even policies banning
mobile phones. In recent years, thanks to investments by cellular carriers, coverage areas have grown,
along with the user’s expectation of a quality signal. Distributed Antenna Systems (DAS) are commonly
used for providing cellular wireless signals while also providing for two-way radio, paging, and first
responder communication systems (HIMSS, 2012b).

Still, unified communications (a combination of messaging, video, and voice) has not yet
realized full potential in healthcare facilities. The value of an emergency room nurse being able to
instantly create a video session with a remote patient is not in doubt. However, the infrastructure to
accomplish this is still fledgling. Enterprise communication platform vendors have provided these
capabilities with devices that integrate with their vendor-specific devices. Broader integration with
common devices such as smartphones and tablets is an ongoing effort. Considerations for mHealth
Planning The role of cellular networks in video and voice applications is expanding rapidly. Advances
in 4G technologies are beginning to provide the bandwidth necessary for video conferencing and
Video Remote Interpreting (VRI). Patients newly discharged from the hospital will be followed by nurses
with devices that allow nurses to see and hear the patient, monitor wound healing, and address family
concerns.

Early intervention for patients with chronic diseases such as asthma, chronic obstructive
pulmonary disease (COPD), heart failure, and diabetes will alert caregivers and prevent
hospitalizations. Remote monitoring of patients is increasingly viewed as essential for mHealth planning.
It is widely believed that, by 2020, the majority of computing will be edge computing, defined by a
constantly changing mix of corporate and privately owned mobile and wireless devices talking to a
corporate or enterprise cloud. As a result, healthcare will become more patient centered, and mobile
and health visits will occur in the home, school, and office (mHIMSS, 2014d). Data from home
monitoring devices to fitness apps raise questions about which kinds of data will be aggregated, and
conventions for meta-tagging the source of that data. Ethical, legal, privacy, and security questions
must be addressed. How is the data protected? Who is authorized to use it and for what purposes?
How will the data be processed to discover patterns (data mining)?
Setting the Stage for mHealth Adoption

Smartphones and tablets offer a new engagement model for patients, their family members,
and healthcare providers. These devices move with their owners from hospital, to home, and beyond.
An Internet search for healthcare applications will yield thousands of results and the list constantly
grows larger. With the public’s increasing interest in wellness, and a large fitness industry attempting to
grow their business, peripheral devices are becoming smartphone-ready. Sensors can now measure
heart rate, pulse, oxygen saturation levels, speed, and distance for exercise regimens. Devices are
emerging for daily blood tests, automated weight tracking, and sleep monitoring.
EKGs can be registered and transmitted through a device no larger than a Band-Aid. The
concept of home health has been a driving factor in the proliferation of remote monitoring devices
(HIMSS, 2012b). Thanks to advances in machine-to-machine (M2M) technology, patients no longer
have to travel to the clinic or hospital for routine monitoring. Patients can check their blood sugar,
blood pressure, oxygen levels, and other vital signs at home with their results wirelessly transmitted to
their healthcare providers. Providing cellular or Wi-Fi communications to the ambulatory practice and
the patient’s home is a technology trend that has seen affiliate physician offices partnering with larger

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hospital systems for access to the EHR and to leverage corporate IT services to provide Wi-Fi for their
offices.

Privacy and Security

The cornerstone of trust in healthcare is privacy and security. mHealth data present a greater
challenge to security and data integrity because this data is in a mobile environment and not
collected in stored access facilities and stored behind firewalls. However, many of the same rules apply
to mHealth as well as the physical hospital environment. mHealth must comply with all Health Insurance
Portability and Accountability Act (HIPAA) mandates, Food and Drug Administration (FDA) regulations,
Office of Civil Rights (OCR) enforcements, and requirements from other governing agencies. The only
difference between a smartphone, a personal computer, and an enterprise server is size. In a large
number of security breaches, the thief simply carried the equipment out the door or removed it from a
car. Size does not play a role in protecting the data. An organization is responsible for securing and
verifying security, and testing to locate vulnerabilities in systems. The goal of privacy and security is to
provide as much effort as needed to protect patient’s personal health information (PHI) from being
compromised. The benchmark for privacy must be 100% secure PHI.
Legal and Policy

State and national policy and regulations have not kept pace with the rate of technology
innovation. The proliferation of mHealth technology creates several fundamental issues related to the
custody of medical information: who owns it, who can access it, and under what circumstances? As
information becomes more portable, the question raised is to what extent records of other providers
should be incorporated into clinical records of the practice, hospital, or specialist. Consider the
transmission of digital radiology images from a hospital or freestanding diagnostic center to a
provider’s smartphone. Consumers and patients use a multitude of devices to collect wellness data.
Should all data be incorporated into the EHR, or just portions of the data? Should data from all devices
be incorporated into the record, or data from just one or a few devices? Does having too much data
obscure potentially critical information? Under what circumstances is the healthcare provider required
to maintain records of these transmissions?

If the transmissions are received, must all data be reviewed? What does the record look like for
legal purposes? Must the source of the data (e.g., patient-provided, wearable device, etc.) be
transparent? Clinical significance is the central consideration in the determination of whether wellness,
monitoring, and other data transmitted by consumers to their providers should be incorporated into
the patient’s EHR. Incorporating vast amounts of routine data might detract from clinically relevant
findings. When data is shared between patient and clinician from such devices, it is desirable to have
a thorough understanding between the treatment team and the patient about how the data is going
to be reviewed, incorporated (or not) into the record, and used in patient care. Historically, there has
been reluctance to accept any data other than the information collected within the physical
boundaries of the hospital or practice, with the exception of routine consultations.

Hesitancy to accept outside data is based on the receiving provider’s inability to verify the
accuracy of the data. Today, however, that paradigm is changing. Healthcare professionals must be
engaged in care coordination across the care continuum. Excluding data from other sources may
provide an incomplete picture of the patient’s care, resulting in inappropriate or substandard
treatment. The term “social media” immediately brings to mind Facebook, LinkedIn, and Twitter, which
are accessible at all times, and in all locations via smartphones. Indeed, the world often learns of
breaking news through a tweet. User content is developed and shared through platforms such as
YouTube, and video is shared through services such as Skype and FaceTime.
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As pleasant as it is to receive a new picture of a loved one, social media also presents several types of
legal and regulatory concerns:

 Professionalism: Because social media is so ubiquitous, healthcare professionals may face

new questions such as whether or not it is appropriate to “friend” a patient.
 Privacy: There have been several widely reported incidents of healthcare professionals
posting data related to patients on social media sites. Even if the patient’s name is not
revealed, releasing data that is not completely de-identified violates the HIPAA Privacy
Standards.
 Who owns health-related data posted to a social media site? Is ownership relevant? There
is no question that great change is happening in healthcare and among healthcare
professionals. The new technology is mobile. The new face of healthcare will be mHealth.

Reference:

Saba, V., McCormick, K. (2015) Essentials of Nursing Informatics, 6th Edition

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