Social Science Homework Help


# Description Question

You are expected to interview someone who had been to another country/ies in a business trip or as a tourist, or an international student/person who visited came to this country. You may interview a “Westerner” who did not travel but had interactions with “foreigners” in his/her Western country. Your interview will focus on the social and business interactions that your interviewee engaged in. After providing information about your participant and a rational for choosing him/her, you can ask questions similar, but not necessary limited, to the following:


1-    When were you in that country?

2-    How did you find your social/ business interaction similar/different from what you are used to.

3-    Can you relate the most shocking or strange incident(s) that you witnessed or been part of?

4-    Did you have any orientation (including personal research) about the customs and traditions of that country?

5-    How did your learning of the culture of the country affect your experiences?

6-    Did you notice that the religion, attitudes, and beliefs of the people affected their interactions or the way they conduct business? How?

7-    What things would you do differently if you are to relive your experience doing business in that country?

8-    What advice would you give to a foreigner going in a trip to that particular country? 

You may report your interview in any format you like (e.g. essay or question and answer). However, you need to conclude in a paragraph in which you link what your interviewee mentioned and what has been discussed in the class, the concepts of intercultural communication. 

Please remember that the provided questions should serve as a guide or sample for your interview. Make sure to ask about comparisons between the country your interviewee visited and the common expected behavior in similar settings in the United States.

You are expected to interview someone who had been to another country/ies

Chapter 7:

  • How are patients prioritized for bed assignment?
  • Describe some of the advantages and disadvantages of this new software; include the stated organizational goals in your answer.
  • Discuss how this software might share data with other institutional  applications to provide a dashboard view of census-type activity.

Chapter 8:

  • Which components are critical to Mrs. Smith staying safely in her home?
  • Describe whether Mrs. Smith’s regimen might be augmented using mhealth applications.

   For each case study, your paper should be include the title and reference pages, and formatted according  to APA guidelines as outlined in the Ashford Writing Center. In  addition to the textbook, utilize a minimum of two scholarly sources per  case study to support your statements. 

Chapter 7 Applications for Managing Institutions Delivering Healthcare

Michael H. Kennedy

Kathy H. Wood

Gerald R. Ledlow


    If a healthcare system cannot effectively track the total cost of all materials used to treat an individual patient and aggregate data to determine the cost of treating groups of patients, managing the cost of healthcare is not possible.



At the completion of this chapter the reader will be prepared to:


    1.Outline the evolution of financial information systems (FISs) in healthcare organizations

    2.Discuss the basic FISs and their application in healthcare organizations

    3.Compare and contrast practice management systems (PMSs) and integrated healthcare systems

    4.Describe and explain the attributes of an efficient materials management (supply chain) system in a healthcare organization

    5.Appraise how a quality supply chain system supports the operation and management of clinical systems

    6.Describe the human resources management actions associated with the subsystems typically deployed with a human resources information system

    7.Define business intelligence

    8.Distinguish between enterprise-level and application-level business intelligence


Key Terms

Accounts payable, 108

Accounts receivable, 108

Assets 108

Business intelligence (BI), 121

Charge description master file, 116

Claims denial management, 109

Claims processing and management, 109

Financial information system (FIS), 107

Fixed asset management, 110

General ledger, 108

Incentive management, 120

Materials management, 115

Open shift management, 120

Patient accounting, 109

Payroll, 109

Practice management system (PMS), 114

Predictive scheduling, 120

Supply chain management (SCM), 110

Supply item master file, 116

Transaction history file, 116

Vendor master file, 116


This chapter addresses the administrative applications within health information systems that are designed to facilitate the delivery of healthcare, such as financial, practice management, supply chain and materials management, human resources, and business intelligence systems.


Health information systems are “complexes or systems of processing data, information and knowledge in health care environments.”1(p270) These environments comprise a variety of settings, including hospitals, ambulatory settings, long-term care facilities, and managed care organizations.

Typically, the applications within health information systems are categorized as clinical or administrative. This chapter focuses on the administrative applications within health information systems designed to facilitate the management of healthcare delivery. The chapter considers in turn financial, practice management, materials management, human resources, and business intelligence systems.

Vendor Resource Guides

The applications required to process information in healthcare settings are primarily provided by vendors. The vendor market for hospital information systems alone in 2011 had total revenues of $12 billion, with the top five vendors in terms of revenue being McKesson ($3.2 billion), Cerner ($2.2 billion), Siemens ($1.7 billion), Allscripts ($1.4 billion), and Epic Systems Corporation (nearly $1 billion). These revenue statistics exclude vendors that do not sell a comprehensive suite of applications designed to automate both the administrative and the clinical departments in a hospital.2

Vendors that deploy a comprehensive suite of applications are referred to as enterprise vendors. The Healthcare Information and Management Systems Society (HIMSS) ( publishes annually a white paper titled “Essentials of the U.S. Hospital IT Market,” which lists the top enterprise healthcare information technology (IT) vendors for the U.S. hospital market. Top niche vendors promoting specialized applications are listed separately. When specialty vendors and vendors targeting nonhospital markets are included, the health information system marketplace becomes a confusing morass of products whose capabilities are difficult to assess.

Fortunately, professional organizations like the HIMSS, hard copy and online content publishers like Health Data Management (, and trade and technology research companies like Gartner ( and KLAS ( help stakeholders to make more informed decisions.

HIMSS provides an online conference exhibitors guide ( in the form of a searchable database with an exhaustive list of healthcare IT companies, products, and services. Clicking on a product category results in the retrieval of vendor names, contact information, and brief descriptions of the products and services offered. HIMSS Analytics ( is a wholly owned not-for-profit subsidiary of HIMSS that offers services to providers and healthcare IT companies. Hospitals and other providers that participate in an annual study gain access to the HIMSS Analytics Database and a number of benefits free of charge, including an Electronic Medical Record Adoption Model Score, an American Recovery and Reinvestment Act Hospital Scorecard, benchmarking reports, up to four market overview reports, and the Annual Report of the U.S. Hospital IT Market. The HIMSS Analytics Database is available by subscription to healthcare IT companies, which may also purchase ad hoc data reports.

In addition to publishing a monthly magazine of the same name and maintaining an extensive website, Health Data Management maintains a resource guide ( by subject category. Similar to the HIMSS online conference exhibitors guide, clicking on a subject category returns vendor names, contact information, and brief descriptions of the products and services offered.

Gartner and KLAS provide fee-based ratings services. Gartner states, “We deliver the technology-related insight necessary for our clients to make the right decisions, every day.”3 KLAS declares that its mission is “to improve healthcare technology delivery by honestly, accurately, and impartially measuring vendor performance for our provider partners.”4 This is done by monitoring vendor performance based on feedback from healthcare providers and by conducting independent analyses of products and services. KLAS publishes a Best in KLAS Awards report annually for software, professional services, and medical equipment. KLAS's reports should be used with some caution, as the vendors cited by KLAS represent the rankings of just one ratings service, but they do serve as a resource. Additional information about these services is included in Chapter 16.

Major Types of Applications

Financial Systems

A financial information system (FIS) is a system that stores and records fiscal (financial) operations within an organization that are then used for reporting and decision making. There are various “financial” types of functions that healthcare organizations, like any other business, must perform to remain viable. These involve the following components:


    •A customer (patient) purchasing the product (receiving the service)

    •Salespeople (healthcare personnel) providing the service or product

    •A facility to receive the service or product (healthcare facility)

    •Supplies needed for a procedure (materials management)

    •Payment received by the healthcare organization for the product (service) received (receivables)

    •Monies received to be deposited in accounts (accounting)

    •Payment made to healthcare personnel and support staff for services performed (payroll)

    •Expenses paid (payables) to external constituents that made it possible to perform a procedure (mortgage, utilities, etc.)


The architecture of a typical FIS is illustrated in Figure 7-1. As Rogoski noted, FISs can no longer be regarded as “back-office” systems.5 Although it is true that financial functions are usually not a matter of life or death for the patient, an ill-fitted FIS can be life or death for the fiscal viability of the organization. Therefore one must choose wisely and update the FIS often to keep up with the ever-changing regulations and variations that affect the revenue and profitability of the organization.

Evolution of Healthcare FISs

Automated FISs were the first type of systems to be used in many healthcare facilities. The main purpose of these initial FISs was basic bookkeeping and payroll. Basic accounting systems were then put into place to help with the billing function. As Latham quotes: “Cash is king, so cash flow is the lifeblood of the kingdom.”6(p1) To get cash flow, charges must be captured and collected from the patient or the patient's third-party payment system. Entering charges and creating claims to send to insurance companies and patients were some of the first, and easiest, functions for an FIS. Payroll was also a very simple function for an FIS to perform. There was no need for analytics or importing to spreadsheets and reporting functions were limited.6 Healthcare organizations embraced the basic financial functions to remain financially viable. Figure 7-1 shows how financial transactions fit within the FISs.

Some of the basic financial systems required by healthcare organizations and other businesses are general ledger, payroll, patient accounting, claims processing, claims denial management, contracts management, and fixed asset management.

General Ledger.

The general ledger consists of all financial transactions made by the healthcare organization. This is similar to a personal checking ledger where any checks written or deposits made are recorded in the account. Numerous financial areas need to be tracked and as a result a healthcare organization will also maintain various subsidiary ledgers. Each of these ledgers tracks customer and vendor names,

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FIG 7-1 Financial information system architecture.


(Healthcare Financial Management Association Certification Professional Practicum PowerPoint.)

dates of transactions, types of transactions, and balances remaining. The FIS managing the general ledger must be able to track and report information in a variety of ways to meet the needs of the decision makers. Types of financial data that need to be tracked include the following:


    •Assets: Assets are property items that can be converted easily into cash. Assets are classified as tangible and intangible. Tangible assets include current and fixed assets such as inventory or buildings and equipment. Intangible assets include nonphysical resources such as copyrights or computer systems.

    •Accounts payable: Accounts payable are the monies that are owed to vendors and suppliers for items purchased on credit (very similar to using a personal credit card and then paying back the amount on a monthly basis). These usually occur in the form of invoices or statements. This would fall under the category of disbursements in many systems. Since many vendors offer discounts when paid by a certain date, the FIS needs to be able to track the dates that payments need to be made in order to receive the discount or avoid the penalties that may be applied for late payments.

    •Accounts receivable: The opposite of accounts payable, accounts receivable are monies that are owed to the institution. The vast majority of the dollars owed to the healthcare organization come in the form of patient-generated revenues. Once claims have been submitted to insurance companies (if the patient is covered by insurance), the remaining balance is sent to the patient for payment. The FIS has to be able to track the amount owed by the insurance, minus any negotiated rate such as managed care contracting, and the remaining balance owed by the patient. Ideally, the system estimates the amounts owed up front so the collection process can begin at the time of the visit.


Payroll Application.

The application that handles compensation payments to employees is the payroll system. This is also referred to as a disbursement system. The FIS application must be able to deduct taxes, benefits, possibly savings amounts, and other deductions. At the onset of FISs for payroll, the minimal functions could be performed. In today's more advanced systems, automatic payroll deposits and much more can be performed. In addition, overtime pay, pay rates, and payroll histories must be tracked and reported. At the end of the calendar year the system must be able to generate W2 forms for the employee to use in income tax preparation.

Patient Accounting Application.

A patient accounting application tracks the accounting transactions related to patient services. All charges that are incurred as a result of the patient visit need to be tracked and added to the patient's financial record. This can include inpatient fees if the patient is hospitalized; healthcare provider (physicians, nurse practitioners, etc.) and medication fees associated with the treatment; and procedure costs, including surgeries, radiology, and whatever else is necessary for the care of the patient. The procedural and diagnostic codes also become part of the patient billing record in order to complete the information necessary for the insurance payer to submit payment for the claim. Without critical information such as charges and coding, the claim process is delayed, resulting in reduced cash flow for the healthcare organization.

The collection process can begin at the time of the visit. This statement implies that the patient can receive services without paying anything up front. This is the reality in emergency situations. Because of the Emergency Medical Treatment and Active Labor Act (EMTALA), patients must be treated in the case of emergency regardless of their ability to pay. This can lead to hundreds of thousands of dollars outstanding that the healthcare facility will try to collect after the service has been performed. Therefore the collection process in healthcare is much different than the process in a traditional business that requires payment before the product or service is provided. Hence the FIS also needs to be able to track outstanding balances and assist in tracking these for the patient accounts personnel who will be attempting to collect the balances. The older the balances are, the more difficult they are to collect. The FIS needs to be able to differentiate the balances based on several factors, including, but not limited to, amount, payer, age of the account, and so forth. The features needed in today's FISs are much more complex than in the past. For example, today managers may need to track the revenue generated by staff as a measure of productivity.

Claims Processing and Management System.

As patients present for registration and admission, a single healthcare facility must be prepared to bill numerous insurance companies (third-party payers) representing hundreds of coverage and payment plans across government and private insurance. Some patients have primary coverage and supplemental coverage (e.g., Medicare as primary insurer and another insurer for supplemental coverage). Other patients receiving charity care or those with no insurance are categorized as private pay patients.

Claims processing and management is the submission of the insurance claim or bill to the third-party payer, either manually or electronically, and the follow-up on the payment from the payer. The application must be able to keep each of the payer types separate and know the requirements of how to bill the claims, who to bill for the balances, or if the balances need to be written off and not billed to anyone. Collections can be very challenging for the healthcare facility. Many new standards have been adopted for claims processing but there are still numerous different standards and requirements that must be followed for the various insurance companies and plans.

Sending “clean” claims is the key to getting payment quickly. Clean claims are those claims that contain all critical information such as patient demographics, charges and procedures performed, procedural and diagnostic coding, and other information required by the insurance company in order to remit prompt payment. Timely claims processing and collection are key to the fiscal health of institutions so they can meet the financial obligations in their disbursements and accounts payable functions. The claims processing application must review the claim before it is submitted to ensure that all necessary data fields are complete and accurate. If the claim is not clean, it will be denied, creating a delay and generating increased labor costs to correct errors before payment can be received for the service provided.

Claims Denial Management Application.

Denials from insurance companies are tracked and require follow-up. The claims denial management application can prevent denials imposed by the insurance carrier in a variety of ways. For example, the application can issue an alert on a request by clinical personnel for a patient to stay an additional day in his or her current patient status (i.e., observation, inpatient) if that request is likely to be denied by the insurer. The submitted insurance claim for a patient's stay may also be denied for improper coding or missing information. When the denial occurs, the application needs to be able to track the update and the progress on having the denial reversed. Because a claim or request was denied initially does not mean that the decision cannot be reversed. Persistence and proper documentation can be the deciding factors leading to reversal. Documentation must be detailed and included with the denial reversal request in order to be effective.7 In addition, the communications that took place between each area of patient care must be documented, collected, and stored in an orderly manner for the proof to be shown. This is just one example of why the FIS must be carefully integrated with the clinical systems.

Contract Management Application.

Healthcare organizations have a variety of contracts they must track, including those for supply chain management (SCM) and managed care. These types of contracts affect the bottom line of the organization, so the contracts must be tracked and managed in order for the organization to obtain maximum financial gain. SCM contracts include group purchasing, where healthcare systems negotiate a price for using a standard vendor. Vendor price comparisons and usage need to be tracked and the system must ensure that employees are adhering to the purchasing policies. Additional SCM functions can include providing incentives for healthcare providers to reduce the cost of their preferred supplies. For example, some surgeons may have particular instruments or supplies they prefer for surgical procedures. These supplies may be much more expensive than an alternative brand. The FIS could help the organization track the supply costs and the costs for procedures and provide reports for physicians to accompany requests for their assistance in reducing those costs.

Managed care contracting can be very challenging and complex. The contracts can be numerous and each contract can have different terms. The FIS needs to be able to track these contracts and manage the terms and results of each contract individually. For example, when a patient is covered by a nongovernmental insurance plan, the insurance company may have negotiated an agreed-upon amount for reimbursement per service or per patient. The insurance and patients need to be billed according to that contract's terms and any negotiated discount should not be billed.

Fixed Asset Management Application.

Fixed asset management applications manage the fixed assets in a healthcare facility that cannot be converted to cash easily, sold, or used for the care of a patient, such as land, buildings, equipment, fixtures and fittings, motor vehicles, office equipment, computers, software, and so forth. Each fixed asset needs to be tracked by location, person, age, and other factors. In a healthcare organization, the assets can be issued to a person, a procedure room, a department, and others. The FIS therefore needs to be able to handle the vast number of assets and the various areas in which the assets can be located. This system tracks depreciation, maintenance agreements, warranties related to the assets, and when the asset needs to be replaced.

Even though healthcare FISs during the first decade of the twenty-first century supported a number of improvements in the business processes, including patient scheduling, laboratory and ancillary reporting, medical record keeping and reporting, and billing and accounting, many opportunities still remain to improve efficiency, productivity, and quality, such as fiscal decision support.8

Financial Reporting

One of the primary functions of an FIS is providing the reports that demonstrate the financial condition of the organization. The most common reports for healthcare organizations are summarized in Table 7-1. Note that the titles may vary depending on whether the organization is for profit or not for profit.

TABLE 7-1 Financial Statements


Balance Sheet   Statement of Financial Position

Income Statement   Statement of Operations

Statement of Cash Flows    Statement of Cash Flows


TABLE 7-2 Income Statement

Description: C:\Users\chanda\AppData\Local\Temp\978-0-323-10095-3_0034.jpg

From Healthcare Financial Management Association Certification Professional Practicum PowerPoint.

The income statement or statement of operations is a good representation of the bottom line, or money left over (net income or loss), of the organization (Table 7-2). This report lists all revenues (monies coming in) and expenses (monies going out) and these are often compared to prior years and to the budget plan.

The balance sheet or statement of financial position shows a glimpse of the organization's financial condition at any given point in time (Table 7-3). The FIS needs to pull the financial data from assets, liabilities, and equity to present the report so the organization can determine whether the numbers in the categories are balanced. Balance sheet data are based on a fundamental accounting equation (Assets = Liabilities + Owner's equity), so each side must “balance” to show the financial condition of the organization.

The cash flow statements show whether the organization will be successful in paying its bills (have more money than it owes). Table 7-4 provides an example of a cash flow statement. Figure 7-2 illustrates how the cash flow statement reconciles with the income statement.

A healthcare organization keeps track of certain financial ratios to help it evaluate its financial condition; these can be important when borrowing for future capital investments. The FIS must be able to calculate and report ratios on demand so that at any given time the organization can assess its financial condition. Ratios are classified into several categories, such as solvency, debt, management or turnover, profitability, and market value. Several ratios are unique to the healthcare industry (Table 7-5), such as length of stay and bed occupancy. Average length of stay in the U.S. for most procedures is 4.8 days. Decision makers can analyze the length of stay for their hospitals to determine whether they are on track for most procedures. Keep in mind, however, that a shorter length of stay does not necessarily mean lower costs. Bed occupancy provides a quick glance at how many inpatient beds are being used. The occupancy is typically higher during flu season and other epidemics. The other ratios reported in Table 7-5 are typical of financial ratios for any organization. Accounts receivable days in a healthcare organization are generally higher than in other organizations since the services are provided before payment is made by the patient or insurance company.

TABLE 7-3 Balance Sheet

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From Healthcare Financial Management Association Certification Professional Practicum PowerPoint.

TABLE 7-4 Statement of Cash Flows

Cash Flow from Operations   $1,800.00

Net Income  $259.00

Adjustments  $1,541.00

Depreciation Expense   $(100.00)

Accounts Payable   $130.00

Credit Card Account    $50.00

Patient Credits  $0.00

Sales Tax Payable   $1.23

Accounts Receivable   $986.77

Inventory Asset    $473.00

Cash Flow from Investing    $(1,000.00)

Equipment    $(1,000.00)

Cash Flow from Financing    $1,500.00

Opening Balance Equity    $2,000.00

Owner's Equity    $(500.00)

Draw    $(500.00)

Investment   $0.00

Net Change in Cash  $2,300.00

From Healthcare Financial Management Association Certification Professional Practicum PowerPoint.


Challenges with FISs

One of the challenges that large healthcare organizations face with the implementation of FISs is ensuring that the various systems in place at numerous locations are integrated. Larger healthcare organizations can include 20 or more facilities. Within each of these facilities can be numerous subfacilities. The different financial systems, applications, and SCM systems can become very complicated when they are merged and the information systems do not interface well.5

The purpose of healthcare organizations is to provide quality patient care. While generating maximum revenue is not its defining purpose, an organization must generate income to stay in business and advance new programs and services. What this means is that patient care systems can be seen by some as a higher priority than FISs. Decision makers may have a more challenging time realizing the return on investment or understanding the importance of the investment in FISs since IT software applications such as patient accounting or revenue are considered an intangible asset. The key is to ensure the integration of the various applications.9 If an information system meets the requirements needed for patient care and it includes integrated applications such as patient accounting, the organization will have the best of both worlds. True integration supports the effective transfer of captured data across all applications. This leads to improved efficiency and enhanced cash flow, and the total cost of ownership is lower.

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FIG 7-2 Statement of cash flows and reconciliation with income statement.

(Healthcare Financial Management Association Certification Professional Practicum PowerPoint.)


FIS Integration

Financial systems matured much faster than clinical systems.10 Integration within the FIS and across clinical systems eliminates duplication of effort, which also reduces the number of potential errors. Williams points out the following benefits from integration:


    •A transition is provided between front-end and back-end operations.

    •Information required for billing such as demographics and insurance can be gathered and verified at the point of service or admission and the information is immediately available for patient care and financial personnel.

    •Eligibility checking for insurance can be done online; automated charging is supported, eliminating the need for charge entry.

    •Availability of clinical records with detailed charges that has been secured through proper access allows staff to respond to questions from patients, payers, or others without having to pull paper charts.10


All of these features of integration result in an improvement to the bottom line, which is what healthcare finance is about. In addition to the basic accounting systems such as general ledger, accounts payable, and accounts receivable, FISs handle more complex functions such as activity or project management. Advanced revenue cycle IT, or new generation, is often referred to as integrated “bolt-ons.”9 TechTarget describes a bolt-on as a product or system similar to an add-on but one that can be attached securely to an existing system ( Besides integrated bolt-ons, there are workflow rules engines, advanced executive scorecards, and single database clinical and revenue cycle systems.9 Workflow rules engines help to manage workflow. For example, documents can be stored in a document management system and email or event reminders can be automatically sent to the people involved with the tasks. Advanced executive scorecards are strategic management tools that aggregate data from electronic health records

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FIG 7-3 Revenue cycle function.

(Healthcare Financial Management Association Certification Professional Practicum PowerPoint.)

(EHRs) in concert with an FIS, thereby providing a snapshot of how the company is performing in certain areas. These “scores” can be compared to other companies in the same line of work.

A single database clinical and revenue cycle system is a system used to ensure accuracy, availability, and data integrity for patient care and billing for the healthcare organization. When changes are made to information contained within the database, those changes are managed throughout the system. In other words, the user does not need to make the change in multiple locations; the database management system will do that for the user to ensure that all necessary changes have been made. This is particularly important when dealing with procedures, documentation for those procedures, and the charges that accompany those procedures. In line with the original accounting systems, these advanced systems are designed to improve billing by reducing billing errors, improve the timeliness of billing to cash collected and the cost to collect, provide real-time eligibility, and provide improvements to current operational efficiencies via other functions.9

Improvement in cash flow has remained a constant goal since the onset of FIS. Adaptability and flexibility in healthcare are the key to successful patient care and quality and the same applies to FIS choices. An example of the revenue cycle is provided in Figure 7-3.

One of the more recent IT tools used to positively affect the revenue cycle is a communication management system. The variety of communications (e.g., patient care, insurance coverage, patient admission), the method of communication (e.g., face to face, phone, fax, Internet), and the number of people engaged in communications make organizing and tracking communications a complex process. As Cruze points out, communications surrounding care of the patient and payment can be very difficult to track and retrieve.7 A centralized management tracking system could assist in this area. An audit trail needs to be very detailed and include all communications that capture and travel with the patient as well as the authorizations associated with each step. In other words, these communications need to be captured, indexed, and archived for future retrieval.7

Efficiency Tools

Decision makers need tools to capture productivity for various activities within the financial services area of the organization. For example, collecting balances from the patient may fall within the responsibilities of a handful of employees. At the front end, patients who have been preregistered can be asked for payment on the estimated amount owed. At the back end, patients who have a remaining balance after insurance has paid will need to pay that balance. How does an organization know which employees are having success at collecting payments? The reporting tools need to provide a snapshot of the data so the decision makers can immediately analyze financial events within a particular area.

In addition to reporting tools, the application needs to be able to assist end-users with the questions that need to be asked, and when. For example, if a patient has an outstanding balance from a previous visit, the patient access personnel may need to know whether they should request payment. Information needed should be readily available and easy to access. When adaptable and flexible designs between clinical and financial systems are combined, powerful analytics are deployed via the web to every desktop; many activities are self-service, freeing up valuable time and resources for the healthcare organization.9

Operations have become more complex. For example, charge capture has increased in complexity just as medical care has.9 As a result, there needs to be a more seamless flow of charges as a natural by-product of the care process to help reduce lost, late, or duplicate charges. These new functions require an investment in a new system to handle revenue cycle management.11 A dashboard provides a visual analysis of specific data points so an organization can gauge how it is performing in certain areas (it is called a dashboard since it resembles the visual data points provided on an automobile dashboard). In addition, Moore points out features needed in an FIS to increase efficiency, including integrated compliance (i.e., coding edits), flexibility to override default values when the decision maker deems it necessary, ease of use (which increases employee efficiency), and executive dashboard capabilities.11

Practice Management Systems

Practice management systems (PMSs) are very similar to the information systems supporting integrated healthcare systems, only on a smaller scale. These applications focus on the services provided in a healthcare provider's office compared to the services provided in a large healthcare system or hospital. Similar to the hospital revenue cycle management system, the PMS is designed to collect patient demographic information, insurance information, appointment scheduling, the reason for the visit, patient care procedures performed for the patient, charging information for the billing process, and collection and follow-up. As with inpatient or acute care systems, PMSs require integration. The primary differences between PMSs and information systems supporting hospitals are specific provider scheduling templates and types of visits, transaction or line-item provider billing compared to account-driven hospital billing, and provider-based medical record content (orders, referrals, provider documentation, problem lists) that differs from the typical comprehensive hospital medical record.12 The charges from a medical practice office are connected to codes used for practice management billing and include Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT). Therefore the information system must be able to generate claims using this type of coding, usually through an electronic submission. Electronic medical records (EMRs) have become much more common modules within a PMS as the U.S. government has implemented incentives supporting EHRs (discussed in Chapter 6). An explanation of the difference between an EMR and an EHR can be found at Information on the episodes of care maintained in the EMR can be passed along to the hospital or health center should the patient need to be admitted. Sharing this information helps to ensure that the information in the EMR becomes part of the EHR. However, this is often not a “plug and play” environment. Creating a successful interface to share data between the EMR of a practice and a hospital or health center information system is a complex process. Chapter 12 includes additional information on health information exchanges (HIEs) and health information organizations (HIOs) and the issues involved with these.

In outpatient settings healthcare providers can spend much of their time documenting the details of the patient visit. There are a variety of ways to accomplish this, including documenting and recording what is being said and done while the patient is in the examination room, dictating and transcribing based on written notes, or using voice recognition software during or after the visit. Traditionally, visit notes were often transcribed by a third party, leaving room for error through misreading of handwriting or mishearing of dictation. There is also a time delay until the documentation becomes part of the patient record because of the multiple processes required. As well, the healthcare provider is required to review and sign off on the final documentation but time constraints can encourage the provider to rush and perhaps overlook some details.

A method using more enhanced technology and providing quicker turnaround is voice recognition. These software capabilities have greatly improved over the last few years. Voice recognition eliminates the need for a third party and allows healthcare providers to input information themselves, saving steps, time, and money. The application allows text to be viewed in real time and providers can edit and approve it immediately. The time savings can result in much more timely billing and improved cash flow versus waiting for dictated notes to be approved after being transcribed.

Box 7-1 Benefits of Implementing an Online Payment Tool

For Patients and Provider Offices


    • Self-management of their open accounts

    • Ability to pay outstanding balances

    • Secure communication on a 24/7 basis with the business office (the practice will determine the turnaround time of communications to the patient)

    • Ability to update address or demographic changes

    • Ability to update changes to insurance coverage (which often occur annually)

    • Preregister for services or appointments

    • Enhanced customer service capabilities

    • Ability for staff to accept payments in person or over the phone

    • Ability for staff to view the patient statement exactly as submitted to the patient, which helps to improve communications and efficiencies for payment collection


Data from Conley C. Improve patient satisfaction and collections with efficient payment processes. Healthcare Financial Management Association. January 1, 2009. Accessed December 18, 2011.

Patient Outreach System

Some practices specialize in providing preventive care to manage patients with chronic illnesses. In these practices an electronic registry of the clinic's entire patient population can be used in a patient outreach system. The registry includes the demographic and medical record information needed to notify patients and an automated reminder capability.13 Patient outreach systems should incorporate evidence-based, specialty-specific protocols—or recommended care guidelines—for chronic and preventive care. Then, once the outreach system identifies patients due for preventive screenings and follow-up care for chronic diseases, the patients are contacted via an automated phone messaging system or another computerized method.

Online Billing and Payment Tool

Collections in a practice can be just as challenging as collections in a hospital except that few emergency cases occur in a provider practice setting, allowing office staff to determine the acceptability of denying services to a patient until a payment plan has been established. In addition to routine collection practices, implementing an online billing and payment tool (e.g., using a credit card to pay online) can help to improve the management and collection of fees owed by patients.14 Conley states that the healthcare facility can realize increased patient satisfaction and improved staff efficiencies by implementing an online payment tool.14 Benefits for the patient and the provider's office are outlined in Box 7-1.

Hospital–Healthcare Provider Connection

PMSs integrated with the hospital information system can be more efficient for healthcare providers in a clinic or private practice. According to Cash, physicians, nurse practitioners, physician assistants, and others with staff privileges who participate in the hospital network have certain expectations about the IT, including that it should:


    •Provide a single sign-on to an integrated information system from all key system entry points

    •Automate the provider's day as much as possible using mobile access (automation means that access is available wherever the clinician is and that the information is in a useful format)

    •Have 24/7 support for any device, anywhere

    •Provide a dashboard to view critical clinical and financial information with the ability to act on it immediately15


Healthcare provider dissatisfaction can occur if the information system:


    •Slows him or her down in the task at hand

    •Reduces the ability to bill insurance or the patient

    •Adds more administrative duties to already maxed-out schedules (remember that providers want to practice medicine and leave administrative tasks to office personnel)


A Matter of Perspective

All healthcare providers have patient care as a top priority. While the provider's focus may be on care of the patient, office personnel must focus on receiving maximum payment for the care of that patient. The records stored at the practitioner level must be accessible and transferable to the hospital in the case of an admission or referral. Health information exchanges are making this possible for referrals, consultations, admissions, discharges, and transfers. IT solutions such as EMRs, digital storage of patient data, voice recognition software, and emailing of correspondence can offer efficiency, cost savings, and improved patient care, which should be the priorities of practice management.16

Materials Management

Materials management in healthcare is the storage, inventory control, quality control, and operational management of supplies, pharmaceuticals, equipment, and other items used in the delivery of patient care or the management of the patient care system. It is a subset of the larger function of SCM; the supply chain also includes the acquisition of materials of care and the logistics or movement of those materials to caregiving facilities and organizations. Routinely, health systems deploy information system solutions to support SCM.

Healthcare Supply Chain and Informatics

The acquisition, logistics, and management of materials in healthcare are complex and require a sophisticated information system to provide effective, efficient, and efficacious materials as needed. Typically materials management, also known as central supply in the hospital, bears the burden of having the right item at the right place at the right time. The healthcare supply chain is complex, with requirements that go across, for example, the equipment for operating suites, pharmaceuticals, and medical and surgical supplies for all settings. In any health system with hospitals, clinics, and

Description: C:\Users\chanda\AppData\Local\Temp\978-0-323-10095-3_0031.jpg

FIG 7-4 Extract sample of a supply item master file.

(Dr. Jerry Ledlow, personal files.)

employees ordering from the supply chain, thousands of transactions occur daily across hundreds of vendors.

The sophistication in automating this process has increased tremendously in the past 2 decades. Applications now include electronic catalogs; information systems such as enterprise resource planning (ERP) systems from vendors such as Lawson ( or McKesson (; warehousing and inventory control systems from vendors such as TECSYS ( and Manhattan (; exchanges from vendors such as Global Health Exchange (GHX) (; and integration with other systems from vendors such as clinical, revenue management, and finance. An innovative technology in this area is radio frequency identification (RFID); more information can be found at

These systems have improved supply chain performance and management in healthcare, with more innovations expected in the future. The healthcare supply chain is an untapped resource of financial savings and revenue enhancement opportunities.17 Recognizing these opportunities, HIMSS advocated for more improvements in a white paper titled Healthcare ERP and SCM Information Systems: Strategies and Solutions. HIMSS indicated that ERP systems will be tools for quality and safety because they integrate capabilities such as procure-to-pay, order-to-cash, and financial reporting cycles. These functions should help institutions match needed materials with care in a more timely and cost-effective manner.

Integrated Applications in Supply Chain Management

The importance of these ERP and SCM systems should be apparent, including the technology associated with them, such as bar code scanners and electronic medication cabinets (e.g., Omnicell,; Pyxis, The basic components of an integrated healthcare supply chain system include the following:


    •Supply item master file: A list (hard copy or electronic) of all items used in the delivery of care for a healthcare organization that can be requested by healthcare service providers and managers. This file typically contains between 30,000 and 100,000 items. Figure 7-4 shows a supply item master file.

    •Charge description master file: A list of all prices for services (e.g., Diagnosis-Related Groups [DRGs], HCPCS, and CPT) or goods provided to patients that serves as the basis for billing.

    •Vendor master file: A list of all manufacturers or distributors (vendors) that provide the materials needed for the healthcare organization along with the associated contract terms and prices for specific items. This file typically contains 200 to 500 different vendors or suppliers.

    •Transaction history file: A running log of all material transactions of the healthcare organization. In a computerized system, it is a running list of all supplies and materials being used to deliver care or manage the operations of the institution.


These four files must be integrated to support the operations and management of the supply chain. The integration necessary in the modern healthcare organization is illustrated in Figure 7-5 as a diagram of interfaces across supply chain, clinical, and financial systems.18

Supply Cost Capture

“In all industries, not just healthcare, three out of four chief executive officers consider their supply chains to be essential to gaining competitive advantage within their markets.”19(p2),20 According to Moore, if the trend in the cost of the healthcare supply chain continues to grow at the current rate, supply chain could equal labor cost in annual operating expenses for hospitals and health systems between 2020 and 2025.21 Clearly, maximizing efficiency of the healthcare supply chain is an increasing concern.

Consider supply charge capture events in which patient-specific supplies are ordered for the care of that patient and the items are then billed separately to the patient. “Every year, hospitals lose millions of dollars when items used in the course of a patient's care somehow slip through the system without ever being charged or reimbursed.”22(p1) Point-of-use technology, or capturing charges when supplies or materials

Description: C:\Users\chanda\AppData\Local\Temp\978-0-323-10095-3_0032.jpg

FIG 7-5 Wire diagram of healthcare supply chain information systems.

(Dr. Jerry Ledlow, personal files.)

are used, allows healthcare institutions to increase productivity, increase accountability, and reduce downtime through improvements in their internal supply chain. Automated dispensing machines for medications or supplies can be used to decentralize store operations, capture charges, and bring supplies and materials to employees without compromising security and accountability.23 These systems, if integrated with a solid business process, can enhance efficiency and effectiveness of the healthcare supply chain.

Strategic factors associated with supply success and enhancement are important as well. These include the following:


    •Information system usefulness, electronic purchasing, and integration

    •Leadership supply chain expertise

    •Supply chain expenditures

    •Provider level of collaboration

    Box 7-2 Process Standardization

    Process Standardization in Conjunction with Utilization of an Information System

        •Develop standard (or more standardized) processes for:

            •Item Master and CDM maintenance and synchronization

            •Supply stock selection, reduction, compression and management

            •Supply charge item capture (accurate and timely)

            •Accountability measures for Central Supply and clinical units

            •Standardize clinical/floor stocked supplies replenishment processes

            •Daily reconciliation of pharmaceuticals and medical/surgical supply items, especially supply charge capture items

                ○Taking into consideration:

                    ▪Clinical unit needs

                    ▪Physical layout variations may require modification to an accepted standard

                    ▪The business process must be efficient before a technological solution can be integrated into the process

                    ▪“One size” solution will not fit all

    Process Standardization in Process Improvement: Balancing Trade-Offs

        •Competing goals exist between various stakeholder groups; trade-offs will be required to find the proper balance that best meets all needs.

            •Clinician Goals

                ○Does not impede caregivers or patient care delivery

                ○Minimize rework

                ○Right supplies, right place, right time

            •Supply Chain Managers/Central Supply Goals

                ○Improve accuracy for supplies consumed

                ○Improve timeliness for supply consumption

                ○Efficient use of labor

            •Revenue and Cost Avoidance Goals

                ○Procure and acquire material wisely with contracted compliance goals

                ○Efficient management of materials considering utilization rates, preferences, expiration dates and Food and Drug Administration requirements

                ○Reduce number of supply charge capture items

                ○Improve accuracy for charge capture

                ○Improve timeliness for charge capture

                ○Improve charge capture rate

    CDM, Charge description master.

    From Ledlow JR, Stephens JH, Fowler HH. Sticker shock: an exploration of supply charge capture outcomes. Hospital Topics. 2011;89(1):9. Reprinted by permission of the publisher (Taylor & Francis Ltd,

    •Nurse and clinical staff level of collaboration

    •Leadership team's political and social capital

    •Capital funds availability19


This section has provided a high-level overview of technology in materials management. Box 7-2 details specific considerations for automating SCM and materials management.24

Human Resources Information Systems

Human resources information systems (HRISs) leverage the power of IT to manage human resources. They integrate “software, hardware, support functions and system policies and procedures into an automated process designed to support the strategic and operational activities of the human resources department and managers throughout the organization.”25(p58) The authors distinguish between operational, tactical, and strategic HRISs. Operational HRISs collect and report data about employees and the personnel infrastructure to support routine and repetitive decision making while meeting the requirements of government regulations. Tactical HRISs support the design of the personnel infrastructure and decisions about the recruitment, training, and compensation of persons filling jobs in the organization. Strategic HRISs support activities with a longer horizon such as workforce planning and labor negotiations. In contrast, Targowski and Deshpande state that generic HRISs typically include the following subsystems defined by function: recruitment and selection; personnel administration; time, labor, and knowledge management; training and development; pension administration; compensation and benefits administration; payroll interface; performance evaluation; outplacement; labor relations; organization management; and health and safety.26

Human Resources Information Systems as a Competitive Advantage

Khatri argues that the management of human resources in healthcare organizations is a central function because the healthcare and administrative services delivered are based on the knowledge of staff delivering these services.27 Human resources management should focus on employee training as well as developing and refining the work systems to improve the work climate and the quality of service to customers. Although healthcare organizations should include the effective management of human resources as part of strategic planning, most fail to do so. Khatri offers three reasons why many healthcare organizations do not employ optimal human resource practices. First, he argues that human resource activities are institutionalized and undervalued in many healthcare organizations. Second, the clinical culture of healthcare focuses on the clinical delivery of care with less attention paid to the effective management of resources. Finally, low skills in the human resource function have limited the ability of human resource managers to engage effectively in strategic and operational planning. Khatri's premise is that improving human resource capabilities should help human resource managers engage more effectively in managing human resources.

Box 7-3 Sample Vendors Offering Comprehensive Human Resources Information Systems


    • Lawson Healthcare Solutions Suite (

    • McKesson Enterprise Resource Planning Solution (

    • Oracle PeopleSoft Enterprise (


Khatri further proposed five dimensions of human resources capability. The first four are a competent human resources executive in the C-suite, a skilled human resources staff, an organizational culture that elevates human resources to a central function, and commitment to continuous learning. An integrated, computerized HRIS is the final capability.

Human Resources Information Systems Vendors

KLAS analyzed whether HRISs deployed in healthcare institutions have similar capabilities and whether HRISs have developed additional capabilities in the intervening years. The reports should be used with some caution, as the vendors cited by KLAS represent the rankings of just one ratings service; however, this strategy does pare down a much more extensive list of HRIS vendors to just a handful to assess the capabilities representative of these systems. Three examples with comprehensive solutions are listed alphabetically in Box 7-3.

Two vendors offer component solutions that provide some but not all of the components of a complete human resources information system. Although not cited as current Best in KLAS Award winners, the component solutions these vendors offer compete with those of the enterprise human resources suites for the component services that they offer.


    •API Healthcare Human Resources and Payroll (

    •Kronos Workforce HR/Payroll (


Human Resources Subsystems

The human resources subsystems described below reflect a modification of the subsystems described by Targowski and Deshpande and represent a taxonomy of functions typically described by the vendor websites for HRISs.26

Personnel Administration.

The centralized and integrated management of employee data is a key feature of HRISs. Personnel records are maintained and updated with information such as employee identification and demographics, dates of service, position and job code, location code, and employment status (permanent or temporary, full time or part time). Systems also maintain records of licensure, credentials, certifications, and skill proficiency levels. Increasingly, self-service capabilities allow employees to maintain a personal profile with the ability to access and modify personal information such as name, address, contact information, marital status, and information about dependent family members.

Managing Human Resources Strategically and Operationally.

HRISs can be used to address in whole or in part the challenge of managing human resources from a strategic and operational perspective. First, strategic management of human resources can be accomplished by accurately reflecting the organizational structure of the healthcare institution. This can be completed by using a wiring diagram to illustrate the hierarchy of positions in the organization, the job descriptions associated with each position, and whether the positions are filled or vacant. This analysis is then used to support the recruiting process for vacant positions. Functions that support this process include posting job announcements and application forms; providing status reports for submitted applications; maintaining interview schedules; and providing selection tools such as dynamic interview guides, multistage testing, computer adaptive testing, and minisimulations. Once a decision is made, the formal job offer letter and new employee benefits can be viewed online. Vendors who offer these types of functionality include Oracle's PeopleSoft ( and Kronos (

HRISs should also have the capability to assist employees in transitioning out of the organization when discharged, displaced by reductions in the workforce, or retiring.26

Staffing and Scheduling.

Staffing and scheduling replaces the subsystem “time, labor, and knowledge management” as a more accurate representation of the activities supported by this HRIS subsystem. Staffing and scheduling are two different activities. Staffing involves the assignment of personnel to job positions while ensuring that they are qualified by virtue of degree, licensure, certification, training, and experience. Scheduling involves the assignment of qualified personnel to a scheduling template within a work area in the organization to fulfill the mission of that organization. Scheduling of personnel such as nursing staff is extremely challenging, so much so that nurse scheduling can be considered a definitive representative of the archetypal multishift scheduling problem found in operations research and management sciences literature.

Each of the vendors discussed in Box 7-3 offers both staffing and scheduling modules. Other modules manage scheduling for nurse education and facilitate self-scheduling in conjunction with temporary staff management to fill openings in the schedule. Another vendor, Unibased USA RMS, has been the Best in KLAS award winner for enterprise scheduling for the past eight years (

Key requirements for staffing and scheduling include cost-effective staffing while meeting constraints imposed by required qualifications, scheduling visibility, and matching the level and number of caregivers to patient classification and acuity levels as mandated by law or regulation. An example of an enterprise staffing and scheduling product focused on nurse scheduling is McKesson's ANSOS One-Staff. Functions provided by these systems include the following:


    •Staff schedules derived from patient acuity and workload data collected by the software

    •Hospital schedules automatically generated to meet core coverage goals while enforcing scheduling rules customized to meet schedule constraints and accommodate individual scheduling preferences

    •Synchronous staffing data provided to managers to ensure that nurse-to-patient staff ratios are met

    •Web-based self-scheduling

    •Productivity and labor cost reporting28


Once scheduled, employees' time and attendance are tracked. Key elements include accurate time collection, implementation of user-defined pay rules, compliance with a variety of labor laws, and expeditious identification of productivity or overtime issues.

Just as schedules must be explicitly developed, time-off policies must be proactively managed because of their effect on the schedule. These time-off policies are designed to meet the requirements of federal labor laws such as the Family and Medical Leave Act (FMLA) and state and local laws. In addition to meeting legal and regulatory constraints, time-off policies must enforce organizational policy for vacation, maternity leave, and sick leave. The software used to do this is referred to as “leave management” or “absence management” and is typically a rules-based application designed to manage absence requests while interfacing with workload scheduling.

Because of the difficulty of scheduling in healthcare, innovative scheduling solutions are becoming increasingly common. API Healthcare provides software incorporating three solutions:


    •Open shift management: This is a web-based self-scheduling solution in which the nurse manager broadcasts openings in the schedule to qualified staff via a number of instant communication tools. Staff members respond by tendering schedule and shift requests for consideration and approval.

    •Incentive management: This involves the use of monetary and point-based rewards for staff who volunteer to fill openings in the schedule.

    •Predictive scheduling: Predictive modeling is used to forecast bed demand while accounting for variables such as bed turnover, changes in patient acuity, workload distribution, and variability caused by shift, day of the week, month, and seasonality.29


Another vendor, CareWare (, is a relatively new entry into the health care staffing and scheduling arena, with a suite of products that manage time and attendance, assess patient acuity and estimated nurse workload, and employ intelligent scheduling algorithms to create optimal nursing schedules.

Training and Development.

The three comprehensive vendors featured in Box 7-3 also addressed staff training and development. IT solutions should be able to be used as the infrastructure to plan and manage employee training, to serve as the delivery mechanism synchronously and online, and to link training with the developmental plan for each employee by identifying shortfalls in skills and competencies and then recording when those shortfalls have been remediated.26

Compensation, Benefits, and Pension Administration–Payroll Interface.

“Compensation and benefit plans vary from company to company. They include various plans like flexible and non-flexible healthcare plans, short and long-term disability plans, saving plans, retirement plans, pension plans and Flexible Spending Accounts.”26(p46) When coupled with personnel administration and staffing and scheduling systems and supported by timekeeping and absence management software, management of compensation, benefits, and pension administration becomes more accurate and less time consuming.

One example of a vendor offering integrated compensation, benefits, and payroll applications is Oracle's PeopleSoft ( This type of system permits managers to view and update employees records online, receive alerts and decision support when changes in salary and benefits are being considered, receive reports on individuals as well as groups of employees, and permit employees to view and maintain their own records as appropriate. For example, employees may record the renewal of a license or changes in addresses.

Performance Evaluation.

“Talent management” and “performance management” are terms used by several vendors. From the healthcare provider's perspective the focus is on recruiting and training employees and developing competencies required to fulfill institutional goals and objectives. The individual career goals of employees are also considered. Information capabilities in this area include the following:


    •Profiling employee competencies and any gaps

    •Identifying when employee and organizational goals are met

    •Identifying top performers

    •Manager capabilities such as a dashboard to display unit performance


Lawson's Performance Management is an example of this kind of software.30

Underrepresented Subsystems.

Labor relations and health and safety have received less attention from vendors developing information for managing human resources. On the other hand, web-based expense and travel applications have become more prevalent in healthcare organizations. These areas may represent future directions for ERP systems.

Business Intelligence Systems

For the past 2 decades healthcare institutions have been building data warehouses and integrating data. Along with the technical aspects, data warehousing includes improving data quality, developing protocols for governance, and determining how to select and employ the appropriate analytic measures. This is difficult because of practice variation and changes to the standards of practice over time. Dick Gibson, the CIO of Legacy Health, notes, “We generate and use data like any other industry, but health care does not lend itself to the use of discrete data because the outcomes are necessarily fuzzy and ongoing. Airlines have seats, schedules and know if you landed on time. In health care, we know if you are alive but the big money goes to broad sets of descriptive terms around patient care that are very qualitative.”31(p29) These descriptive terms can be captured more succinctly by the use of diagnostic and procedural codes but data quality and integration is a problem because of the number of procedures and number of providers engaged in the delivery of care.31

Many organizations are turning to business intelligence (BI) software to provide tools to effectively manage and leverage their massive amounts of data. BI software is purported to lead to an improvement in financial (particularly revenue cycle) and operational performance, as well as patient care.32 Implementing BI in healthcare that successfully integrates financial and clinical data is regarded as one of the four pillars of the Value Project undertaken by the Healthcare Financial Management Association.33 Business intelligence is defined as the “acquisition, correlation, and transformation of data into insightful and actionable information through analytics, enabling an organization and its business partners to make better, timelier decisions.”34(p142) However, Glaser and Stone warn that for the BI to be most effective, the following must happen.32 For the analysis to be understood, the BI tools must be placed in the hands of the people who actually do the work; training must be done initially and throughout the project so that users will have time to use the basic functions and expand their knowledge; questions that arise throughout the analysis must be reviewed and answered; and the BI should be used for long-term planning. Glaser and Stone describe the BI platform as “a stack—one technology on top of another.”32(p69) Their description was used to construct Figure 7-6. Effective management of this stackable technology involves making the business case for BI; establishing implementation targets; enlisting BI champions; governing effectively; and establishing BI roles to include data stewards, data owners, business users, and data managers.32

As with the other information systems discussed in this chapter, BI systems may be part of an enterprise system, provided as component software, or employed at application level. Most of the major healthcare information system vendors have BI software imbedded in their products. For example, McKesson has Enterprise Intelligence, Cerner has Knowledge Solutions, Seimens has Decision Support Solutions, and Allscripts has Integrated Performance Management.

KLAS lists the following vendors in this category of software but they are not part of an enterprise healthcare

Description: C:\Users\chanda\AppData\Local\Temp\978-0-323-10095-3_0033.jpg

FIG 7-6 Business intelligence (BI) platform.

(Data from Glaser J, Stone J. Effective use of business intelligence. Healthc Financ Manage. 2008;62[2]:68-72.)

information system. Instead, they provide BI solutions intended to support analytics in conjunction with enterprise software or they provide analytics for a segment of the healthcare marketplace.


    •Dimensional Insight's The Diver Solution ( provides BI and performance management solutions whose applications specific to healthcare include productivity reporting, provider network management, outcomes measurement, disease management, usage review, and Meaningful Use. Other applications that could have utility in healthcare include customer service, finance, human resources, sales and marketing, and supply chain analytics. Capabilities include data discovery and integration without the need to build a data warehouse, interactive dashboards and scoreboards available through a web-based portal, a consolidated view of enterprise data, a variety of data visualization options, and access through a variety of mobile devices.

    •IBM Cognos Business Intelligence ( offers a tailored line of BI software products, with Cognos Enterprise providing large-scale BI and performance management with capabilities similar to those described for Dimensional Insight, Cognos Express targeting midsize companies and work groups, and Cognos Insight providing desktop analytics for the individual user. IBM also owns the SPPS suite of statistical products.

    •Information Builders WebFOCUS ( advertises capabilities similar to Dimensional Insight and IBM Cognos Business Intelligence.

    •Omnicell Pandora Clinicals ( is part of Pandora Analytics, a suite of products that also includes Pandora Financials. Omnicell Pandora Clinicals provides the analytics to manage medication compliance and clinical operations. Pandora Financials facilitates cost and inventory management.

    •Vitera Practice Analytics ( provides clinical and BI for ambulatory practices.


Given the cost, time, and complexity of the large-scale implementation of enterprise BI, application-level BI should be employed strategically to address “key processes, functions, or service lines.”35(p95) Application-level BI software provides some of the data integration and visualization of enterprise packages, analyzes existing data that may be overlooked in traditional reporting, and creates actionable knowledge. However, some caution is necessary. Glaser and Stone note that ad hoc, smaller-scale analysis may lead to the creation of data silos, inefficient or repetitive management of data, and unnecessary duplication.32 These are appropriate cautions but application-level BI can complement the development of enterprise BI by producing results in the interim as the enterprise capabilities are developed.35

Conclusion and Future Directions

Given the magnitude of the investment in health information systems and the fact that administrative applications are more mature than clinical applications, a salient question is whether these administrative applications have made healthcare delivery more productive. In “Unraveling the IT Productivity Paradox—Lessons for Healthcare,” Jones, Heaton, Rudin, and Schneider explore the paradoxical relationship between “the rapid increase in IT use and the simultaneous slowdown in productivity.”36(p2243) Several lessons emerge from the authors' analysis:


    •Mismeasurement partially contributed to the paradox. The authors suggest that “assessment of the value of healthcare outputs could be improved through the more sophisticated use of clinical data to understand access, convenience, and health outcomes.”36(p2244)

    •New information technology often requires redesign of the processes that were previously tailored to the technology or manual system just replaced.

    •New information technology that fails to be user-centered compromises productivity.

    •Finally, healthcare organizations can no longer afford to have an abundance of untapped data that fails to improve decision making. Improvements in healthcare information systems, BI, and analytics must continue to improve the quality of decision making.


Administrative systems in this chapter were listed as separate applications because they evolved independently of clinical systems. Many of the future benefits will accrue from integrating data from all systems. For example, if a healthcare system cannot effectively track the total cost of all materials used to treat an individual patient and aggregate data to determine the cost of treating groups of patients, managing the cost of healthcare is not possible. As new information becomes available for decision making, healthcare professionals on both the administrative and the clinical sides of the organization will need to learn new interprofessional approaches to using these data in making decisions.



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Discussion Questions


    1. Explain why healthcare facilities would require the use of an FIS and provide examples of this type of system.

    2. Describe how a decision maker would use the FIS reporting function to make decisions and provide a summary of what the various reports tell the decision maker.

    3. Explain the importance of physicians using a PMS and provide examples of tools that can be used at the point of care.

    4. Describe and defend three principles of a quality SCM system with regard to patient care and support of clinicians providing care.

    5. Discuss how self-service applications are typically deployed in HRISs.

    6. Discuss the advantages and disadvantages of using BI at application level as opposed to enterprise level.


Case Study

Michael H. Kennedy, Kim Crickmore, * and Lynne Miles *

Managing the flow of patients and bed capacity is challenging for any hospital, especially for unscheduled admissions. For Zed Medical Center, a large regional referral center in the South and a member of the University HealthSystem Consortium, the challenge is even greater. As the flagship hospital for a multihospital system with more than 750 licensed beds and a Level 1 trauma center with 50-plus trauma beds, approximately 70% of annual admissions are unscheduled.

The Assistant Vice-President for Operations has a PhD in Nursing, is a Fellow of the Advisory Board Company, and has more than 20 years' tenure at Zed Medical Center. Three of the ten departments under her purview (Patient Care Coordinator, Bed Control, and Patient Transfers) are directly engaged in managing patient flow and bed capacity. The division is also responsible for systemwide care coordination for patients discharged to skilled nursing facilities, to home health, and to home without planned service delivery. Current operational goals include (1) decreasing the current length of stay by 0.3 days from 5.7 to 5.4 days and (2) “ED to 3”—a slogan incorporating the intention to place patients from the emergency department into a bed within 3 hours of the decision to admit. With the Centers for Medicare & Medicaid Services in the process of clarifying penalties for readmissions within 30 days, Zed Medical Center has begun to prepare by determining its baseline percentage of readmissions within 30 days.

The eight staff members assigned to Patient Transfers coordinate with hospitals within the region wanting to transfer patients to Zed Medical Center. They take calls, connect outside transfers with accepting physicians, and arrange transport. The accepting physician determines the patient's needed level of care, special care needs (e.g., diabetic), and the time frame for transfer. The Patient Transfer Department uses the software package CentralLogic (, specifically the ForeFront module (, to manage the transfer and admission of patients. After a patient has been accepted for admission by the admitting physician, Bed Control makes the bed assignment. The staff members of Bed Control assign incoming patients to specific beds once the Patient Placement Facilitators from the Patient Care Coordinator Department identify the nursing unit to which patients should be assigned. This determination is made based on the level of care required, physician preferences in choice of nursing unit, and the scope of care supported by the nursing units. The Bed Control Department uses the Capacity Management Suite ( of TeleTracking software ( The PreAdmitTracking module keeps track of bed status through the use of an “electric bedboard,” which provides a graphical user interface through which planned admissions, transfers, and discharges can be annotated. The status of a bed freed by patient discharge for which a cleaning request has been made is also noted (dirty, in progress, cleaned). The Bed Tracking module uses the medical center's paging network to notify the environmental services staff of a cleaning request and the head nurse of the unit that a patient is incoming. The TransportTracking module automatically dispatches patient transport requests via phone or pager.

Discussion Questions


    1. How are patients prioritized for bed assignment?

    2. Describe some of the advantages and disadvantages of this new software. Include the stated organizational goals in your answer.

    3. Discuss how this software might share data with other institutional applications to provide a dashboard view of census-type activity.


* Kim Crickmore and Lynne Miles are Advisory Board members for the East Carolina University Health Services Management Program.

Pageburst Integrated Resources

As part of your Pageburst Digital Book, you can access the following Integrated Resources:


    Bibliography and Additional Readings

    Web Resources


Chapter 8 Telehealth and Applications for Delivering Care at a Distance

Loretta Schlachta-Fairchild

Mitra Rocca

Vicky Elfrink Cordi

Andrea Haught

Diane Castelli

Kathleen MacMahon

Dianna Vice-Pasch

Daniel A. Nagel

Antonia Arnaert


    Growth in telehealth could result in a future where access to healthcare is not limited by geographic region, time, or availability of skilled healthcare professionals.



At the completion of this chapter the reader will be prepared to:


    1.Discuss the historical milestones and leading organizations in the development of telehealth

    2.Explain the two overarching types of telehealth technology interactions and provide examples of telehealth technologies for each type

    3.Describe the clinical practice considerations for telehealth-delivered care for health professionals

    4.Analyze operational and organizational success factors and barriers for telehealth within healthcare organizations

    5.Discuss practice and policy considerations for health professionals, including competency, licensure and interstate practice, malpractice, and reimbursement for telehealth

    6.Describe the use of telehealth to enable self-care in consumer informatics

    7.Discuss future trends in telehealth


Key Terms

Digital literacy, 141

Telehealth, 125

Telehealth competency, 131

Telemedicine, 126

Telenursing, 126

uHealth, 141


Rapid advances in technology development and telehealth adoption are opening new opportunities for healthcare providers to leverage these technologies in achieving improved patient outcomes. Telehealth provides access to care and the ability to export clinical expertise to those patients who require care, regardless of the patients' geographic location. This chapter presents telehealth technologies and programs as well as telehealth practice considerations such as licensure and malpractice challenges. As telehealth advances, healthcare providers will require competencies and knowledge to incorporate safe and effective clinical practice using telehealth technologies into their daily workflow.


Rapid advances in technology development and telehealth adoption are opening new opportunities for healthcare providers to leverage these technologies in achieving improved patient outcomes. Before we discuss these technologies and outcomes, it is important to explore the definitions of telehealth-related terminology.

Telehealth encompasses a broad definition of telecommunications and information technology–enabled healthcare services and technologies. Often used interchangeably with the terms telemedicine, ehealth, or mhealth (mobile health), telehealth is “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.”1 Telehealth is being used in this text to encompass all of these other terms. Telemedicine is the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care, treatment, and services.2 Telenursing is the use of telehealth technology to deliver nursing care and conduct nursing practice.3,4

Telehealth enables the delivery of clinical care to those who are in need regardless of the geographic location of the patient or the healthcare provider. Well-established telehealth programs and evidence-based research supports the effective use of telehealth across most disciplines and specialties within healthcare (i.e., teleradiology, teledermatology, telepathology, telenursing, etc.).5–10 Telehealth services provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance.11 As a result telehealth is now being integrated into routine care delivery of patients around the globe. Figure 8-1 depicts how telehealth can change healthcare delivery. Telehealth services can be classified as clinical or nonclinical. Clinical telehealth services include but are not limited to diagnosis, patient communication and education, disease management, triage and advice, remote monitoring, caregiver support, and provider-to-provider teleconsultations. Nonclinical telehealth services include but are not limited to distance education for healthcare consumers or clinicians, video conferencing or conference call meetings, research, healthcare administration, and healthcare management.

Providing care to underserved populations can be a challenge, especially in rural areas or where there is a shortage of healthcare professionals. Patients may face physical, financial, geographic, and other barriers to accessing care. However, telehealth can overcome many of these barriers. Telehealth proponents seek to improve quality, access, equity, and affordability of healthcare in the United States and throughout the

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FIG 8-1 How telehealth changes healthcare delivery.

(Copyright 2010 iTelehealth Inc. All Rights Reserved.)

world by using telehealth.11 Healthcare professionals who use telehealth can export their clinical expertise to patients regardless of geographic location.

Telehealth technologies include configurations as simple as a telephone conversation between a healthcare provider and a patient or as sophisticated as a doctor performing robotic surgery on a patient across continents. Telehealth technologies include but are not limited to telephones; facsimile machines; email systems; cellphones; video conferencing; web-based, remote patient monitoring devices; transmission of still images; and Internet applications (ehealth) including patient portals, remote vital signs monitoring, continuing medical education, and direct consumer applications such as online physician consultations via the Internet.

Telehealth is used in a variety of settings, among which are rural hospitals, home health agencies and patients at home, prisons, dialysis centers, and nursing homes; telehealth is also used to provide care to astronauts in space.11,12 The benefits of remote monitoring, diagnosis, and intervention have been proven in numerous scientific studies and include increased access to care, decreased costs of healthcare and increased healthcare provider productivity, and a high level of patient satisfaction.3,13 Furthermore, the advantages of telehealth to patients are numerous and include the following:


    •Decreased travel time or distance and removal of travel barriers

    •Immediate access to care

    •Early detection of disease processes or health issues

    •Ownership of healthcare and feelings of empowerment

    •Long-term health and independence

    •Caregiver reassurance

    •Patient satisfaction with healthcare


Examples of Successful Telehealth Programs

The following three examples of telehealth programs demonstrate the wide range of such programs currently providing services to patients at a distance.


    •Rochester General Health System, Rochester, New York, developed a clinic-based telehealth program in 2008. Its healthcare providers use a video conferencing system for live patient consults with remote physician specialists. They have the capability to send video images and 12-lead digital electrocardiograms. The Director of Telehealth coordinates and schedules 34 physicians and 5 midlevel healthcare providers who see patients remotely. Rochester General's telehealth program developed a rigorous 1-day training session for all end-users.

    •Sea Coast Mission Telehealth Program, Bar Harbor, Maine, provides seagoing health services to islanders living on four islands with no healthcare providers available.14 Daily use of live video conferencing from a 72-foot boat called the Sunbeam V occurs with the support of a boat crew that includes a nurse. The telehealth program coordinator, an early adopter of telehealth, described herself as “technically challenged” during the site's implementation. Since then she has developed excellent clinical and technical skills to work proficiently in an austere environment. In this setting attention to a patient's health condition can at times be urgent, requiring immediate diagnosis and treatment. The goal is to diagnose sick patients in a timely manner so that they can be transferred off the island for access to a higher level of medical care on the mainland. Maine Sea Coast Mission's most recent project has been to implement health centers with video conferencing systems on four islands (Frenchboro, Matinicus, Swan's Island, and Isle au Haut), thereby providing access to remote health and education services year-round (Sharon Daley, RN, personal communication, March 2010).

    •University of Miami, Miller School of Medicine, Miami, Florida, provides both live video conferencing and store-and-forward capability as part of its telehealth program. Its program reached out in 2010 to provide medical support after the earthquake in Haiti. One unique program is the Teledermatology Program for private cruise ships. The program uses expert dermatologists to evaluate an array of skin problems such as lesions, burns, infections, and rashes seen by emergency physicians on board cruise ships. The Clinical Telehealth Coordinator provides online training to cruise ship staff for using a digital camera and image capturing and transmission via a dermatology software application. Images are then reviewed by the dermatologist and patient reports with diagnosis and recommendations are sent back electronically to the emergency physician within a specific time frame.15


Telehealth Historic Milestones

In contrast to the common perception that telehealth is new and futuristic, it actually has a long history. The first documented report of healthcare delivery at a distance dates back to 1897 in The Lancet, when a case of croup was diagnosed over the telephone. In the United States modern telehealth programs began in 1964, with a closed-circuit television link between the Nebraska Psychiatric Institute and the Norfolk State Hospital for teleconsultations. Shortly thereafter, in 1965, a cardiac surgeon in the U.S. transmitted a live video feed of a surgical case to spectators in Geneva, Switzerland, via satellite. The surgeon discussed his case and answered live questions from the spectators in Geneva.16

The National Aeronautics and Space Administration (NASA) led telehealth initiatives in the 1960s with the transmission of physiologic signals from astronauts in space to command centers on Earth. NASA also funded several telehealth research programs in the late 1960s and early 1970s that contributed to the profession as a whole.17 A landmark study completed by Kaiser Permanente in 1997 concluded that “technology in healthcare can be an asset for patients and providers and has the potential to save costs; therefore, this technology must be a part of continuous planning for quality improvement.”18(p45) The researchers were emphatic about the benefits of telehealth, inspiring many of today's telehealth programs.

From July 2003 to December 2007 the U.S. Department of Veterans Affairs (VA) conducted a home telecare program analysis to coordinate care of chronically ill veterans and reduce long-term care admissions. The program evaluation was highly successful, realizing a reduction in long-term care bed days and inpatient hospital admissions among participants. Further, the veteran participants reported a high level of satisfaction. Costs to provide the program were and are substantially less than other VA programs or nursing home care. The program is now known as Care Coordination/Home Telehealth (CCHT) and is a routinely offered VA service to support aging veterans with chronic conditions.19

In the United Kingdom the Whole System Demonstrator (WSD) program was launched by the National Health Service in 2008 in order to determine the effectiveness of telehealth. As of its start date, the study was the largest randomized controlled trial of telehealth in the world, involving more than 6000 participants. The study confirmed that telehealth promotes well-being and should be a part of any complete healthcare system.20

Leading Telehealth Organizations

Starting in the 1990s, a number of professional, industry, and government organizations have provided the leadership needed to initiate effective telehealth programs. These leaders include the American Nurses Association (ANA), United States federal government agencies, the American Telemedicine Association (ATA), and the International Council of Nurses (ICN).

American Nurses Association (ANA)

With the advent of technology and rapidly emerging telehealth practice in the twentieth century, healthcare professionals sought guidance on incorporating telehealth into their care offerings. Multidisciplinary standards were needed to create a cohesive unity for telehealth across professions. To address the expansion and to create unified definitions and policies and a standard of care, the ANA brought together the Interdisciplinary Telehealth Standards Working Group. This group was composed of 41 representatives from different healthcare organizations and professional associations. The report of the interdisciplinary team, Core Principles on Telehealth, represents a “sense of the profession” as a whole.21 The purpose of the core principles is to create a baseline standard of care in order to provide quality care as well as protect patients from harm.

United States Federal Government Agencies

NASA, the VA, the U.S. Department of Defense (DOD), and other government agencies have continued to lead the U.S. in telehealth research and programs. As an early adopter of telehealth, the VA operates the nation's largest telehealth program. The widespread adoption and positive research findings led the U.S. government to establish the Office for the Advancement of Telehealth (OAT), a division of the Office of Rural Health Policy within Health Resources and Services Administration (HRSA) at the U.S. Department of Health & Human Services (HHS). OAT promotes the use of telehealth technologies for healthcare delivery, education, and health information services and increases the use and quality of telehealth delivery through the following activities:


    •Fostering partnerships within HRSA and with other federal agencies, states, and private sector groups to create telehealth projects

    •Administering telehealth grant programs

    •Providing technical assistance

    •Evaluating the use of telehealth technologies and programs

    •Developing telehealth policy initiatives to improve access to quality health services

    •Promoting knowledge exchange about “best telehealth practices”1


American Telemedicine Association (ATA)

The American Telemedicine Association (ATA) is a nonprofit organization founded in 1993 and headquartered in Washington, D.C. The mission of ATA is to “promote professional, ethical and equitable improvement in healthcare delivery through telecommunications and information technology” through education, research, and communication.22 ATA is a mission-driven, nonprofit organization that seeks to incorporate telehealth seamlessly into healthcare so that it is not necessarily a separate program but integrated into healthcare delivery as a whole.

International Council of Nurses (ICN)

Representing more than 200 national nursing organizations, including the ANA, Canadian Nurses Association, and associations of more than 198 other countries, the ICN initiated the Telenursing Network in 2008. As telenursing advances, this virtual collaboration is serving to share competencies and other jointly developed telenursing resources.

Telehealth Technologies

Telehealth technologies enable the exchange of all types of data (i.e., voice, video, pictures of wounds, pathology or radiology images, device readings, etc.) between patients and healthcare providers or between healthcare providers on behalf of patients. Early telehealth technologies were “stand-alone” systems in which a telehealth encounter occurred and data were stored in a telehealth system database. With the increasing adoption of electronic health records (EHRs), telehealth technologies are being increasingly integrated with the EHR. Telehealth services can be delivered using two overarching types of technologies: synchronous (or real-time) technologies or asynchronous (or store-and-forward) technology.

Synchronous or “Real-Time” Technologies

Synchronous, real-time telehealth uses live, interactive telecommunications technology and/or patient monitoring technologies to connect a healthcare provider to a patient for direct care, to other healthcare providers for consultation and collaboration, or to a combination of the two.23 The most commonly used synchronous telehealth employs video conferencing or telephone-based interaction.

Video Conferencing

Video conferencing integrates audio, video, computing, and communications technologies to allow people in different locations to electronically collaborate face to face, in real time, and share all types of information, including data, documents, sound, and picture. Use of interactive video conferencing in telehealth allows for patient–healthcare provider consultations, healthcare provider–specialist discussions, and health education. The technology requires live presence of the healthcare provider and patient or healthcare provider and medical specialist in an interactive environment.

A real-time live environment can include the following:


    •Video conferencing units with a codec (compressor–decompressor) capable of encoding and decoding the video conferencing stream.

    •Peripheral cameras such as high-definition cameras that have remote control pan, tilt, and zoom (PTZ) features.

    •Video display devices such as computer monitors, television sets such as HD Plasma or LCD displays, and LCD projectors. These display devices are used to show the images received from the video conferencing codec.

    •Audio components (microphones and speakers), a network connection, and the user interface. Prior to the availability of high-bandwidth Internet connections, signals were carried over point-to-point connections established via Integrated Services Digital Network (ISDN) lines and plain old telephone service (POTS). The Internet has now simplified some of the connectivity issues and the high-bandwidth requirement of video conferencing.


Patient Monitoring Technologies

Patient monitoring technologies, including home telehealth (also known as telehomecare), use devices to remotely collect and send biometric data to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation by a healthcare provider. Such applications might include a specific vital sign device, such as blood glucose monitor, digital scale, thermometer, heart electrocardiogram (ECG), blood pressure monitor, pulse oximeter, or peak flow meters, or a variety of monitoring devices for homebound patients. Such services can be used to supplement the use of visiting nurses.3 Use of monitoring devices will also allow patients to become more involved in and in many cases to oversee the monitoring process.24

Patient monitoring technologies for home telehealth consist of two major components: hardware and software. The hardware includes a base station where the patient interacts by entering data and answering questions and applies various medical devices that are used to gather patient data. The software enables healthcare providers and technicians to configure the hardware, receive data, and monitor the patient.

The telecommunications used can be wired, such as POTS or direct service line (DSL), or wireless, such as cellular (sometimes seen as code division multiple access, or CDMA), broadband, satellite, Bluetooth, infrared (IrDA), WiFi (or IEEE Standard 802.11), mobile broadband wireless access (MBWA or IEEE Standard 802.20), or Worldwide Interoperability for Microwave Access (WiMAX or IEEE Standard 802.16). mhealth and mobile health are umbrella terms that incorporate mobile or wireless telecommunications for transmitting telehealth-related data and services. Both the

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FIG 8-2 Personal health ecosystem. BB, Broadband; PERS, Personal Emergency Response System; POTS, plain old telephone service.

(Copyright 2010 Continua Health Alliance. All Rights Reserved.)

telecommunication and the hardware can be incorporated in the medical device.

Figure 8-2 provides a diagram of the components of a telehealth system.


    1.Personal health devices monitor basic vital signs such as blood pressure, weight, pulse, oxygen level, and blood sugar values and transmit data via a wired or wireless connection via devices or sensors.

    2.The aggregation and computation manager is a critical component of the connected health system, enabling individual monitoring devices to log data in an EHR for personal and clinician review. The aggregation manager collects and transmits data from an individual's personal health devices to a server using wired or wireless connections. The aggregation manager itself can be a cellphone, a personal computer, a dedicated device, or a personal health record (PHR).

    3.The health service center is a physical location where a patient's digital information is collected, stored, analyzed, and distributed. It can be the doctor's office, the home of a family member, or another type of healthcare-related facility.


Asynchronous or “Store-and-Forward” Technology

“Store-and-forward” technology allows for electronic transmission of telehealth-related information, video, images, and audio files. It can be used when healthcare providers and patients are not available at the same time. The sending healthcare provider or patient prepares an electronic consult package, which includes the patient's history, related diagnoses, and digital images such as x-rays, video, and photos. This package is either emailed or placed on a web server for the receiving healthcare provider to access when his or her schedule allows. The receiving healthcare provider then reviews the package, follows up with clarification questions, and provides a diagnosis, recommendations, and a treatment plan. The receiving healthcare provider's response is transmitted electronically back to the sending healthcare provider or patient. Store and forward technologies can be used in dermatology, radiology, pathology, dentistry, cardiology, wound care, home monitoring, pediatrics, and ophthalmology as well as other areas.

A store-and-forward technical environment can include the following:


    •A personal desktop, laptop computer, tablet, or smartphone for the sender

    •A personal desktop, laptop computer, tablet, or smartphone for the receiver

    •Telecommunication technologies such as local area network (LAN), wireless communications, etc.

    •Digital peripheral medical devices such as digital cameras, x-ray equipment, glucometers, vital sign monitors, and wearable sensors embedded in T-shirts or wristwatches

    •Software such as a web-based application, encrypted email, specially designed store-and-forward software, an EHR, a PHR, and an electronic data repository


Technical Standards in Telehealth

Until recently the demand for telehealth-based medical devices was not sufficient to create unified, global technical standards. However, technical standards that were developed for associated markets have benefited telehealth. For example, use of American National Standards Institute (ANSI) H.32x standards has enabled wide-scale video conferencing interoperability, which led to further growth in nonhealthcare businesses. Not only has telehealth benefited from the video conferencing standards, but it is also benefiting from a reduction in the cost of equipment as well as the improved ability to conduct interactions between parties independent of the particular hardware used. In addition, development of Health Level Seven (HL7), which provides global interoperability standards for health information technology (health IT), and Digital Imaging and Communications in Medicine (DICOM) standards for imaging has also been of great benefit for telehealth.3

In 2006 the Continua Health Alliance was formed by a group of healthcare technology industry companies to establish interoperable personal telehealth solutions and to develop technical design guidelines. The goal is to agree on a set of common technical guidelines that will enable vendors to build interoperable sensors, home networks, telehealth platforms, and health and wellness services. The Continua Health Alliance also has developed a technical certification program based on these guidelines. Technologies that are certified by Continua Health Alliance have been technically tested and validated to work together and be interoperable.25

An example of such a standard is ZigBee/IEEE 802.15. This standard is targeted at applications that require a low data rate, long battery life, and secure networking. ZigBee/IEEE 802.15 has become a useful wireless connectivity standard for home or facility-based telehealth. ZigBee is a low-powered network capability that allows telehealth devices and sensors to operate longer and with smaller power sources, enabling miniature sensors to transmit health data. ZigBee is also a very low cost and easily installed network capability, providing usability and requiring minimal technical support. The ZigBee Alliance offers two specifications (ZigBee and ZigBee RF4CE) that serve as the base networking system to facilitate its interoperable market standards.26

Telehealth and Health Information Technology

A need exists to integrate all relevant medical device images and data from the telehealth technology with the patient's EHR. The interoperability of these systems could dramatically streamline a healthcare provider's workflow and improve the healthcare.

A key to telehealth success is healthcare providers' access to patients' health records at the time of a telehealth encounter—just as it is with in-person care. Telehealth networks serve to establish a link between provider EHRs, and securely moving health-related information that is exchanged among patients, hospitals, and healthcare providers as needed for care and treatment. Telehealth in HIE initiatives is expected to lead to the next generation of interoperability for health IT across and among healthcare enterprises. Existing telehealth infrastructure will also serve as a highway for EHRs and information exchange between and among rural and remote areas.27

Telehealth Clinical Practice Considerations for Healthcare Professionals

Healthcare providers have used the telephone as a communication tool for patient interaction for decades. Adding to the complexity of remote care delivery today, it is becoming increasingly common to use computers, remote monitoring devices, and interactive audio and video conferencing for patient interaction. With expanding telehealth technology capability, new and more efficient models of care are facilitated, allowing for removal of time and distance barriers.

Equal to or Better Than In-Person Care?

Telehealth is considered to be so effective that in 1997 the World Health Organization (WHO) announced that it has become part of the WHO's “health for all” strategy and should be made available to all people.28 Physician–patient encounters via telehealth have been supported by research to be as effective as standard face-to-face visits held in a physician's office or clinic. In 2008 Dr. Gregory Jicha, assistant professor of neurology at the University of Kentucky's Sanders-Brown Center on Aging, led a study called Telemedicine Assessment of Cognition in Rural Kentucky. “The goal of the project was to adapt and validate the UDS [National Institute on Aging's Uniform Data Set, a standard set of questions asked of every patient being screened for Alzheimer disease] and other measures for diagnosing mild cognitive impairment (MCI) and early dementia in the telemedicine setting. An important aspect of the goal was to determine whether the telemedicine consultations were as effective as face-to-face meetings with a doctor.”29(p32) Jicha stated that “developing and validating this telemedicine approach for diagnosing and treating MCI and early dementia will become a model for clinician-researchers at other centers serving rural populations.”29(p32) Per Jicha's perception of using telemedicine to expand healthcare resources, “the bottom line is, our goal is to ensure that though telemedicine is not better than an in-person evaluation, it's as good as an in-person evaluation.”29(p34)

Beginning in 2008, two studies (one in the United Kingdom and the other in Quebec, Canada) concluded that “telemedicine is increasingly seen as an efficient and cost-effective means for improving clinical outcomes and increasing patient involvement in their own care.”30(p59) Both studies demonstrated two important factors that influence healthcare professionals' acceptance of telemedicine: training and support.

Telehealth Clinical Competency

As healthcare providers' use of ever wider and broader technological tools increases, so does the need to ensure telehealth competency to provide safe and optimal patient care. As healthcare further embraces telehealth to gain efficiencies, improve access to care, and reduce costs, there must be a focus on educating and preparing healthcare providers in telehealth technology, techniques, skills, coordination, and “on camera” communications. A telehealth clinical encounter involves multiple new components and competencies, including coordinating healthcare provider and patient scheduling, knowledgeable telepresenting skills (i.e., steps needed to facilitate a telemedicine encounter between a patient and remote healthcare provider), the exchange of prior medical record and new telehealth information, and an understanding of video and audio technology.

From initial academic preparation through ongoing continuing education requirements, healthcare providers practice in a dynamic field with ongoing changes in care delivery. All healthcare providers are required and expected to maintain and update clinical competency in the care they render to patients. Telehealth also requires competency for optimal healthcare delivery. A number of professional associations have stepped forward to identify the specific competencies required. As described earlier in this chapter, the ANA and 41 major healthcare provider organizations developed and endorsed core principles for telehealth delivery in 1998.21 A year later the ANA created and published Competencies for Telehealth Technologies in Nursing.31 In 2001, with further expansion in telehealth, the ANA endorsed the development of telehealth protocols.32 These protocols were developed to encompass the needs and concerns of both clients and practitioners. On an international level the ICN published the research-based, validated International Competencies for Telenursing based on an international survey of practicing telenurses in 36 countries around the globe.4

The National Initiative for Telehealth Framework of Guidelines (NIFTE Guidelines) was a critical milestone in development of telehealth not just for those who authored the guidelines in Canada, but globally.33 This highly important and superbly designed framework was developed in Canada by a multistakeholder interdisciplinary group. The NIFTE Guidelines are designed to assist individuals and organizations to develop telehealth policies, standards, and procedures. NIFTE examines and offers principles and suggested guidelines for five overarching content areas related to telehealth:


    •Clinical standards and outcomes

    •Human resources

    •Organizational readiness

    •Organizational leadership

    •Technology and equipment


In addition, Canadian nurses have provided more than a decade of telenursing leadership and developed extensive practice guidelines for nurses who are becoming or presently in the role of telenurse.34

In November 2011 the ATA developed an expert opinion consensus document on interactive video conferencing. The Expert Consensus Recommendations for Videoconferencing-Based Telepresenting defines the requirements for serving as a telepresenter in a live, synchronous telehealth encounter. As with all patient interactions, processes for patient registration, consent, clinical information, reimbursement information, and privacy are applicable to telehealth encounters.35 The ATA has also developed Telemedicine Standards and Guidelines for Diabetes, Telemental Health, Teledermatology, Home Telehealth, and Telepathology.

Confidentiality, Privacy, and Informed Patients

Patient confidentiality and privacy are paramount when using technology for the transmission of health data and live video presentation of the patient to geographic environments at a distance from the patient's location. The requirements for ensuring confidentiality, privacy, and informing patients receiving care via telehealth are the same as for in-person care. This is particularly true when the possibility exists of others being present in a room but off-camera. Attending to the presence of others at either the sending or receiving locations is an additional, important privacy task for healthcare providers using telehealth. Another important concern is ensuring that patients are being adequately informed and educated regarding telehealth consultation and assessment and evaluation via video conferencing technology.4,32

Scope of Clinical Practice

For healthcare professionals the use of technology does not alter or change the practitioner's inherent standards of practice, ethics, scope of practice, or legalities of practice.32,34 Healthcare professionals may use telehealth for patient consultations or for consultation with other healthcare providers. When telehealth is used for patient consultations, the healthcare professional's credentialing and clinical privileges at the site where the patient is located must be completed. The practitioner will need education, training, and technical support for the necessary technologies before, during, and after telehealth consultations.

The decision to refer a patient to a healthcare professional for consultation via telemedicine or telehealth is determined by multiple factors. Referrals for a telehealth consult need to consider the following factors:


    1.Does the service requested provide telemedicine or telehealth access as an option?

    2.What is the level of the practitioner's expertise and comfort with telemedicine or telehealth?

    3.Is the patient's diagnosis appropriate for telemedicine or telehealth consultation?

    4.Going forward, who will manage the patient's plan of care and how will this be managed?


As with any in-person patient encounter, documentation is of major importance. Appropriate documentation for telemedicine consults at both the sending and the receiving sites is essential for providing accurate and optimal continuity of care for the patient. Both sites need current patient demographic information, billing information, and consultant notes. Referring practitioners need consultant notes in a timely manner to carry out the patient's plan of care. After a telehealth consult, evaluation of telehealth processes and patient satisfaction is essential. The quality assurance and evaluation processes identify how to improve telehealth procedures, safety, effectiveness, and quality of care.32

Types of Clinical Telehealth Applications

In the past 15 years, telehealth specialty areas, such as telecardiology, teledentistry, teledermatology, home telehealth and remote monitoring, teleICU, telemental health, teleopthalmology, telepediatrics, teleradiology, telestroke, telewoundcare, and teletrauma, have been successfully developed and implemented in a variety of healthcare settings. Other telehealth programs outside the hospital setting include emergency preparedness, disaster response, correctional telemedicine, forensic telemedicine, telerehabilitation, and school telehealth.

A complete remote physical examination can be achieved by viewing images and hearing sounds. Healthcare providers can assess and treat a variety of health care problems such as cardiac or respiratory illnesses by listening to digital heart, lung, or bowel sounds live; by sending the data over a video conferencing system; or by using a computer with Internet connection to the computer of another clinician, who can then assess the information. The healthcare provider can use video scopes to conduct ear, nose, throat, oral cavity, eye, pelvic, or rectal exams; cameras or microscopes for skin examinations; radiology images to diagnose orthopedic injuries; and computed tomography (CT) scans of the head to rule out bleeding, brain injuries, or skull fractures. Teleradiology is one of the most commonly used and accepted telehealth applications, where digital images are captured and transmitted to the radiologist, who makes a diagnosis, sends a report, and stores the image. Healthcare providers can send complete readings for a 12-lead digital electrocardiogram to a cardiologist to diagnose heart problems or send a digital spirometry reading to a pulmonologist to diagnose respiratory lung capacity.

Telehealth Operational and Organizational Success Factors and Barriers

Despite the advancements in telehealth technologies, significant barriers and gaps exist in the successful implementation of robust, integrated healthcare technology delivery systems.

B.E.L.T. Framework

In planning for implementation of telehealth technology, four main components must be considered: bandwidth, education, leadership, and technology (B.E.L.T.). The B.E.L.T. framework (Fig. 8-3) is a metaphoric representation of these four interrelated components and may be used to guide planning at macro, meso, or micro levels of implementation.

Bandwidth includes elements of telecommunication technology, including information transmission and connectivity to move and store digital data. Infrastructure and telecommunication architecture in some geographic areas may limit use of telehealth applications and have direct implications for access to and delivery of healthcare. This is particularly problematic for rural, isolated, and underserved regions.36

Education encompasses the preparation of both the existing workforce and future healthcare providers in developing

Description: C:\Users\chanda\AppData\Local\Temp\978-0-323-10095-3_0038.jpg

FIG 8-3 The B.E.L.T. framework.

(Copyright McGill University School of Nursing. Montreal, Quebec.)

competencies in the adoption and use of telehealth technologies. Although research has been done in some areas of competency development, particularly in healthcare informatics and telenursing, scant research has been done in the broader use of telehealth technology to inform curriculum development and education of healthcare providers.4,37 Patient safety in telehealth technology use is one aspect of healthcare delivery that is essential to professional practice and relates to competencies in clinical decision making.

Leadership reflects a broad range of management, change theory, and policy aspects that affect operationalizing telehealth technologies. Barriers to successful telehealth adoption frequently relate to factors such as resistance to technology, information security, stakeholder support, reimbursement, and financial commitment.36,37

Technology spans a large number of considerations such as the types of telehealth software, hardware, and devices available for care delivery and the choice of appropriate telehealth technology. To date, telehealth platforms have limited capacity to address the range of health conditions experienced across the population lifespan, resulting in a narrow focus on overall individual health, fragmentation of care, and duplication of effort for data retrieval and documentation. Since many current telehealth technologies are not interoperable and cannot be integrated into a single environment to support holistic care, data silos are created where information on the same individual may be contained in different systems and cannot be accessed in an efficient, seamless manner. This further fragments care, leads to duplication of services (e.g., repeat of blood work, diagnostics, or information retrieval), and creates unnecessary cost to the patient and to the healthcare system. Another limitation is that most current telehealth technologies focus on direct delivery of clinical services to individuals and do not readily support the broader goals of primary healthcare, such as enhancing health promotion, prevention opportunities, or generating necessary epidemiologic data needed to evaluate and inform healthcare delivery.

Operationalizing Telehealth

Several important steps exist for the success of telehealth programs and services. The first is planning, which includes a needs assessment and analysis to define patient populations and healthcare problems in which telehealth services can have a positive impact. A workplace environment with staff prepared to implement telehealth using specific standards and guidelines is the second important factor for success. Technology preparedness is a third factor for successful telehealth services. For successful telemedicine implementation, appropriate “user-friendly” technology that allows for creative use and quality as well as responsive and accessible technical support are crucial factors.38 The final, critical step is learning how to implement, manage, and support a telehealth project or program. This becomes more complicated when more clinical specialties are involved. New telehealth programs should begin with one focused specialty application, such as teledermatology, and not add other specialties until the initial program has been implemented successfully. Specific procedures are listed in Table 8-1, and project steps are outlined below.

Telehealth Acceptance and Training

Technology education trends have moved toward online courses or certificate education programs in telehealth to reach out to more healthcare providers throughout the United States and globally. Online and on-site telehealth training courses are available through several Telehealth Resource Centers (TRCs), federally funded by OAT. Additional information about these resource centers can be found at The ATA located at provides annual meetings with scientific research presentations, special interest group meetings, educational webinars, educational products, training program accreditations, and white papers and policies.

According to Duclos et al. “the acceptance of a telehealth program by providers who use it is crucial to its success.”39 Healthcare providers who use telehealth in their practice should know how telehealth technologies work and should understand their capabilities in providing patients with better access to healthcare services.

Opportunities abound for clinicians to become adept at using telehealth technologies beginning with a basic proficiency in using room-based video conferencing systems on personal computers (PCs) and mobile video conferencing systems on iPads and smartphones. It is advantageous for healthcare providers to learn to use medical devices with video scopes attached for patient assessments and video or digital cameras for exams. Healthcare providers need to be comfortable using a variety of audio, video, and medical device tools, video conferencing systems, and computer hardware and software applications. New technical challenges often emerge for clinicians, such as using a video ophthalmoscope to view retinal images inside the eye and on a display monitor. Hearing new heart sounds from a digital stethoscope with different high- and low-pitched sounds due to magnification can be another challenge. Clinicians may encounter workflow changes with telehealth software applications in paperless environments, such as digital ECG and spirometry readings that identify patients' heart rhythm and lung measurements. Technology literacy training may also be required for clinicians. Technology literacy includes knowledge of basic computer skills and communication technologies, basic skills to navigate the Internet for up-to-date health information, and the ability to access web-based telehealth software applications. For example, healthcare providers who are fluent in using digital cameras to take dermatology images and who are Internet savvy can access online resources to identify a skin lesion or obtain the latest treatment for the lesion online.

In the 2005 International Telenursing Survey, telenurses were found to have various job skills and to work in more than 30 clinical telehealth settings ranging from nurse call centers to urban and rural hospitals, public and private health clinics, schools, prisons, community health centers, military facilities, native tribe reservations, and private physician and nurse practitioner practices.40 Specific telehealth knowledge regarding equipment, workflow, clinical processes, and technology training is different for each clinical setting.

TABLE 8-1 Telehealth Procedures






Provider credentialing completed at patient site and remote site


Provider is knowledgeable and competent in healthcare needs being addressed during patient-to-provider telemedicine visit


Review plan of care conveyed by provider or consultant and instructions provided regarding treatment plans, with time for patient and family questions and answers

Referral reviewed as appropriate for specialty service and accepted by telespecialist


Introduce patient to all individuals that will be in the patient room and to any individuals at the evaluating physician's location


Complete any necessary forms (e.g., patient consent to treat form; HIPAA forms) and share reimbursement information with both patient and physician sites

Knowledgeable regarding scheduling procedures and policies of facility and scheduling resources


Identify camera and microphone locations to patient and explain any potential for audio or video delay


Provide patient and family with consulting physician contact information, as needed for follow-up

Obtain and review preconsult clinical information and testing


Presenting site provider is knowledgeable of exam requirements, including patient preparation, patient positioning, and use of peripheral devices (i.e., electronic stethoscopes, Doppler, digital cameras, etc.)


Schedule follow-up appointments, treatments, etc. as ordered by physician

Obtain reimbursement information, such as copies of insurance cards, Medicare cards, etc.


Provide support to patient and family and be alert to nonverbal body language


Provide the referring primary care provider with the telemedicine encounter documentation

Provide patient with the appropriate forms for “consent to treat” and HIPAA compliance information


Provide time within the clinical visit for patient and family questions and answers


Evaluate outcomes of the telemedicine encounter, quality of encounter, and patient satisfaction and assess for improvements for future telemedicine encounters; clinical effectiveness is one of the factors associated with success in telemedicine

Contact patient to explain a telemedicine encounter and provide directions to the telemedicine site


Educate patient and family of their right and ability to terminate the telemedicine clinical visit at any time


Ensure that equipment and technology has been tested and is in safe working order, provider and patient have clear audio and video of each other, extraneous noises are reduced, and any necessary peripheral devices and supplies are accessible at time of encounter


Assess and prepare for cultural, language, or disability issues


Establish a backup plan and be prepared to enact it in the event of technical problems


Scheduling dedicated time for healthcare providers' telehealth training is an obstacle and is one of the major barriers to a successful telehealth program. Actual hands-on training is beneficial, using telehealth case scenarios similar to those the healthcare provider would typically encounter. As mentioned earlier, clinical workflow is modified when telehealth technologies are implemented. Healthcare providers can adjust by continuing to use the same patient exam rooms for the telehealth patient, using similar medical devices for in-person and telehealth exams, training with telehealth technologies, and interacting with the same physicians and specialists for telehealth consultations as for in-person referrals.

Telehealth Implementation

There are three phases for successful telehealth program implementation: preimplementation, implementation, and postimplementation.

Preimplementation Phase

Implementing telehealth technologies in any clinical setting is no different than implementing other twenty-first century technologies. As with any informatics project, a team effort is critical to its success. Clinicians will first need to decide what types of telehealth programs provide access to remote healthcare specialists for their patients. Important preimplementation steps are listed in Box 8-1. Forming an administrative or executive team is advisable to oversee the project goals, budget, progress, and growth. The facility may already have a formal committee in place to oversee all IT projects and, if so, can tailor the governance to incorporate telehealth. The executive team should include the following:


    •Hospital or facility administrator

    •Clinical director (often a physician)

    •Chief information officer

    •Director of information technology and/or director of education

    •Telehealth and telecommunications administrator

    •Vendor account managers (may be only at the operational level below)


A second level of management for the telehealth program is a more operational interdisciplinary team including the following:


    •Project manager

    •Clinical champion (often a physician)

    •Telehealth director or program manager

    •Information technology engineer or support technician

    •System administrator (if software is involved)


Super users and vendor trainers will also initiate, train, and support new staff for the telehealth project. The interdisciplinary teams are the change agents that assist in developing policies, procedures, project evaluation criteria, and permission forms prior to beginning the telehealth program.

Box 8-1 Telehealth Preimplementation Steps


    • Identify remote physician specialists and other clinical consultants who are willing to provide remote assessment and advice for treatment

    • Meet standards and requirements for safe use of telemedicine equipment: installation in designated telehealth rooms; biomedical and electrical engineering help may be required

    • Select appropriate telehealth equipment to use for telehealth examinations, including disposable accessories such as nonlatex gloves, gel, measurement tapes, alcohol wipes, gowns and cover sheets, and extra camera batteries

    • Identify electrical and cable sources for power outlets and secure Internet access

    • Designate telehealth exam rooms or areas

    • Identify 24/7 technical support for clinicians at both sending and receiving sites

    • Develop policies and procedures

    • Train interdisciplinary team and staff end-users on telehealth equipment

    • Set up and test telehealth scenarios prior to beginning telehealth consultation


Implementation Phase

Once the equipment is configured or tailored, the implementation phase involves equipment and software testing with mock telehealth patients and remote specialists and then piloting the project by identifying a patient needing a teleconsult. Equipment testing with mock patients should encompass all staff testing all of the telehealth equipment available. Equipment testing should also be conducted periodically after the initial implementation. After identifying differences between standard and telehealth patient encounters, daily use of telehealth equipment for routine patient exams is recommended so that providers become knowledgeable and comfortable using the various telehealth examination tools (electronic stethoscope, video otoscope or ophthalmoscope, digital ECG or spirometry software, video exam camera, telehealth software applications, and audio or video conferencing systems). The goal is for a clinician to present a patient, capture and send patient data, retrieve patient information from stored telehealth software applications, and respond to cases and add patient encounters if needed.

Postimplementation Phase

As with any other informatics project, evaluation criteria address adequacy of training; implementation, equipment, technology, or training issues; and program outcomes. A program of quality assurance and process improvement should be part of the evaluation process so that iterative progress toward implementation phase telehealth program success can be achieved.

Telehealth programs of any size experience similarities in success and failure. Table 8-2 lists common success factors and barriers to successful telehealth program implementation.

Telehealth Challenges: Licensure and Regulatory Issues for Healthcare Professionals

Telehealth enables physicians, advanced practice registered nurses (APRNs), nurses, pharmacists, and other allied health professionals to offer their clinical services remotely. State lines and geographic boundaries have no effect on the potential of the technology to deliver telehealth services. For example, radiologists can read x-ray reports from other countries, mental health professionals can provide care telephonically or with real-time video, and chronically ill patients can be monitored from a distance with telehealth. Despite technological advances, legal and regulatory challenges exist. Provider licensure and the credentialing and privileging processes in facilities remain the biggest hurdles to telehealth adoption in the United States.

TABLE 8-2 Success Factors and Barriers to Telehealth Implementation




High-level organizational members (board of directors, administrator, medical director, champion physician, nurse administrator, nurse educator, program director) who have identified a need for telehealth and are able to provide support and finances throughout all phases of implementation, training, and maintenance of the telehealth program


No designated or dedicated project manager; not enough time or resources dedicated to manage project

Designated and dedicated telehealth project manager or coordinator


Interdisciplinary team not designated or prepared properly

Designated interdisciplinary telehealth team


Funding limited

Adequate facility network infrastructure to support the telehealth system or method selected and prepare setup for the telehealth program prior to installation


Lack of communication between administrative management, interdisciplinary team, and participants

Project management to include and allow time for professional telehealth education and refresher training classes, including participation for professional telehealth conferences, telehealth webinars, telehealth video training, and provision of telehealth resource information


Failure to identify remote clinical partners to whom to refer patients or to provide telehealth services; may be due to reimbursement issues, lack of understanding as to how telehealth works, practice and licensing issues in that state

Initiate telehealth program at local facility and then introduce to affiliated remote facilities


Poor telehealth equipment selection for specialty; poor quality and usability of telehealth equipment purchased

Provide staff with educational tools such as workflow diagrams, charts, digital photos, manuals, and descriptive pathways for how to initiate an urgent or nonurgent telehealth consult


Missing parts of equipment and supplies during installation or patient encounter

Provide education, training, and program development for teleconsultants


No designated telehealth area due to limited room availability

Schedule appointments for follow-up teleconsults with dates and times for physician and patient


Ergonomically poor placement of equipment, limited connectivity or lighting in telehealth area, poor cable management, limited counter size, small room, no storage cart for equipment, equipment not secure

Patient privacy and confidential information forms should be completed prior to teleconsult


No pretraining on telehealth system prior to telehealth installation

Provide on-site dedicated technical support throughout all phases of implementation and provide online support for main site, remote site, and teleconsultants


Healthcare providers not familiar with computer literacy (i.e., basic use of keyboard, personal computer, mouse, navigating software, data, or handling images captured)


Training not formalized, no schedule confirmed to allow for all participants to be trained, not enough time provided for hands-on training or practice of case scenarios


Staff resistant to training, no incentives, and no understanding of telehealth or technology advantages


Off-hour shifts not trained or invited to participate in training sessions


Both the 1997 and 2001 Telemedicine Reports to Congress by OAT identified licensure as a major barrier to the development of telemedicine and telehealth.41 The cost and procedural complexity of current professional licensing policies precludes widespread adoption of telehealth. Currently, many health professionals must attain separate licenses in each state where services are rendered. Licensure authority defines who has the legal responsibility to grant a health professional the permission to practice his or her profession.42 Under Article X of the U.S. Constitution, states have the authority to regulate activities that affect the health, safety, and welfare of their citizens.42,43 Regulating the delivery of healthcare services is one such activity. Exceptions to state licensure requirements include physician-to-physician consultations, educational and medical training programs, border state recognition programs, government employees practicing in military or federally funded facilities such as VA hospitals and clinics, and natural disaster and emergency situations.42,43

Legislation such as the 2011 Servicemembers' Telemedicine and E-Health Portability Act (STEP Act) facilitates the provision of telemedicine and telehealth services. The STEP Act removes the individual state licensing requirements to allow a licensed medical professional in one state to treat a patient in another.41 As of this writing, the STEP Act rules apply only to military and federal personnel, although it is a beginning in terms of advancing telehealth services into the mainstream. Fortunately, major advancements are occurring to streamline licensure requirements. These regulatory alternatives include licensure by endorsement, state compacts and mutual recognition, reciprocity, registration, and limited licensure (Table 8-3).

Nursing has been the most successful healthcare provider group to adopt the mutual recognition model, referred to as the multistate Nurse Licensure Compact.42 The Nurse Licensure Compact law became effective on January 1, 2000, with three states initially participating. As of February 2013, 24 compact states existed. Compact status applies only to registered nurse (RN) licensure. If an RN holds a license in one of the 24 compact states, he or she may practice in any of the 24 compact states, greatly facilitating telehealth interactions across state boundaries. International nurses on a visa who apply for licensure in a compact state may declare either the country of origin or the compact state as the primary place of residency. If the foreign country is declared as the primary place of residency, a single-state license will be issued by the compact state.44 A mutual recognition model is being discussed for APRNs at the time of this writing. The target date to complete that work is 2015. However, currently, APRNs who practice using telehealth across state boundaries must first apply for RN licensure (or endorsement) in the distant state and then apply for advanced practice status, which involves extensive credentialing and privileging processes.45

TABLE 8-3 Telehealth Professional Licensure Options






Allows a state to grant licenses to health professionals licensed in other states that have equivalent standards. States may require additional documentation or qualifications before endorsing a license issued by another state.43

Mutual recognition


The distant state's licensing board accepts the licensing policies of the health professional's home state.45 Federal healthcare agencies operate under this type of system. An analogous licensing system would be the mutual recognition of driver's licenses between states.



A process in which two states voluntarily enter into a reciprocal agreement to allow the health professional to practice in each state without having to become licensed in both states. It does not involve additional review of the health professional's credentials, as endorsement does, and it does not require the participating states to agree to a standardized set of rules or procedures, as mutual recognition does. The negative aspect of this model is that it leaves the healthcare provider subject to different regulations in each state and therefore subject to different sets of laws. This can lead to legal issues of liability and wider exposure to potential malpractice opportunity.46



The health professional licensed in one state informs the authorities of other states that he or she wishes to practice in those states part-time. The provider is licensed in the home (originating) state but still is accountable to uphold the legal stipulations and regulations of the guest (distant) states. Similar to reciprocity, the provider would still be subject to the guest state's malpractice rules as well as the home state's rules and regulations.

Limited licensure


The health professional obtains his or her medical licensure in the home state and then obtains a second “limited” licensure in the guest state. The limited license allows for specific scope of services to be delivered under particular circumstances.46

National licensure


Individual states would voluntarily incorporate the same set of national standards into their laws. Given that most medical professionals pass the same national exam within their particular discipline, it stands to reason that standards of care and practice guidelines should not differ from state to state. Regulatory processes could be retained at the state or national level. For example, the American Medical Association could take full responsibility for the licensing of all physicians at a national level and similarly nurses could be licensed to practice nationally by their national organization, and likewise with other health professions (pharmacists, dentists, physical therapists, etc.). However, disciplinary actions or other procedural activities could be administered at the state level.

Credentialing and Privileging

Credentialing is the process of establishing the qualifications of licensed professionals and assessing their background and legitimacy. For example, if a physician does a telehealth consult from a hospital in State X but the patient resides in a skilled nursing facility in State Y, that physician must be credentialed by both facilities (i.e., the hospital and skilled nursing facility), as well as be licensed in both States X and Y. Each facility could have very different processes and rules for becoming credentialed. Similar to the need for licensing in multiple states, the need for credentialing in multiple, separate healthcare facilities is an obstacle to telehealth services. In May 2011 the Centers for Medicare & Medicaid Services (CMS) modified the existing credentialing and privileging regulations effective July 5, 2011. The new rule under part 42 CFR 410.78 of the CMS regulations allows hospitals or Critical Access Hospitals (CAHs) to use information from a distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners.42 Regarding the legal risks and liabilities associated with these changes, the governing body of each hospital and CAH must weigh the risks and benefits of opting for this more streamlined process of credentialing and privileging telemedicine providers.42 Modifications still need to be made to allow Medicare and Medicaid beneficiaries who reside in urban or metropolitan areas to be eligible to receive the same services.


Telemedicine is often viewed as a cost-effective alternative to the more traditional face-to-face method of providing medical care.42 As such, states in the U.S. have the option to determine whether or not to cover telemedicine- and telehealth-delivered care, what types of telehealth to cover, where in the state it can be covered, how it is provided and covered, what types of telehealth practitioners and providers may be covered and reimbursed (as long as such practitioners and providers are “recognized” and qualified according to Medicare and Medicaid statute and regulation), and how much to reimburse for telemedicine services (as long as such payments do not exceed the Federal Upper Limits).46

Reimbursement by insurance companies for medical services is based on Medicare's Current Procedural Terminology (CPT) codes billing system. As of 2012, Medicare telehealth services can be furnished only to an eligible telehealth beneficiary from an eligible originating site. In general, originating sites must be located in a rural Health Professional Shortage Area (HPSA) or in a county outside of a Metropolitan Statistical Area (MSA). The originating sites authorized by the statute include hospitals, skilled nursing facilities, offices of physicians or licensed healthcare practitioners, rural health clinics, community mental health centers, CAHs, CAH-based dialysis centers, and federally qualified health centers.47 Medicaid reimbursement for telehealth varies by state, with some states electing not to reimburse for telehealth services. Internationally, in countries that provide government-based universal health care, telehealth adoption is flourishing and reimbursement has become a national budgetary decision. Providing more access to more citizens while at the same time reducing costs and more efficiently distributing clinical expertise using technology is a desired goal for any country's health service. Thus countries such as Canada, those in the European Union, Japan, China, and India are all expanding their telehealth capabilities and services.

Malpractice and Liability

Legal issues of liability and malpractice are burdensome for the telemedicine practitioner, as they “face additional vulnerability and uncertainty related to malpractice exposure in multiple states and would likely face additional expenses for malpractice insurance and for other costs should a suit be filed in a distant state.”48 Legal issues involve traditional jurisdictional issues, including the following:


    •The place of treatment dilemma

    •Lack of an established, bona fide doctor–patient relationship similar to the situation with cybermedicine (medical care via the Internet)

    •Violating a particular state's specific regulations related to standards of care

    •Failing to secure appropriate informed consent from a patient

    •Negligence that may arise from technical glitches such as distorted images or poor sound quality of a particular device resulting in injury or misdiagnosis42


The traditional concepts of negligence, duty of care, and practicing within one's scope of legal license still apply to telehealth as they do in traditional face-to-face encounters. Initial case law in telemedicine and telehealth to date has been limited, primarily involving telephone triage and teleradiology. In telephone triage, if advice was given and a poor patient outcome occurred, the triage service and professionals are at risk for malpractice. In teleradiology (as is the case with in-person and in-house radiology readings), if a diagnosis of a lump or a mass is missed on an image, the radiology service and professional would be at risk for malpractice. As telehealth usage increases, further legal cases will illuminate and clarify these issues.

Telehealth and Direct Patient Health Services

While telehealth applications typically involve provider-to-provider teleconsults, patients and other healthcare consumers can use telehealth directly to support their healthcare decision making. Specifically, applications facilitate direct, online patient telemedicine care; provide remote patient telehealth visits and monitoring; and link consumers with online healthcare information.49 As the technology used to deliver telehealth services becomes easier to use and more affordable, the technology is increasingly being used by patients in interaction with their healthcare providers and at times in directing their own care.

Patient-to-Provider Telehealth-Delivered Care

Increasingly, individuals find it difficult to obtain timely care for urgent health concerns from their healthcare provider. A survey of California hospitals found that 50% of the patients who visited an emergency department thought that their medical concerns could have been dealt with by their regular physicians; however, they were unable to obtain timely access to care.50 Online telehealth direct care is a solution to this growing problem and the use of video conferencing for telehealth visits is increasing. Manhattan Research's Taking the Pulse U.S. v11.0 study indicated that nearly 7% of physicians use online video conferencing to communicate with their patients.49 Physicians consider telehealth a method for consulting with patients about nonurgent issues or connecting with geographically dispersed patient populations that may not have nearby access to specialists. The study also found that certain specialty healthcare providers, such as psychiatrists and oncologists, are more likely to use video conferencing with their patients.

Adapt TeleHealth is an example of this approach. Once a community or clinic has identified that it has a need for psychiatric services, it contracts with Adapt TeleHealth to meet its mental health needs. It purchases a consistent number of hours per week, which are fulfilled by an Adapt TeleHealth mental health provider. Other direct patient care technologies focus more on providing a platform for a healthcare provider's office to provide telemedicine care. Companies such as Secure Telehealth (, TelaDoc (, and Online Care Anywhere ( are examples of platforms for direct online medical care.

Asynchronous applications using store-and-forward technologies or online diagnostic surveys are gaining in popularity. Virtuwell ( from HealthPartners in Minnesota is available 24/7 and uses an online survey asking consumers to identify their chief concern. Responses are sent to a nurse practitioner who reviews the information and responds within 30 minutes. Responses are provided via text or email and include a diagnosis, potential remedies, and tips for preventing the condition in the future. If a prescription is needed, the nurse practitioner can send it to a local pharmacy. Forty common conditions, including bladder infections, lice, and yeast infections, are treated by Virtuwell's nurse practitioners.

Another asynchronous telemedicine company is RelayHealth, an online solution to connect consumers with their healthcare providers. Providers license RelayHealth web-based software, with capability for patient visits and consultations, prescription renewal, appointment scheduling, personal health record management, delivery of lab results, referral requests, and access to medically reviewed information.

Remote Telehealth Home Visits and Biosensors

Telehealth systems previously used interactive video conferencing between healthcare providers and patients; however, the ability to self-manage care is a driving fiscal concern.51,52 Machlin and Woodwell noted that nearly two thirds of publicly insured adults in the U.S. under the age of 65 have one or more chronic conditions and that nearly 75% of all healthcare dollars were spent on managing these chronic conditions.53 Use of telehealth technologies for remote home care and biosensor monitoring instruments are gaining momentum to address chronic illnesses and to promote safety for seniors living alone.

Remote Telehealth Home Visits and Monitoring

As mentioned earlier, the most widespread telehealth program in the United States is the VA national telehealth program, CCHT. Built around Wagner's Chronic Care Model, CCHT is characterized by “the use of health informatics, disease management and home telehealth technologies … with the specific intent of providing the right care in the right place at the right time.”19(p1120) The range of technologies for CCHT includes videophones, messaging devices, biometric devices, digital cameras, and telemonitoring devices.52 The videophones and video telemonitors facilitate synchronous face-to-face encounters with a healthcare provider through regular telephone lines or through computer links and the Internet. Biometric devices and digital images are also part of the comprehensive CCHT system and are used to gather timely healthcare data employing asynchronous store-and-forward technologies.

Two specific examples of technologies used with the VA and the general public are HealthBuddy ( and miLife ( MiLife, adopted for use by the VA in 2011, offers live, interactive video combined with remote monitoring. In between video visits, veterans measure and transmit vital signs and other physiologic measurements with devices in their homes, answer self-assessment questions, and receive disease-specific educational information.

HealthBuddy does not include a video visit component but otherwise works in a similar way. Patients access the system and update their health status by answering a series of questions about their health and well-being using the HealthBuddy application. The data are sent over a telephone line or Ethernet Internet connection to a secure data center; the data are then available for review by a healthcare provider via the HealthBuddy desktop system. Peripheral monitoring devices such as blood glucose meters, blood pressure monitor, peak flow meters, pulse oximeters, and weight scales are also supported.

Both miLife and HealthBuddy allow nurses, social workers, and other healthcare provider coordinators to prioritize their patient caseload and develop treatment plans based on the patient's risk. Emerging research findings show that telehealth home visits and home monitoring are care and cost effective.19,54

Biometric Sensors

A number of healthcare applications use information and communication core components to help patients stay safe in their homes and communicate vital healthcare data to providers.52 Box 8-2 provides an overview of biometric sensors. Peripheral health monitoring tools such as blood glucose monitors, pulse oximeters, blood pressure and ECG monitors, and electronic scales, already described as components of a telehomecare visit, fit this definition. They are the backbone of a viable remote disease management program.

More recently, a group of assistive technology devices dubbed “sensor technologies” have emerged and add a layer of connectedness between patients and their healthcare providers by monitoring patients' activity levels and physiologic parameters. Sensor technology has the potential to not only manage disease but also promote a safe and healthy environment for seniors.52 AFrame Digital ( has engineered a low-stigma, intuitive, wristwatch-based sensor system with an intelligent learning and predictive modeling platform that acquires physiologic data from the wearer every 30 seconds. After collecting sufficient data points, the system learns the physiologic normal for the individual. If deviations from normal occur, an alert is sent to a neighbor, relative, friend, or emergency responder. Personalized, tailored remote monitoring and intelligent alerting is the hallmark of this innovative system.

Box 8-2 Biometric Sensor Overview



    • Detect changes in patterns that signal improvement or early failings

    • Signal need for urgent or emergency help

    • Integrate with websites or mobile units to promote communication

    • Have ubiquitous monitoring for peace of mind for older adult and family

    • Keep an inventory of supply levels for medications and other resources

    • Coach and monitor exercise effectiveness and participation in games


Information Potentials


    • Physical: motion, location, activity

    • Physiologic/medical: pulse, temperature, sweat, blood chemistry

    • Social: telephone or web interaction counts or identification

    • Memory support: monitoring cooking stoves, adherence to regimens

    • Communication safety issues: stove use, fire, unsecured doors




    • Devices and protocols networked to connect to computers

    • Statistical and computational paradigms for analysis

    • Applications for interaction with emergency rescues, healthcare providers, and social network


Monitoring Target Examples


    • Restlessness as indicator of disturbed sleep

    • Gait changes as indicator of drug side effect or physical debility

    • Extended bedrest as indicator of depression or physical debility

    • Pill counts as indicator of adherence or side effect issues


One example of sensor technology that may be used in the future to promote a safe and healthy environment is the smart home. The “smart home or intelligent house”52(p237) is expected to use radio frequency identification (RFID) technology.55 RFID technology uses a microchip to uniquely identify and track objects, record and update information, and make all of this accessible through a global network.56 Depending on their use, RFIDs can be active or passive and are capable of being ingested, implanted, or attached externally. While concerns about potential privacy and security breaches exist, RFID benefits include unlimited sight connection and rapid information processing, predicting better utility than other technologies such as bar-coding. Treatment-based applications such as monitoring handwashing practices, transmitting neuromuscular stimulation data, and authenticating medications have the potential to transition from the hospital to the smart home.

Sensor technology also supports next-generation healthcare by virtue of its mobility. Two forms of mobile sensors are wearable embedded technologies and wearable attached technologies.52 Clothing with “smart fabrics” and embedded sensors is currently in use for measuring body temperature and heart activity or signaling a risk for falls. Recently, companies have designed sensors to integrate with smartphones. One example of an integrated sensor comes from WIN Human Recorder Co. Ltd. in Japan.57 Consumers wear a small, portable sensor attached to the body and readings are accessed easily via a cellphone or a networked computer. The WIN Human Recorder is capable of monitoring electrocardiography signals, heart rate, brain waves, accelerated velocity, body temperature, respiration, and pulse waves. Biosensor fabrics will have the capacity to analyze blood chemistry levels from collected perspiration or immunosensors integrated in dressings will be able to detect healing.

Telehealth Technology and Healthcare Consumers

The proportion of American adults seeking information about a health concern from a source other than their physician dropped to 50 percent in 2010, down from 56 percent in 2007.58 At first glance, readers may assume that consumers are not seeking information about their healthcare needs; however, the drop is actually attributed to an 18% decline in their use of print sources: books, magazines, and newspapers. Adults, especially the elderly and those with chronic disease conditions, have increased their Internet use for seeking health information, contributing to their engagement in self-care.58 Online healthcare resources have the potential to aid consumers by supporting shared decision making with healthcare providers, providing personalized self-management tools and resources, building social support health networks, delivering tailored accurate health information, and increasing health literacy.59

Health information websites have been available to consumers since the mid-1990s.60 Websites such as WebMD, a publicly traded company, and the National Institutes of Health's MedlinePlus, a federal government site, have provided healthcare information to a broad population of consumers, including the general public, employers, employees, health plans, and healthcare providers. More recently, however, some health websites have moved beyond one-way communication and developed innovative features and interactive tools that enable consumers to greatly increase their self-knowledge and promote greater safety and independence. Tools such as drug interaction checkers, symptom checkers, various health-related calculators, pill identifiers, patient forums, fitness trackers, and PHRs are becoming more prevalent and helping consumers to gain more control over their health.60

Everyday Health ( is an example of an interactive, consumer-based website. Everyday Health has partnered with experts from Harvard University, Cleveland Clinic, and the American Association of Family Practitioners to provide consumers with healthcare information and has also developed interactive consumer-oriented tools. Consumers can use assessment and tracking tools and online calculators, speak live with a pharmacist, find drugs and treatments, and create a personal plan for health. Additional information concerning interactive consumer-oriented recourses is included in Chapters 13 and 14.

eHealth Literacy: Critical Element for Telehealth Adoption

The proliferation of online healthcare resources has caused the development of a national and international quality standards agenda to help health professionals and consumers alike access and evaluate high-quality online health information that is accurate, current, valid, appropriate, intelligible, and free of bias.61–63

Health consumer advocates espouse the need for ehealth literacy as a way of evaluating the information and services delivered using IT tools.64 Consumers must have basic reading skills in their search for online healthcare resources and use of telehealth tools. They also must have the following skills:


    •Visual literacy: ability to understand graphs and read a label or other visual information

    •Computer literacy: ability to operate a computer

    •Information literacy: ability to obtain and apply relevant information

    •Digital literacy: competency with digital devices of all types; technical skills to operate these devices and conceptual knowledge to understand their functionality; ability to creatively and critically use these devices to access, manipulate, evaluate, and apply data, information, knowledge, and wisdom in activities of daily living; ability to apply basic emotional intelligence in collaborating and communicating with others; ethical values and sense of community responsibility to use digital devices for the enjoyment and benefit of society65


eHealth literacy skills are critical for future telehealth adoption for both consumers and healthcare providers alike.

Conclusion and Future Directions

Telehealth, considered futuristic by some, is actually not a new concept, dating back to 1897. Currently, telehealth services are being provided in diverse settings from islands off the coast of Maine to across the U.S. for remote care of military veterans. Two major types of telehealth exist: asynchronous and synchronous. Applications include teleradiology, teleconsulting, telepathology, telesensors, and remote home visits. Telehealth has the potential to decrease care costs and speed treatments but the field also has challenges, including issues regarding licensure, standards, reimbursement, credentialing and privileging, and lack of integration with other health IT, especially EHRs.

Growth in telehealth could result in a future where access to healthcare is not limited by geographic region, time, or availability of skilled health professionals. The potential to realize comprehensive, integrated, and seamless delivery of healthcare services through virtual environments, capable of spanning a broad range of prevention and health promotion interventions, already has been made possible through advances in telehealth technology. Conditions exist for expanding telehealth to other sectors for sustainable telehealth: rising healthcare costs, increasing prevalence of chronic diseases, an aging population, demands for improved access to healthcare, and global shortages of health professionals.36,37,66–69 Creation of telehealth ecosystems and novel healthcare models requires interdisciplinary and intersectoral approaches spanning technology, education, and health management (Fig. 8-4).

The CuRE framework in Figure 8-4 depicts the Canada-India Centre of Excellence for uHealth Research and Education (CuRE). It provides a uhealth (ubiquitous health) view for operationalizing future global collaboration in advancing telehealth.

Policy decisions to adopt and implement telehealth technology in healthcare delivery are influenced by many drivers, such as global socioeconomic contexts, political motivations, capacity of technology to address healthcare needs, and fundamental understandings of telehealth capabilities.66,70 Inconsistencies in telehealth research methods and data reporting have had an impact on empirical data available to evaluate telehealth technology in the areas of cost–benefit, effectiveness, and patient engagement.67,68 Issues of authentication, data security, and practical aspects of telecommunication infrastructure remain critical challenges for the adoption and broader use of telehealth technologies.71,72

A consistent and coordinated approach in tracking healthcare technology use is lacking; therefore the effectiveness of

Description: C:\Users\chanda\AppData\Local\Temp\978-0-323-10095-3_0039.jpg

FIG 8-4 Components of telehealth.

(Copyright 2012 Daniel Nagel and Antonia Arnaert. All Rights Reserved.)

telehealth is difficult to determine. Much available information on use and trends has been generated through industry and market analysis rather than through independent research. Significant challenges exist in tracking telehealth technology use and trends in healthcare, including the following:


    1.How telehealth is defined; terms such as telehealth, telemedicine, and informatics are frequently and inconsistently used interchangeably in the literature

    2.The variety in modalities of telehealth technologies being used and the capacity to which they are used

    3.The vastly different contexts in which telehealth may be employed, such as varying models and settings for healthcare delivery, geographic regions, and cultural settings

Telehealth Industry Growth

One market research firm valued the market for remote patient monitoring, one form of telehealth care, in the United States at about $7.1 billion in 2010 and anticipated this market will grow to $22.2 billion by 2015.73 Healthcare technology usage in Canada during 2010 includes delivery of 260,000 telehealth encounters and 2500 patients enrolled in telehomecare services, reflecting a 35% annual growth during the previous 5 years.74 In Europe, outpatient telehealth services are provided by either public or private hospitals. A report provided to the European Commission in 2011 indicated that 8% of hospitals provided telemonitoring to patients.74 Continued global growth in telehealth is anticipated as technology evolves and the need for cost-effective healthcare delivery increases in both developed and developing countries.36,37,66,75

Rapid advances in technology, such as electronic platforms for healthcare services and technologies used in transmitting data, continue to expand the reach of healthcare delivery and the potential services available. Initially telehealth relied on Internet connections; however, a shift to more mhealth formats has occurred, particularly in developing countries. Growth in the mobile phone industry in countries such as China and India has increased 321% compared to 46% in developed countries.76 In India, use of cellular phones is estimated at 742 million phones, with many of these new “mobile citizens” living in poorer and rural areas with scarce infrastructure and facilities, low literacy levels, and low Internet access.77 mHealth capabilities now provide a wide range of wireless monitoring opportunities to transmit information for a variety of health conditions, such as diabetes and cardiovascular diseases. mHealth has also increased access to healthcare for persons and communities in rural and isolated regions.66 A recent endorsement of 4G standards in wireless telecommunications by the International Telecommunications Union, a branch of the United Nations, will have significant implications for speed and quantity of data transmission and for the future capacity of mhealth technologies in healthcare delivery.

Telehealth to uHealth

At present a lack of integrated, secure technology “spaces” exists to facilitate migration of data between the various telehealth platforms, ehealth technologies, and mhealth devices for effective and efficient support of healthcare delivery. This gap in interoperability largely reflects industry strategies to protect proprietary rights; however, the lack of interoperability between technologies limits sharing of health information and the ability to implement a cohesive model of healthcare delivery in a virtual environment.36

Advancements in “cloud computing” technology, a more integrated wireless telecommunication architecture that supports accessible and seamless transmission and storage of digital data, may make it possible to facilitate a connection between healthcare information systems and to expand the capacity of healthcare delivery.71,72

More recent research and development has focused on ubiquitous (uhealth) technologies that integrate core components of computers, wireless networks, sensors, and other modalities (such as mhealth devices) to create an environment to monitor, respond to, and assist in meeting the healthcare needs of individuals.78,79 An example of the utility of uhealth is the development of smart home systems that provide persons who have health concerns with a safer environment in which to live more independently.78 As the number of people living longer with complex health conditions grows and the elderly population increases, uhealth innovations can be used to detect changes in health status, communicate pertinent patient information, and alert healthcare providers to facilitate efficient interventions.79

Improve Healthcare Provider Shortages and Access to Care

As telehealth expands, further integration with informatics will continue. Telehealth encounters will be integrated within PHRs and EHRs. Self-care data will also be integrated into data repositories for individuals and populations. As the global population increases, the supply and distribution of healthcare providers can be optimized using telehealth to provide services regardless of the geographic location of those in need. Shortages in primary care providers and nurses, for example, can benefit from redistribution of portions of clinical expertise using telehealth as the export mechanism.4,40

Future migration of telehealth to uhealth will require practicing healthcare provider licensure models that are not only interstate, but also international, enabling healthcare providers to practice in countries that have healthcare needs that can be met using telehealth technologies. This will require cooperation on the part of politicians, governments, and policy-makers on behalf of fully operationalized telehealth.70,80



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Discussion Questions


    1. What licensure model would be most useful to support telehealth clinical practice across international boundaries, for example, Canadian doctors or nurses (virtually) seeing and treating U.S. patients or U.S. pharmacists and occupational therapists (virtually) seeing and treating Australian patients?

    2. How do the different models for delivering healthcare, including covering the cost of that healthcare, affect the telehealth programs in different countries?

    3. What actions can individual healthcare providers take in the next 3 years to advance the benefits of telehealth for their profession?

    4. Why has telehealth adoption taken so long in the healthcare industry when Skype, cellphones, and other video conferencing applications have been used in personal and business interactions for decades?

    5. How much does usability affect you and your friends when deciding to accept or not use a new technology? Does this also apply in your role as healthcare provider?

    6. What actions can individual healthcare providers take to improve their patients' ehealth literacy?

    7. What needs to occur on an international basis in order for uhealth to be operationalized?

    8. What are the first five steps you would take to start a telehealth program or application in the healthcare facility where you work?

    9. What key success criteria for telehealth programs are “must have” and what criteria are “nice to have” when considering a new telehealth initiative?

    10. What factor or factors will be most important in driving the exponential growth of telehealth in the future?


Case Study

Mrs. Smith is 82 years old and is diagnosed with hypertension, diabetes, and congestive heart failure. Her two children live in California, while she lives in North Carolina in a small family home on 10 acres of land in the Blue Ridge Mountains. Mrs. Smith has been in the hospital four times in the last year due to congestive heart failure. As her eyesight and mobility get worse with age, she found it a challenge to stay on her medical plan and to do her shopping for the right foods she knows she should be eating. Mrs. Smith's health plan, Purple Cross of North Carolina, assigned a nurse case manager to address her situation. Purple Cross provided a digital scale and a remote monitoring device that recorded Mrs. Smith's condition every day by uploading her weight and transmitting the answers to a series of questions on a touch screen kiosk. The case manager also coordinated delivery of Meals on Wheels, providing low-sodium, diabetic-compliant dinners to Mrs. Smith on an ongoing basis. The case manager calls Mrs. Smith twice a week, taking the time to educate her about her medications, her activities, and the disease-specific elements that will keep her healthy and out of the hospital. When the case manager identifies that Mrs. Smith can no longer organize her daily medications, a digital medication dispenser will be provided that will keep her on her medication regimen. The medication dispenser will be preloaded with Mrs. Smith's medications and will issue a subtle doorbell tone when it is time to take her medicines. With the combination of remote and real-time (telephonic) support persons and technologies, Mrs. Smith is able to remain in her home and avoid further inpatient admissions.

Discussion Questions


    1. Which components are critical to Mrs. Smith staying safely in her home?

    2. Describe whether Mrs. Smith's regimen might be augmented using mhealth applications.


Pageburst Integrated Resources

As part of your Pageburst Digital Book, you can access the following Integrated Resources:


    Bibliography and Additional Readings

    Web Resources




Select two of the following case studies and answer the questions associated with those case studies.


You must answer one short-essay question (worth 20 points) and one long essay question and the required question (each worth 40 points) and have until Wednesday at class time (03-28-18) to get the completed essays to me. I require that the essays are double-spaced, spelling and grammar checked with one-inch margins.  Points will be deducted for spelling errors, problems with conventional grammar, over reliance on quotes (at most you should only have one or two quotes per question), incorrect assessments, and a lack of clarity.  In other words, I should be able to understand and read what you write.  In your essays be sure to demonstrate the breadth of your understanding.  While you may use any course materials except each other, I do expect that you use a variety of course texts.  Try to be as specific as possible.  Use examples, research studies, and ideas from your research paper, videos, and textbooks to illustrate your ideas.


Short Essay

(rough minimum for the short essay about two-three pages)

1.  Under what conditions are police most likely to arrest a juvenile?  Discuss what you believe to be the four most important answers to that question.  What factor(s) are considered the most significant?


2.  After having gone through a juvenile delinquency course, what are the five most important characteristics of juvenile delinquency?  Briefly explain your reasoning on each based only on course materials and your community service.


3.  What is the most promising direction in dealing with juvenile delinquency in America?  What reasoning leads you to that conclusion?


4.  Explain, analyze, and critique the emphasis of Juvenile Court in theory and in application.


5.  Explain how the juvenile justice system responds to the challenge of youth street gangs.  Be sure to draw upon class resources and Detective Ruchti’s comments in your answer.


6.  Construct your own short essay question in Juvenile Justice and Delinquency based on relevant course materials.  Points will be awarded both on the basis of the answer and the question.  Be sure that this question is unique to the other questions on this exam.


Long Essay (rough minimum for each long essay about three pages)

7.  Ignoring all of the political realities of the day, if you had the political power, resources, and will to change the juvenile justice system in Ohio, what would you do?  What would be the impact of the changes that you would make?


8.  Explain the purpose and use of youth Jails (called the Departments of Youth Services in Ohio) and Detention.  How does the practice of these facilities compare to the philosophy and nature of youth court?  Be sure to draw on all relevant course materials (i.e., guest speakers, text, films, and class discussions).


9.   Drawing upon all course materials, explain the purpose of diversion and treatment alternatives.  Be sure to utilize the information from video, our discussion of shock incarceration, group homes, and any information that you accumulated in your readings.


10.  What reasons are used to support the dismantling of the juvenile justice system?  How compelling are these arguments?  What might these arguments overlook?


11.  Construct your own long question in Juvenile Justice and Delinquency based on relevant course materials.  Points will be awarded both on the basis of the answer and the question.  Be sure that this question is unique to the other questions on this exam.


12.  Based on Somebody else’s Children and No Matter How Loud I Shout, what are the dominant characteristics of the juvenile court?


13.  Compare and contrast the application of due process rights for juvenile and adults. How are they similar?  How are they different?


14. Explain how the juvenile court operates.  Based on the totality of class readings and presentations, what three changes would you make to the juvenile court to prevent delinquency if you could do so?  Be sure to draw upon class resources and Assistant Prosecutor Hayden’s comments.


15. Drug use and abuse are often a significant aspect of juvenile delinquency.  Explain the basis for making the connection between juvenile delinquency and drug use and abuse.



The Required Question

(rough minimum about four pages)


Differences between the juvenile and criminal justice systems are significant.  Discuss the ONE characteristic which you believe best illustrates the difference (i.e., transfers, procedures, case law, probation, parole, incarceration, etc...) and defend your choice by comparing differences and similarities between the juvenile and criminal courts.  Is this characteristic related to American beliefs about childhood?  Or is it about justice in our society?  Or about how we think of crime?  Be sure to draw on all relevant readings, class presentations, and guest speakers.



Due Process and the Juvenile Justice System

The first specialized juvenile court in the United States was created on July 1, 1899, as part of an Illinois legislative act establishing the juvenile court division of the circuit court for Cook Count y." The 1899 Illinois legislation codified a more progressive way to treat wayward youth: instead of showing them the error of their ways by punishing them, the state would help youth correct their course and become productive, law-abiding citizens. Because the goal of the newly-created system focused on rehabilitation and not just punishment, the state law required only cursory legal proceedings that placed judicial economy and youth rehabilitation before due process.' There was no role for defense attorneys-and little role for prosecutors-in that system.

Social workers and behavioral scientists advised the court on the most appropriate disposition of the cases. For the first time, detained youth were separated from adult offenders and placed in training and industrial schools, as well as in private foster homes and institutions." This type of specialized juvenile court was quickly duplicated in the larger cities of the East and Midwest, so that by 1925, some form of juvenile court existed in all but two states."

Until the 1960s, constitutional challenges to juvenile court practices and procedures were consistently overruled. Children were denied the rights to counsel, public adjudications, and jury adjudications. They did not have any immunity against self-incrimination. They could be convicted on hearsay testimony." They could also be convicted by only a preponderance of the evidence. Previous case law found that juvenile proceedings were civil in nature and that their purpose was to reha­bilitate rather than punish.' Research on the juvenile justice system had begun to show that juvenile court judges often lacked legal training;" that probation officers were undertrained and that their heavy caseloads often prohibited meaningful social intervention; that children were still regularly housed in adult facilities; and that juvenile correctional institutions were often, in reality, overcrowded and violent juvenile prisons serving as little more than breeding grounds for further criminal activity.

In 1963, the United States Supreme Court held that the Sixth Amendment right to counsel requires that indigent adults charged with a felony offense be appointed an attorney at public expense. In that seminal case, Gideon v. Wainwright,9 a unanimous court wrote that any person too poor to hire a lawyer cannot be assured a fair trial unless counsel is provided for him, explaining that "lawyers in criminal court are necessities, not luxurics.t"? In the wake of Gideon, in a series of cases starting in 1966, the Supreme Court extended this and other bedrock elements of due process to youth facing delinquency proceedings. Arguably the most important of these cases, In re Gault, 11 held that juveniles facing delinquency proceedings have the right to counsel under the Due Process Clause of the United States Constitution, applied to the states through the Fourteenth Amendment. The Court observed that youth in juvenile court were getting "the worst of both worlds," ex­plaining that youth received, "neither the protections accorded to adults nor the solicitous care and regenerative treatment postulated for children."!"

The Court continued: "[t}he probation officer cannot act as counsel for the child. His role ... is as arresting officer and witness against the child. Nor can the judge represent the child."!' The Court concluded that no matter how many court personnel were charged with looking after the accused child's best interests, any child facing "the awesome prospect of incarceration" needed "the guiding hand of counsel at every step in the proceedings against him" for the same reasons that adults facing criminal charges need counsel. 14

The introduction of legal advocates into the juvenile court system was meant to infuse the informal juvenile court process with more of the strictly observed constitutional protections of adult criminal court and its concomitant adversarial nature: the Court observed specifically that juvenile respondents needed defenders to enable them "to cope with problems of law, to make skilled inquiry into the facts, to insist upon regularity of the proceedings, and to ascertain whether [the client} has a defense and to prepare and submit it."15 The Court specifically denounced the typical pre-Gault courtroom proceeding in which the child's due process rights were not protected by juvenile defense counsel, in acknowledgement of the unfortunate reality that the "absence of substantive standards hard} not necessarily meant that children receive[d} careful, compassion­ate, individualized treatment. "16

Perhaps most importantly, beginning with this line of due process cases, juveniles accused of delinquent acts were to become par­ticipants, rather than spectators, in their court proceedings. In addition to the right to counsel, Gault also extended to youth the right to notice of the charges against them, the privilege against self-incrimination, 17 and the right to confront and cross-examine




adverse witnesses. IS In later cases, using fundamental fairness as its touchstone, the Court held that a youth cannot be adjudi­cated delinquent unless the state proves his or her guilt beyond a reasonable doubt, 19 that a delinquency proceeding constitutes being placed "in jeopardy" and bars future prosecution for the same allegations," and that youth have the right to a formal hearing and an attorney before being transferred to adult court for criminal prosecution." In each of these cases, the Court reaffirmed, that "civil labels and good intentions do not themselves obviate the need for criminal due process safeguards in juvenile court[.}"22

As the President's 1967 Commission on Law Enforcement and the Administration of Justice stated, "[N]o single action holds more potential for achieving procedural justice for the child in the juvenile court than provision of counsel.":"


The defense lawyer plays a critical role for youth in delinquency court by protecting clients from unfairness, promoting accuracy in decision making, providing alternatives for decision makers, and monitoring institutional treatment, aftercare, and re-entry. Throughout the entire court process, the juvenile defender is the singular individual responsible for bringing the child's perspective before the court.

The role of the juvenile defender has evolved to require a complex and challenging skill set, as well as an acute understand­ing of what it means to be an advocate for a child client. By the early 1980s, there was professional consensus that defense attorneys owe their juvenile clients the same duty of loyalty as owed to their adult clients." That coextensive duty of loyalty requires defenders to represent the legitimate "expressed interests" of their juvenile clients, and not the "best interests" as determined by the individual judge, a probation officer, or a guardian ad litem." This role is central to the kind of juvenile court Gault requires: one in which there is an advocate whose sole responsibility is protecting the due process rights of the child within the well-intentioned efforts of the other system stakeholders.

In order to effectuate this role, juvenile defenders have ethical and professional obligations that are central to their work. Unlike other actors in the system, juvenile defenders must empower their clients to understand and make important and reasoned decisions about their cases, such as whether to accept a plea agreement or exercise the right to trial; whether to exercise the right to remain silent or testify; whether to choose a jury trial or bench trial, when applicable; and whether to advocate for particular services. This kind of empowerment can be difficult with an adult client, but with children, the ability to properly advise and counsel a client is even more challenging because it requires an understanding of developmen­tally-appropriate communication styles and interview techniques.

Juvenile defenders have the added complication of maintaining client confidentiality when so many players­parents, teachers, mentors, service providers, etc.-have a stake in and an opinion about what should happen in the case. While each of these players can be an ally that helps further the goals of the youth within the case, not every actor will always share the same goals. It is impossible to understand a child in a vacuum, and these other people are vital to the defender's understanding of the circumstances of the case in context. However, defenders have the difficult task of maintain­ing relationships with all the people who are important in the child's life while ensuring that a confidential relationship is maintained.

Every lawyer has an ethical responsibility to represent his or her client with competence and diligence. This requires more than simply being well-versed in the law, rules, and procedures of a juvenile court. For juvenile defenders, the day-to-day in­teractions with their clients require fluency in areas of child and adolescent development, an understanding of and comfort with age-appropriate communication techniques, and familiarity with non-courtroom advocacy that includes everything from special education systems to mental health providers.

Juvenile defense counsel plays a vital role throughout the duration of the court's jurisdiction over the young person. The scope and duration of appointment ought to extend from the initial hearing, at the latest, through post-disposition rep­resentation. Access to counsel is needed for post-disposition review hearings, sentence modifications, appeals or other col­lateral reviews, accessing particular services such as drug or mental health treatment, or challenging dangerous or unlawful condition of confinement.


The breadth of responsibilities an expressed interest representation requires are difficult, if not impossible, to live up to if the defender does not build a trusting relationship with the client. All codes of professional conduct and defender practice guides acknowledge that good communication is at the heart of the attorney-client relationship. Communicating effectively,




building rapport, and cultivating client engagement take time, which is a luxury many defenders feel they do not have. The reality, however, is that the entire system is better served when defenders are able to develop these kinds of relationships and are able to ensure that children not only understand what is happening, but have the ability to engage thoughtfully in the decision-making process. Juvenile defense counsel cannot assume that he or she knows what is best for the client, but instead must employ a client-centered model of advocacy that actively seeks the client's input, conveys genuine respect for the client's perspective, and works to understand the client in his or her own socioeconomic, familial, and community con­text. Juvenile defense counsel's abiding purpose is to empower the client to make informed decisions." It is only through skilled, developmentally and age-appropriate communication that the lawyer can be prepared to competently advise and represent the client's interests.

Developing a good working relationship with youth under highly stressful circumstances raises unique challenges and re­quires special awareness and responses by counsel. A defender's ability to both perceive and appropriately address a youthful client's fears and anxieties is central to his or her ability to work effectively with the client to ensure high-quality defense. Youth in delinquency systems often have disabilities that affect critical aspects of their functioning, especially their ability to communicate and comprehend. Juvenile defenders must be alert to the special needs or challenges of each client, while also identifying the client's strengths-be they familial, personal, or potential-and help integrate those strengths into the theory of the case and the disposition planning.


Children are different from adults; this is a fact that has been regularly upheld by the United States Supreme Court. Juvenile defenders and the public defense delivery system must respond accordingly. Juvenile defense is a highly specialized practice that requires not only the trial skills of an attorney in the criminal system, but also knowledge of a whole host of juvenile­specific procedures, systems, and statutes." According to a Colorado Department of Public Safety report, the Colorado juvenile justice system is more complex than the adult criminal justice sysrem.:" The report states that "The juvenile justice system comprises complex processes involving multiple agencies with different objectives and mandaces.'"?

The job of the juvenile defense attorney is enormous. Beyond their complexity, delinquency cases carry consequences with significant and lasting implications for youth and families. A juvenile defender has dual responsibilities to prepare and present not only the criminal case, but must also be skilled in presenting the social case to assist courts in making determinations at every stage of the proceedings. Balancing these sometime competing tensions makes juvenile defense especially challenging. Counsel must be patient and build rapport with his or her client, explaining the confidential nature of their relationship.

At a minimum, juvenile defenders must be aware of the strengths and needs of their juvenile clients and of their clients' families, communities, and other social structures. Juvenile defenders must also understand child and adolescent devel­opment to be able to communicate effectively with their clients and to evaluate their level of maturity and competency and its relevance to the delinquency case. Juvenile defenders must have knowledge of and contacts at community-based programs to compose individualized disposition plans. Similarly, they must be familiar with mental health, education, special education, and immigration laws and services. Juvenile defenders must be able to enlist the client's parent or guardian as an ally without compromising due process or the attorney-client relationship. Juvenile defenders must help the client understand the impact of a plea or other juvenile court adjudications, and the direct and collateral conse­quences that attach to that decision.

Juvenile defense delivery systems must reflect the field's knowledge of the unique attributes of adolescence in defense prac­tices. To do otherwise would be irresponsible because it ignores our understanding of adolescent development, impedes counsel's ability to communicate effectively with a young client, and limits a child's ability to meaningfully assert his or her rights. If counsel must guide youth toward informed decision making, systems must provide juvenile defenders with the training and support needed to perform accordingly. Juvenile defense counsel has an obligation to maximize each client's participation in his or her case, and they can only be expected to do so with ongoing and specialized skills and training. Underscoring this importance, the United States Supreme Court noted in 2010 that there are "special difficulties encoun­tered by counsel in juvenile representation."30 Indeed, "the features that distinguish juveniles from adults also put them at significant disadvantage in criminal proceedings."!' The role of a juvenile defender is multifaceted and challenging. It requires extraordinary sensitivity as well as all the legal knowledge and courtroom skills of a criminal defense attorney representing adult defendants.



You must answer one short-essay question (worth 20 points) and one long essay question

Now that you have your proposal finalized, begin working on your literature review. This week you will submit an annotated bibliography. 


In week 1 part of your proposal template was to include at least 5 references that you would be using for your capstone project.


Using those five references, more if you have them, you will submit a brief synopsis of each reference. What this means is that you will demonstrate that you have conducted a cursory review of the resource material that you are proposing to use, and you are going to provide the reader, which would be me, a brief overview of what the article, book, etc. is about. 


You will submit this as a word document. In numbered order, you will list the reference, in proper APA format, and then underneath that reference heading you will provide the synopsis.


Be aware of the resource material that you choose! Web sites such as .com, .net. are not considered scholarly. I would prefer that the majority of your references come from scholarly, peer reviewed journal articles. If you must utilize something from a web site, it will only be acceptable if it is a .gov or .edu site.


Try your best to turn this in early so that you can allow for any corrections that you may need to make based on my feedback. If you have any questions please reach out to me through email.

Now that you have your proposal finalized, begin working on your literature review.

Answer the following as best you can. You do not need to answer all the questions, but your paper should address the major points of gender socialization.

1. From what you know about your own upbringing, what were the major socializing agents in your childhood? Discuss what behaviors, attitudes, beliefs, etc. you learned from these agents and how your socialization has influenced the person you are today.

 2. Toys for female children often socialize them to be talkative, relational, expressive, and domestic. Toys for male children often socialize them to minimize talking while focus on strategizing (army toys), on physical aggression (guns, actions figures), on thinking (building blocks), on danger (swords, grenades). Think of your experience as child and what toys helped to socialize you. Describe what toys, items, or activities you think had a significant influence on your present adult behaviors, attitudes, values, etc. and how/why. I tend to agree with research in that both sexes lack characteristics due to gender socialization. For instance, females may focus too much on relationships while males have difficulty discussing their feelings. Do you think the way our culture socializes girls and boys is positive or negative? Both? How do you think you might socialize a child if you were the parent? Would you do it the same or differently from the way you were raised? Why?


The Woman Behind Marvel's Newest Team Of Heroines:  (Links to an external site.)Links to an external site.

DOVE SKETCHES (Links to an external site.)

Answer the following as best as you can

Due 3/16 9p,m est

500 words APA MIN 4 References



  • Sanitary Conditions of Food Vending Sites and Food Handling Practices of Street Food Vendors in Benin City, Nigeria: Implication for Food Hygiene and Safety
  • P. W. Okojie and E. C. Isah      (ARTICLE ATTACHED)

Journal Article Critique: Food Safety

Discussion of journal articles is important to the development of critical thinking and evaluation skills. You are provided with citations for two different articles to discuss with your colleagues, in a “journal club” style. A journal club typically refers to a group of individuals who meet to critically evaluate journal articles in their academic field. You will participate in a journal club style critique in this module’s Discussion. This type of evaluation is very useful to broaden your knowledge of the field and practice critical thinking skills. Your discussion must be relevant to the journal article and must provide a scholarly critique of the contents.  Post your discussion under the appropriate topic threads for each article. 


To get the discussion going, you may wish to consider the following topics:

What do you think the public health significance of the research question in this study was? Is it mostly of local significance or is there a global impact? Explain. Does the study fill an important gap, in your opinion? Why or why not? Critique the methodology. Why do you think the authors chose this methodology and what would you have done differently? Explain. Interpret the results in your own words and then discuss with your colleagues whether you agree or disagree with the author’s interpretations and why.

Discuss with your colleagues what you believe is the social change impact of the findings. Do you think that the outcomes of the study are modifiable and/or actionable? Why or why not? What would you propose as a reasonable action from the findings, and why? How might the precautionary principle apply to this study?

What other recent studies can you find that either contradict or support these findings? Do the other studies impact your assessment of the significance and interpretation of this study? How? Be sure to provide the full citation for the other studies that you bring up.


Hindawi Publishing Corporation

Journal of Environmental and Public Health Volume 2014, Article ID 701316,6 pages 14170 1316


Research Article

Sanitary Conditions of Food Vending Sites and Food Handling Practices of Street Food Vendors in Benin City, Nigeria:

Implication for Food Hygiene and Safety

P. w. Okojie and E. c. Isah

Department of Community Health, University of Benin Teaching Hospital, PMB 1111, Benin City 30001, Nigeria

Correspondence should be addressed to P. W Okojie;

Academic Editor: Pam R. Factor-Litvak

Received 12 March 2014; Revised 7 August 2014; Accepted 14 August 2014; Published 3 September 2014

Copyright © 2014 P. W Okojie and E. C. Isah. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. To determine the sanitary conditions of vending sites as well as food handling practices of street food vendors in Benin City, Nigeria. Methodology. A descriptive cross-sectional study was done using an observational checklist and researcher­administered questionnaire. 286 randomly selected vending units were surveyed, and their operators interviewed on their food handling practices. Results. A higher proportion, 259 (90.5), of the observed vending sites appeared clean. The following sanitary facilities were observed in and around the respective food premises of the respondents: waste bin, 124 (43.4), refuse dumpsite, 41 (14.3), wash hand basin, 201 (71.2), hand towel, 210 (73.4), and soap, 220 (76.9). There were also the presence of flies 118, (41.3), and the presence of rats/cockroaches, 7 (2.4). Respondents with tertiary education, 5 (38.5), vended foods in environment with good hygiene status compared to those with secondary, 45 (31.7), and primary education, 33 (27.3). There was no statistically significant association between educational status and the hygiene status of food premise (P = 0.362). Conclusion. This study showed that street food vending sites in Benin City were sanitary and that food vendors had good food handling practices.

1. Introduction

In many developing countries including Nigeria street food vendors have formed an integral part of the food supply chain, particularly following the advent of urbanization [1]. The street food industry has contributed immensely to human and economic development as studies conducted in some of the African countries like Nigeria, Morocco, and Kenya have shown that major street food vendors usually earn above the countries' minimum wage [2-4]. The socioeconomic role of the street food sector in terms of its potential for employ­ment creation, yielding income particularly for women, and provision of food at affordable cost to lower income groups in the cities has been documented [5]. In Nigeria, urban city dwellers spend as much as half of their food expenditure on street foods [6].

As in other developing countries, the street food sector in Nigeria is confronted with challenges. There is inadequate supervision and proper monitoring by food safety officers

and the enforcement of food hygiene regulation is weak [7]; lack of training in food safety and good hygiene practices is also rife among food handlers. Hence street foods are at risk of contamination, often at all stages of handling. Street foods are sometimes stored at improper temperatures and sold from vending sites which include kiosks, make-shift accommodation, and push carts as well as other temporary structures [8]. They are prepared at very dirty surroundings with waste water and garbage disposed nearby, providing nutrient and breeding ground for rodents and vermin [9]. In most cases running water is not available at vending sites, washing of hands and crockery are done in bowls or buckets and sometimes without soap [9, 10]. Furthermore the conditions under which street food is prepared and vended are worsened by weak implementation of relevant environmental and public health regulations.

As an integral part of its National Health Policy, Nigeria launched the National Policy on Food hygiene and Safety in 2000. Responsibilities for food safety and hygiene practice



devolve on different tiers of government and their agencies­federal, state, and local. The control and regulation of street food vending, catering establishment, and the enforcement of food hygiene and safety are, however, carried out at the local government level, where Health Officers enforce relevant sections of the Public Health Laws [11]. In some cases, local government council authorities develop byelaws which apply specifically to the regulation and control of food premises. Specific laws enacted to ensure food safety in Nigeria include The Public Health Law/Ordinance Cap 164 (1917/1958), Standards Organization of Nigeria (SON) Decree (1971), the Food and Drugs Decree number 35 (1974), the Animal Disease Control Decree number 10 (1988), and the Marketing of Breast Milk Substitute Decree number 41, (1990). Others are Consumer Protection Council Decree number 66 (1992), National Agency for Food and Drugs Administration and Control (NAFDAC) Decree, number 15 (1999) and, the Counterfeit/Fake drugs/unwholesome pro­cessed Food Decree, number 15, 1999 [3]. The need to revise some existing food safety legislations has been emphasized, as some of them are out of date and do not meet current realities and trends in food safety [11].

In Nigeria, there are a large number of local eateries, where a significant number of people eat daily [12]. There has also been an observed increase in the patronage of ready- to­eat food vendors within Benin City, Edo State [12]. However, their poorly regulated operations raise serious questions about food safety and hygiene standard, as well as monitoring by relevant authority [9, 10]. Benin City is a fast growing urban centre, expanding rapidly in size and population and is characterised by "people on the move"; this creates a suitable environment for the street food trade which unfortunately operates under unsanitary conditions. These circumstances make a survey of safety and hygiene of street foods being served in the city both timely and unavoidable for early identification of emerging food safety issues in order to pre­vent them from developing into health risks. This study will generate information that can aid health and environment authority to improve on the implementation of existing food hygiene laws, leading to a more effective regulation of the practice of street food vending in Benin metropolis. This study was therefore undertaken to determine the sanitary conditions of vending sites as well as food handling practices by food vendors on the streets of Benin City, Nigeria.

2. Methodology

2.1. Study Area. This study was conducted in Benin City, located in the South -South geopolitical zone of Nigeria. The city is made up of three Local Government Areas, namely, Oredo, Egor, and Ikpoba-Okha. The population of Benin City based on a seven-year projection (from the 2006 census figure 1, 085676) [13] is 1,326,196. The inhabitants of Benin City are mainly small- to medium-scale business owners, farmers, artisans, civil servants, bankers, and students. The people are a combination of Christians, Muslims, and tradi­tionalists. The majority of the inhabitants are Benin-speakers. There are major markets and abattoirs within the city that

Journal of Environmental and Public Health

also serve as points of preparation and sale of street foods. Popularly vended street foods in Benin include local snacks like bean cake, roasted plantain, and bean pudding. Among the main meals are rice, beans, and spaghetti, amongst others.

2.2. Study Design. A descriptive cross-sectional study design was used in conducting this study. The study hypothesised that food safety training had a positive influence on a food vendor's practice of food and environmental hygiene. The study population comprised food vendors in their respective food vending units within the Benin City metropolis.

2.3. Inclusion and Exclusion Criteria. Stationary food vend­ing units used for preparation/sales of street food as well as operators of such were included in the study. All mobile food vending units such as push carts and their vendors were excluded.

2.4. Study Duration. The study was carried out over a period of four months from April 2012 to July 2012 among street food vendors/vending units in the Benin metropolis.

2.5. Sample Size Determination. The minimum sample size of 272 for food vending sites was calculated using the formula n = Z2pq/d2 for a cross-sectional study [14].

2.6. Sampling Technique. A walk-through survey of ran­domly selected food vending sites was done and a total of 286 vending units were observed using a checklist. One vendor per vending site was selected by simple random sampling technique to participate in the survey.

2.7. Data Collection Tools. A structured researcher-admin­istered questionnaire was used to collect data on back­ground characteristics of respondents. An observational checklist adapted from the "WHO essential requirement for the safety of street-vended foods" was used to determine sanitary conditions of food vending sites/vending practices of food vendors [15]. The study instrument was pretested among selected street food vending sites/vendors operating in Ekpoma, Esan West Local Government Area of Edo State, located 50 kilometres from the study area.

2.8. Data Analysis. Questionnaires were screened for com­pleteness, coded, and entered into the Statistical Package for Scientific Solution (SPSS) version 17.0 software for analysis. Discrete data were presented as proportions while continuous variables such as age were expressed as means ± standard deviation. Statistical analysis of difference between propor­tions was carried out by the use of l (Chi squared test). Fisher's exact test was used to test for association between variables when 20 cells or more had expected values less than five. Statistical significance was set at P < 0.05.

2.8.1. Vending Practices. A total of ten items were assessed: (1) food sold from tray/basin with covering; (2) food sold from tray/basin with no covering; (3) food exposed to flies; (4)


Journal of Environmental and Public Health

food reheated before sale; (5) vendor wearing hand jewellery; (6) vendor having long nails; (7) vendor having boils/cuts on the hand; (8) vendor using apron; (9) vendor having hair covering; and (10) vendor blowing air into cellophane bag before serving. A score of "1" was assigned for the correct practice while a score of "0" was assigned for wrong food handling/vending practice. The total score was converted to 100 percent. A score of :0:;50 was classified as poor vending practice while a score of >50 was classified as good vending practice.

2.8.2. Sanitary Condition of Vending Premises. A total of eight parameters were assessed: (1) appearance; (2) presence of waste bin; (3) presence of nearby refuse dump site; (4) presence of wash hand basin; (5) presence of hand towel; (6) presence of soap; (7) presence of flies; and (8) presence of rats/cockroaches. A score of "1" was assigned for the presence of relevant item while a score of "0" was assigned for its absence. The total score was converted to 100 percent. A score of :0:;50 was classified as poor environmental hygiene while a score of >50 was classified as good environmental hygiene.

3. Ethical Considerations

Ethical approval was obtained from the University of Benin Teaching Hospital's Research Ethics Committee before the commencement of this study. Permission was obtained from the respective city area council authorities. Written informed consent was obtained from each respondent before the conduct of interviews after adequate information was pro­vided by the interviewers. Confidentiality and privacy were respected during the course of the study: serial number rather than name was used to identify each respondent. Names and addresses of food premises were not used as they were rather coded. There were no penalties or loss of benefit for vendors who refused to participate in the study or withdraw from it. Group health education was conducted for food vendors who participated in the study.

4. Results

Two hundred and fifty-eight (90.2) respondents were females and twenty-eight (9.8) were males. One hundred and forty- two (49.7) of the respondents attained secondary level of education; forty- two percent (42.3) of them attained primary education. Twenty-eight percent of them had food safety training (Table 1).

Respondents with tertiary education, 5 (38.5), vended foods in environment with good hygiene status compared to those with secondary, 45 (31.7), and primary education, 33 (27.3). There was no statistically significant association between educational status and the hygiene status of food premise (P = 0.362).142 (69.6) respondents who had no training in food safety vended foods in premises with poor environmental hygiene compared with their counterparts who had training in food safety, 56 (68.3). There was no statistically significant association between having training in food safety and the hygiene status of food premise


TABLE 1: Background characteristics of respondents.

Background characteristics

Frequency (n = 286)

Percent ()










Educational attainment


















Food safety training






Not trained



Awareness about food safety law






Not aware



TABLE 2: Background characteristics of respondents and sanitary conditions of food vending sites.

Background characteristics

Environmental hygiene

Poor () Good ()                  Total ()

Educational attainment

None Primary Secondary Tertiary Vocational Total

Fisher's exact = 4.15 Food safety training Trained

Not trained


l = 0.047

Awareness of food safety law

    Aware                                    67 (72.8)       25 (27.2)

5 (55.6)

4 (44.4)

9 (100.0)

88 (72.7)

33 (27.3)

121 (100.0)

97 (68.3)

45 (31.7)

142 (100.0)

8 (61.5)

5 (38.5)

13 (100.0)


1 (100.0)

1 (100.0)

198 (69.2)

88 (30.8)

286 (100.0)


P = 0.362


56 (68.3) 26 (31.7) 82 (100.0) 142 (69.6) 62 (30.4) 204 (100.0) 198 (69.2) 88 (30.8) 286 (100.0)

P = 0.827

92 (100.0)

Not aware Total

l = 0.823

131 (67.5) 63 (32.5) 194 (100.0) 198 (69.2) 88 (30.8) 286 (100.0) P = 0.364

(P = 0.827). One-third (32.5) of respondents who were not aware of food safety law/regulation vended food in good hygienic environment were compared to 25 (27.2) of vendors who were aware of food safety law/regulation. There was no statistically significant association between awareness of food safety law and the environmental hygiene of food premise (P = 0.364) (Table 2).

A high proportion 259 (90.5) of the vending sites appeared clean. The following were observed in and around the respective food premises of the respondents: waste bin, 124 (43.4), refuse dump site, 41 (14.3), wash hand basin, 201 (71.2), hand towel, 210 (73.4), soap, 220 (76.9), presence



TABLE 3: Environmental hygiene of food vending premises (n = 286).

Frequency' Percent ()

Environmental hygiene parameters



Clean environment



Waste bin present



Refuse site present



Wash basin present



Presence of hand towel



Soap present



Presence of flies



Presence of rats/cockroaches



Indices of environmental hygiene status









• Multiple responses.



TABLE 4: Observed food handling/vending practices (n = 286).

Frequency' Percent ()

Observed practices



Food in covered container



Food in uncovered container



Food exposed to flies



Food reheated before sale



Vendor wore hand jewelry



Vendor had long nails



Vendor had hair covering



Vendor had cut on the hand



Vendor wore apron



Vendor blew air into cellophane bag



use for vending food

Indices of food handling practice









• Multiple responses.



of flies, 118 (41.3), and presence of rats/cockroaches, 7 (2.4) (Table 3).

Two hundred and seventy (94.4) respondents were observed to vend food from containers with cover while 31 (10.8) of them sold food to customers from containers without cover. In 79 (27.7) of cases, vended foods were exposed to flies. Other practices observed among vendors were reheating of food, 66 (23.1), keeping oflong nails, 19 (6.6), wearing of head cover, 208 (72.7), and blowing of air into cellophane bags for serving food, 66 (23.1). The major­ity, 237 (84), of the vendors were observed to have good food handling practices at the point of sale. Only 49 (16) of the vendors were observed to have poor vending/food handling practice on a cumulative scale (Table 4).

Most, 27 (96.4), of the vendors who vended food from containers with covers were males, compared to 243 (94.2) of their female counterparts who did. There was no significant

Journal of Environmental and Public Health

TABLE 5: Sex and mode of keeping food containers by respondents.

Covering of food containers Yes () No ()

Total ()






27 (96.4)

1 (3.6)

28 (100.0)


243 (94.2)

15 (5.8)

258 (100.0)


270 (94.4)

16 (5.6)

286 (100.0)

l = 0.24


P = 0.624


association between gender and the practice of covering food containers (P = 0.624) (Table 5).

5. Discussion

In Africa, women are commonly involved in preparation and serving of food; they are taught how to cook from a young age. The predominance of female food vendors (90.2) in this study is therefore not surprising. In Nigeria women are popularly involved in street food vending [2], as they depend on it as a means of complementing family income in the midst of a harsh economy. Previous studies conducted in Ilorin, Abeokuta, in Nigeria and Accra in Ghana, respectively, showed similar trend [2, 16, 17]. This was, however, not the case in studies conducted in South Africa and Kenya, respectively, where street food vendors were mostly males [18, 19]. Gender role in socioeconomic development is often influenced by cultural orientation and varies from one geographical location to another.

There were more respondents who had attained sec­ondary education. A study among two hundred street food vendors in South Africa documented a similar finding, where the majority, 181 (90.5), of the study participants attained secondary education [20]. However, it contrasts with other studies in which most street food vendors had only attained primary education [21, 22]. This may be attributed to the fact that most street vendors belong to the socioeconomically disadvantaged group and hence may lack a ready opportu­nity to pursue higher education due to social deprivation occasioned by poverty. In addition, many cultures in Africa invest less in female education, making the girl child socially disadvantaged in a male-dominated world.

Food hygiene and safety training among a small pro­portion of the respondents as observed in this study is similar to findings from a study conducted among 185 food vendors in secondary schools in Ilorin, Nigeria, in which only 39.0 of the respondents had a form of training in food hygiene and safety [23]. This activity may not be regularly organized in the study area by the concerned authority. Apathy towards food safety seminars can also be a reason particularly when food vendors rely more on their experience from long years of practice [19]. The public health laws prescribe that health officers organize regular trainings and food safety education for food handlers. Some unwholesome food handling practices of food vendors are deeply rooted in traditions and customs and thus require messages tailored to address such beliefs.


Journal of Environmental and Public Health

The observation of good sanitary condition in the major­ity of the food vending sites is similar to findings of studies conducted in Owerri, Nigeria, and Accra, Ghana [16, 24], where the majority of the food premises were observed to be tidy, with the use of waste bin and the presence of on­site water source for sanitary purposes. This phenomenon is in line with requirements of standard guidelines and recommendations for street food vending practice and is thus commendable [IS, 2S]. This finding is, however, at variance with that of a study in Brazil where the sanitary conditions of sale points of commercial foods of plant origin vended in Sao Gancalo and Rio de Janeiro were poor [26]. Not only are sanitary conditions in and around an eatery suggestive of health consciousness by the service provider, they are also likely to boost consumer confidence and increase vendor patronage.

Vendors who had no formal training in food hygiene and safety appeared to vend food in premises with poor environmental hygiene compared with their counterparts who had food safety training though the statistical test did not support its invariability. By implication it can be opined that receiving food safety training may not always lead to maintaining good environmental hygiene on the part of the vendors. Among other factors, a positive attitude is required on the part of the vendor to translate the knowledge gained from trainings into practice. This is not to say however that food safety training is less contributory to food hygiene. There was no statistically significant association between awareness of food safety regulation and the hygienic status of the food premises even though the majority of respondents who vended in premises with good environmental hygiene were aware of food safety regulation. By implication, awareness of food safety regulation did not necessarily influence good environmental hygiene among the respondents. However, more public health enlightenment is required to sensitize food vendors on the need to maintain environmental sani­tation as unsanitary environment and other nuisance gives opportunity for breeding of insect/vectors, including vermin that can compromise food product quality. According to the public health laws, as part of their food safety enforcement roles, health officers are empowered to abate such nuisances in a food premise and destroy any food material or product which constitutes a food safety risk.

Most of the respondents vended food items in envi­ronments that were observed to be clean. This finding is, however, at variance with what was reported in a Kenyan study where it was observed that about 8S.0 of the vendors prepared their food in unhygienic condition [19]. A clean food stand or premise will attract more consumers based on aesthetic appeal. Though food aesthetics is desirable, as it contributes to increase in sales, it does not rule out the significance of other aspects of food hygiene such as hand washing and regular medical examination. The practice of the use of head covers and the wearing of aprons by the vendors is commendable as many food safety regulations including the Public Health Laws of Edo State specify the wearing of caps/aprons as a part of a vendor's food safety responsibility. However, the wearing of clean-looking aprons may be contributing more to fueling consumer's subjective


assessment of a vendor's sense of personal hygiene. Food vendors should not only wear clean aprons as part of food aesthetics, but they should also perform periodic medical examination and store food items in such a way that they are free of contamination.

Even though some of the vending sites had the presence of flies, the situation was better when compared with those of sanitary conditions in a study conducted in Nairobi, Kenya, where flies were present in all stalls operated by vendors of fish and fresh fruit salad [19]. Flies are mechanical vectors and thus can spread infective agents to food and water for human consumption, leading to potential foodborne diseases such as cholera, dysentery, and typhoid. This study revealed no statistically significant association between sex and how food containers were kept. Even though a higher proportion of male vendors were observed to cover their food containers most of the time compared to their female counterparts, it was not enough to conclude that male vendors had better food vending practices. In addition upbringing and training can also play a role; a girl child who is untrained in the etiquettes of handling and maintaining utensils may perform averagely below her male counterpart who had learned these skills. Thus emphasis should be placed on training for all food handlers irrespective of gender to influence their hygiene practices in the interest of public health.

6. Conclusion

It was found from this study that street foods were vended under relatively good sanitary conditions and that the ven­dors had good food handling practices. It is recommended that food vendors should continue to maintain standard environmental and personal hygiene while preparing and packaging or serving food products to consumers.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.


[1] O. A. Akintaro, "Food handling, hygiene and the role of food regulatory agencies in promoting good health and development in Nigeria;' International Journal of Health and Medical Infor­mation, vol. 1, no. 1-3, pp. 1-8, 2012.

[2] A. M. Omemu and S. T. Aderoju, "Food safety knowledge and practices of street food vendors in the city of Abeokuta, Nigeria;' Food Control, vol. 19, no. 4, pp. 396-402, 2008.

[3] G. E. Ifenkwe, "Food safety regulation: reducing the risk of food-borne diseases in rural communities in Abia state, Nigeria;' Agricultural Science Research Journal, vol. 2, no. 7, pp. 384-389, 2012, ARJ/Pdf/2012/July/ Ifenkwe.pdf.

[4] A. Mwangi, Nutritional, hygienic and socioeconomic dimension of street foods in urban areas: the case of Nairobi [Ph.D. thesis], University ofWagenigen, 2002.

[5] N. Tavonga, "Operations of street food vendors and their impact on sustainable urban life in high density suburbs of Harare, in



Zimbabwe;' Asian Journal of Economic Modelling, vol. 2, no. 1, pp. 18-31, 2014.

[6] M. J. Cohen and J. L. Garnet, "The food price crisis and urban food (in) security;' Human Settlement Working Paper Series; Urbanization & Emerging Population no. 2, IIED/UNFPA, 2002.

[7] S. N. Oyeneho and C. W Hedberg, ''An assessment of food safety needs of restaurants in Owerri, Imo State, Nigeria;' International Journal of Environmental Research and Public Health, vol. 10, no. 8, pp. 3296-3309, 2013.

[8] Food and Agricultural Organization, "Report of an FAO expert consultation;' FAO Food and Nutrition Paper 46, Food and Agricultural Organization, Jakarta, Indonesia, 1990.

[9] N. Barro, A. R. Bello, A. Salvadogo, C. A. Ouattara, A. J.

IIboudu, and A. S. Traore, "Hygienic status assessement of dish washing waters, utensils, hands and pieces of monies from street food processing sites in Ouagadougou (Burkina Faso );' African Journal of Biotechnology, vol. 5, no. 11, pp. 1107-1117, 2006.

[10] M. A. Abdalla, S. E. Suleiman, Y. Y. H. A. Alien, and O. Bakheit, "Food safety knowledge and practices of street food vendors in Khartoum City;' Sudanese Journal of Veterinary Science & Animal Husbandry, vol. 47, no. 182, pp.123-136, 2008.

[11] R. K. Omotayo and S. A. Denloye, The Nigerian Experience on Food Safety Regulation, FAO/WHO Global Forum on Food Safety Regulations, Marrakesh, Morocco, 2002, http://www.fao . org/ docrep / meeting/004/ ab53 8e.htm.

[12] M. D. Wogu, M. 1. Omoruyi, and H. O. Odeh, "Microbial load in ready-to-eat rice sold in Benin City;' Journal of Microbiology and Antimicrobials, vol. 3, no. 2, pp. 29-33, 2011.

[13] Federal Government of Nigeria, "Legal Notice on Publication of the details of the breakdown of the National and State Provisional Totals 2006 Census;' Federal Republic of Nigeria Official Gazette, vol. 94, no. 24, article B184, 2007.

[14] M. O. Araoye, Research Methodology with Statistics for Health and Social Sciences, Nathadex Publishers, Ilorin, Nigeria, 2004.

[15] World Health Organization, "Essential safety requirement for street vended foods;' Revised version, WHOFNU/FOS/96.7, http:// apps. iris/handle/10665/ 63265 ?mode=full.

[16] C. O. Chukuezi, "Food safety knowledge and practices of street food vendors in Owerri, Nigeria;' Studies in Sociology of Science, vol. 1, no. 1, pp. 50-57, 2010.

[17] E. S. Donkor, B. B. Kayang, J. Quaye, and M. L. Akyeh, ''Appli­cation of the WHO keys of safer food to improve food handling practices of food vendors in a poor resource community in Ghana;' International Journal of Environmental Research and Public Health, vol. 6, no. 11, pp. 2833-2842, 2009.

[18] A. G. Duse, M. P. da Silva, and 1. Zietsman, "Coping with hygiene in South Africa, a water scarce country;' International Journal of Environmental Health Research, vol. 13, no. 1, pp. S95- S105,2003.

[19] O. K. Muindi and E. Kuri, "Hygiene and sanitary practices of vendors of street foods in Nairobi, Kenya;' African Journal of Food & Nutritional Development, vol. 5, no. 1, pp. 1-15, 2005.

[20] J. H. Martins, "Socio-economic and hygiene features of street food vending in Gauteng," South African Journal of Clinical Nutrition, vol. 19, no. 1, pp. 18-25, 2006.

[21] c. Georges, "FAO technical support for improvement within the street food sector;' Pretoria, South Africa, 2000.

[22] Food and Agricultural Organization, "Report of an FAO expert consultation;' FAO Nutrition Paper, Jakarta, Indonesia, 1990.

Journal of Environmental and Public Health

[23] O. 1. Musa and T. M. Akande, "Food hygiene practices of food vendors in secondary schools in Ilorin," The Nigerian Postgraduate Medical Journal, vol. 10, no. 3, pp. 192-196, 2003.

[24] P. Mensah, D. Yeboah-Manu, K. Owusu-Darko, and A.

Ablordey, "Street foods in Accra, Ghana: how safe are they?" Bulletin of the World Health Organization, vol. 80, no. 7, pp. 546- 554,2002.

[25] FAO/WHO codex alimentarious commission guideline for the design of control measures for street-vended foods in Africa CAC/RCP 1-1969, Rev. 3, Amended, 1997.

[26] B. N. Nunes, A. G. Cruz, J. A. F. Faria, A. S. Sant' Ana, R. Silva, and M. R. L. Moura, ''A survey on the sanitary condition of commercial foods of plant origin sold in Brazil;' Food Control, vol. 21, no. 1, pp. 50-54, 2010.



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Sanitary Conditions of Food Vending Sites and Food Handling Practices

i need someone to read through the pages i provides, and write approximately 2 pages critical response paper base on the content,   the content is about RACE, you do not have to read all of pages in order to write the paper, just give out some insights and discuss deeply about those.  i also attached an example response paper, read on that before you start off.


Reading respond paper - Gender

This week's class topic is focusing on Gender, which takes place in chapter eight in the

reading lecture "You may ask yourself - an introduction to think like a sociologist" fourth

edition written by Dalton Conley. Gender, is a topic that is always present and was always

present, but especially the last years, gender and gender related topics are getting more and more

discussed in society. Just this week, about one month after same sex marriage became legal in

Germany, Germany's court has ruled that there must be the option of registering a gender that is

neither male nor female on birth certificates. But what exactly does it mean, if someone is neither

male or female and why is it necessary change the law?

"When someone is born with any of several variations in sex characteristics including

chromosomes, gonads, sex hormones, or genitals that, according to the UN Office of the High

Commissioner for Human Rights, "do not fit the typical definitions for male or female bodies,

they are intersex."] "The UN says the condition affects up to 1.7 of the world's population.t"

A case like that in which a person who is medically neither male nor female and was forced to be

registered as female was brought up to the judges. The judges decided that a person's sexual

identity is a fundamental right enshrined in the country's constitution and it must be protected.

There are already countries, like India, New Zealand, Australia and Nepal, who notice intersex

on their official documents. The first person who has successfully petitioned for a non-binary

gender classification in 2016 is Jamie Shupe?

In our society most of the people are not aware of what intersex is or what it's like to be

intersex. But latest movements are bringing change, "so that children who are born intersex are



3 https :// d/2016/j u n/16/ja m ie-sh u pe-first-n on-bi n a ry-pe rson-oregon


not forced into biological categories, either socially, by being made to identify female or male on

birth certificates and other official paperwork, or in the operation table." For decades doctors

used surgery to put young children into the biological category of male or female. "A general

rule among doctors is that phallus less than 2 centimeters in length constitutes a "micropenis"

(although that standard changes from time to time), and male infant would be better odd raised as

a female rather than suffer the shame of a small penis." People who get a gender assigned at birth

can develop a feeling of being trapped or incomplete over their lifetime. "But not everyone has

ambiguous genitalia, and some don't discover their conditions for years, for example when they

have complete androgen insensitivity syndrome (CAIS).,,6 Not only mental issues can appear,

also the procedure of the surgery is painful and can lead to physical issues and complications.

They could end up being isolated and ashamed. That is why it is so important to make a change

in society and in the law. People should be aware of intersex and they need to know that is

something normal. I am sure if the law will change people will also get more tolerant.

Ifwe look at the Navajo tribe of Native American, it is great to see how they include the nadle

(who is neither male or female) into their society. "The nadle might be born with ambiguous

genitalia at birth or they may declare a nadle identity later on regardless of genitalia. The nadle

perform both masculine and feminine tasks and dress for the moment, according to whatever

activity they're doing. Although they are often treated like woman, they have the freedom to

marry people of any gender, with no loss of starus.'" I see this as a great example how society

should be handling a situation like that.

4 https :!/ d/2016/j u 11021 ma 1 e-an d-fem a le-what-i s-it-I ike-ta-be-inte rsex

5 "You may ask yourself - an introduction to think like a sociologist" fourth edition written by Dalton Conley page 281


7 "You may ask yourself - an introduction to think like a sociologist" fourth edition written by Dalton Conley page 285


The topic of intersex makes me also think especially about four people that I know in Germany who were in my friend's circle. They all have been born as females, but during their puberty, they all felt like not be born in the right body. All of them struggled with their self­identity and they way how society sees them. They dressed up in boy's clothes and they also had some typical male behavior characteristics. I remember how hard it sometimes was for them, even the smallest things, like going to the bathroom, became a big deal. First of all, they felt weird using the girl's bathroom and second the people who were using the bathroom were disrespectful and mean to them. They gave them the feeling of not belonging here. So they started also to question themselves, where do I belong? In the end all of them made the step to start the transformation from female to male. All of them are doing pretty well, one of even started to play and sing in a band and to go on stage. I guess he could have not imagined that 8 years ago, when he was just quietly and shy playing the guitar from time to time. His self­imagine got so much better and he is so confident now.

I am wondering, if they would have still made the step of the transformation, if they would have grown up in a society like the Navajo tribe. I would like to know how much actually our environment can influence us in making such a big decision about our life. Maybe they would not have needed to make the step towards the transformation, because they would haven been accepted, in the way they were showing themselves towards society. But in our society, they got pushed into a category, if you dress and behave like a boy, then you might be actually a boy. But why can't someone be a girl and just be like a boy? I guess it is just easier for society if everything stays simple and easy to categories. People are not able to handle someone like that, they don't know how they should behave and interact, because it is not clear for them, if they


should treat that person as a boy or a girl. People need to learn to treat someone like a person and treat the person the way they want to be treated.

i need someone to read through the pages i provide

In terms of LENGTH, this paper should be between 8-10 pages, double spaced, font 12, Times New Roman. 

Please do not rewrite any of the questions in your answers. You should number your answers so I can be clear when you are moving onto the next question, but do not rewrite the question.

 you do not need a cover page, you don’t need to write an abstract, etc. PLEASE USE AT LEAST FOUR CITATIONS (NO WIKIPEDIA!)

Instructions: Focus on the topic of violence against women. Choose one subtopic in this area (for example, rape as a weapon of war or sexual assault on college campuses). Next, choose a specific country to focus on (you can choose the United States if you would like).

Six questions to answer:

1. You want to answer questions about prevalence, frequency, and duration (e.g. How often does the problem occur? How long has this been going on? Has the problem worsened over time? etc). Make sure to include statistics here (3 points)

2. Describe how individuals in this country and various cultures within this country conceptualize and think about this topic(s)? (1 point)

3. What are current laws and punishments that impact your topic(s) in this country? (3 points)

4. How is this topic(s) relevant to issues regarding intersectionality/intersecting identities in this country? Choose two identities. For example: in what ways is this topic relevant and impacted by race/ethnicity, sexual orientation, gender identity, age, class, religion, etc in this country? (4 points)

5. List and describe at least two different systems, institutions, or processes that contribute to this issue/ problem (for example: capitalism, globalization, culture, poverty, politics, technology, military presence/war, history of colonialism, etc) (4 points)

6. Identify a non-profit organization or non-governmental organization that is addressing your topic(s) in this country. What are their goals/mission? How successful have they been? (1 points)

In terms of LENGTH, this paper should be between 8-10 pages,

Overview of Assignment:  

This project involves the analysis of cultural patterns from TV, film, or literature. Make sure that your choice addresses cultural or anthropological themes that have been discussed in class. These themes include but are not limited to cross-cultural treatment of family, marriage, religion, subsistence patterns, gender, etc.     

One television program that regularly dealt with cultural themes is Stargate SG1, especially some of the early episodes.  StarTrek (all of the various incarnations) also have had episodes that would be suitable. When using television, be very careful. There is a strong tendency for television producers to over sensationalize. If you decide to go with a TV program, make sure that it has material that would allow you to analyze it critically.   

Some good films include: 

  • The Gods Must Be Crazy (1980)  
  • Monsoon Wedding (2002) 
  • My Big Fat Greek Wedding (2002) 
  • Bend It Like Beckham (2002)
  • The Story of the Weeping Camel (2004)  
  • The Saltmen of Tibet (1998) 
  • The Fast Runner (2002)
  • Fight Club (1999) 
  • Rabbit-Proof Fence (2002)
  • Walkabout (1971)  
  • Brooklyn (2015)
  • Avatar (2009)
  • The Help (2011)

Books that would be suitable: 

  • The Spirits Catch You and You Fall Down, Anne Fadiman, 1997. Farrar, Straus and Giroux  
  • Indian Summer, Thomas Jefferson Mayfield, 1993. Heyday Books
  • Pride and Prejudice, Jane Austin, 1813
  • The Left Hand of Darkness, Ursula K. Le Guin, 1969
    • probably any of Le Guin's novels (Earthsea, The Lathe of Heaven, etc.) would be acceptable... the Left Hand of Darkness is particularly good in its dealings of sex and gender, but because Le Guin's parents were anthropologists (A.L. and Theodora Krober), her use of anthropological themes is evident in anything she wrote. 

You are not limited to these options, but if you wish to use something not on my list you should either talk to me about it in advance, or submit a brief description of the program, film or book and why you think it would be appropriate. 

View the film or read the book carefully. You may want to watch a film or television program several times. Analyze the story for cultural issues and write a roughly 4- to 5-page essay analyzing the film or book and it’s treatment of the themes we’re discussing in class. You want to address which cultural themes are present, how they are handled, and if the program, film, or book depicts the cultural issues from an anthropologically sound perspective. Make sure that you use clear examples to illustrate your interpretation. Note that the focus is on the analysis. I don’t want 4 pages of summary with a single paragraph of analysis. The point of the assignment is the analysis… use examples from the film or book to support the analysis; don’t treat the analysis as an afterthought to a summary of the storyline.


The essay should be 1000-1250 words, double-spaced, with 1” margins and in a 10 or 12 size font- Times, Palatino, or Ariel are preferred, but any plain, standard fonts are acceptable. No fancy, “handwritten” looking fonts, please. Clearly identify the book or film in ChicagoPreview the documentAPAPreview the document or MLAPreview the document format. Submit the file to Canvas as a PDF (other formats can create problems when I’m trying to grade them). Upload the file, then wait for the originality report to be generated. Check the report for any sections that are insufficiently paraphrased, and revise your submission accordingly. You can resubmit as many times as necessary. I only grade the most recent submission. 

310-film project guidelines

STEP 1: Initial Discussion Board Post (600 words)

Topic: Wrap-Up

Thread Prompt: Summarize your experience attending the AA meetings by sharing the thing that you are most surprised about after attending 6 meetings. What surprised you the most? What expectations did you have that were not realized? What have you learned in attending that you would not have learned, or what concepts from the course would you not have understood as well if you had not attended?
Reply Prompt: For your replies, respond to at least 2 classmates. In each reply, share further insights you have gained through reading your classmate’s reflections on meeting attendance. 

STEP 2: Reply to this post below (200 words) J. Franklin

The experience that I got from attending the AA meetings was wonderful. I’m appreciative for the warm welcome that I received there. The thing that I was surprised about most was the open and transparent way some members shared. They would almost share as if in a therapy session where you can share freely. I would have thought before that the sharing would be more of what you thought someone wanted to hear instead of what was really going on with you. Besides being surprised by that, the other thing that really surprised me was that there were couples there that were recovering together. One man had 27 years and his wife had 22 years sober. When one of them shared that it shocked me and that they didn’t meet in AA, they were together before coming to AA.

 I think that’s amazing to see them recovering together. There was at least two couples like that and they shared that they were all close friends who started out together in the program. I expected that after initially introducing myself to the chairperson before each meeting and stating that I am a student attending as a requirement for a class that it would influence how the members shared. The members embraced me, and it seemed they had gotten used to seeing me come to the meetings. An expectation that was not realized is that I would like to see the full transformation and growth of a member from the start. That would be the ultimate experience of attending AA meetings for me.

I have learned that all alcoholics share similarities in their experiences with addiction and I would not have conceptualized that element had I not attended those meetings. I know I had ideas about different aspects surrounding AA members and meetings but, it was not the way I thought in most instances. Just to reiterate I’m glad for the experience to attend the meetings and would go on to say that all the classes that I have taken thus far at the ending of my degree completion have been quite helpful for future reference working in addiction. Thank you for an informative class and the tools that you have deposited in me.

You mentioned that the family dynamics have an influence on the child which I agree. “Frequently families will not talk or express feelings about the user’s behavior in an effort to maintain a general sense of stability (Clinton & Scalise, 2013, p. 73). They would rather pretend that it’s not happening. “Also, they are often told not to trust anyone else with the problem because there is power in holding on to the “secret” (Clinton & Scalise, 2013, p. 73). It is quite the opposite that when we share our problems the load is lessen which is a good thing. I realize that in counseling that every client situation may be different and therefore the solution cannot be generalized to everyone.

It was inspiring to see young people come to AA and during one meeting an older member shared that he wished he had the been introduced to AA when he was their age, instead of when he was 62. I get that, my hope is that the younger members stick around to recover maintaining sobriety. I think that most of what I witnessed in meetings attendance has been reflected on and gives so much more meaning to what I saw and heard from the members. Matthew 6:33 King James Version (KJV) But seek ye first the kingdom of God, and his righteousness; and all these things shall be added unto you.


STEP 3: Reply to this post below (200 words) J. Hudson

Since I began walking this path to become a counselor, I have experienced and learned a many new thing.  As my initial motivation and inspiration for pursuing this career was based on both my own past experiences with substance abuse and seeing the plight of this affliction on our society; this area of counseling has been a distinct interest of mine during my studies.  All that being said, it would be easy to say that I have had a lot of experience with most aspects of addiction, including self-help groups.  Having been to a few different types of meeting and different Alcoholics Anonymous groups, I felt that there was not much that would surprise me.  I was delightfully incorrect.

            What surprised me most with my experience with AA, was the commitment that this particular group has to the spiritual aspect of the program.  As Hester and Miller (2003) note, the core principal of Alcoholics Anonymous is surrendering your addiction to a higher power, often some sort of spiritual entity (i.e. God).  Despite this being a keystone of the process, there are many groups that try to avoid this topic, glossing over it or taking the time to note all the non-spiritual things that can represent the higher power in a person’s life.  Unfortunately, this has been something I have witnessed first hand in some of my past encounters with Alcoholics Anonymous.  That being said, you can imagine how surprised and impressed I was to hear nearly every member (particularly those with the longest tenure with the organization) testify to the importance of this step and the impact it had on their life and sobriety.

            I firmly believe that this spiritual aspect also facilitates the support portion of the process.  The group process can prove invaluable to most people, due largely to the fact that the person is surrounded by people who are going through the same troubles and are supported by them fully (Hester & Miller, 2003).  This is an aspect of the program that I have understood, but it carried so much more affect to see it happen in front of me.  This group would freely offer help of any kind to one another at all times of the day and night for phone calls or meeting up for coffee, all in the name of being supportive and helping the individual resist the temptation to drink.  In the end, that support is not only valuable to the person who is fighting the temptation; but, it is also valuable to the person or persons providing support, as it makes them feel like they are giving back some of the support and love that they have received over time.  Again, this is a pillar of the program that often gets overlooked and under-appreciated.

            Finally, I have to admit I was somewhat reluctant to undertake this part of the course.  As I said, I have attended AA in my tenure as a counseling student and have had some experiences that were not all that favorable.  After seeing Alcoholics Anonymous groups that avoid steps, skirt issues and break down to infighting and negative thought process, it was a breath of fresh air to be part of one that embodies the core principals of the group.  Furthermore, I feel like knowing what we know about the history of the organization and its founders, the core of Alcoholics Anonymous has always been in Christ; and not some vague, nebulous spiritual concept.  I realize that the idea is put in place to be inclusive and to help underscore the necessity for people to understand that there is something greater than themselves in this universe; but at the end of the day, that power needs to be recognized for who and what it is:  God, the creator of the universe, who sent forth the son, Christ, to sacrifice His life so that we may all be free from the bondage of all sin, including addiction.



STEP 1: Initial Discussion Board Post (600 words)

Topic: Wrap-Up

Thread Prompt: Summarize your experience attending the AA meetings by sharing the thing that you are most surprised about after attending 6 meetings. What surprised you the most? What expectations did you have that were not realized? What have you learned in attending that you would not have learned, or what concepts from the course would you not have understood as well if you had not attended?
Reply Prompt: For your replies, respond to at least 2 classmates. In each reply, share further insights you have gained through reading your classmate’s reflections on meeting attendance. 

STEP 2: Reply to this post below (200 words) J. Franklin

The experience that I got from attending the AA meetings was wonderful. I’m appreciative for the warm welcome that I received there. The thing that I was surprised about most was the open and transparent way some members shared. They would almost share as if in a therapy session where you can share freely. I would have thought before that the sharing would be more of what you thought someone wanted to hear instead of what was really going on with you. Besides being surprised by that, the other thing that really surprised me was that there were couples there that were recovering together. One man had 27 years and his wife had 22 years sober. When one of them shared that it shocked me and that they didn’t meet in AA, they were together before coming to AA.

 I think that’s amazing to see them recovering together. There was at least two couples like that and they shared that they were all close friends who started out together in the program. I expected that after initially introducing myself to the chairperson before each meeting and stating that I am a student attending as a requirement for a class that it would influence how the members shared. The members embraced me, and it seemed they had gotten used to seeing me come to the meetings. An expectation that was not realized is that I would like to see the full transformation and growth of a member from the start. That would be the ultimate experience of attending AA meetings for me.

I have learned that all alcoholics share similarities in their experiences with addiction and I would not have conceptualized that element had I not attended those meetings. I know I had ideas about different aspects surrounding AA members and meetings but, it was not the way I thought in most instances. Just to reiterate I’m glad for the experience to attend the meetings and would go on to say that all the classes that I have taken thus far at the ending of my degree completion have been quite helpful for future reference working in addiction. Thank you for an informative class and the tools that you have deposited in me.

You mentioned that the family dynamics have an influence on the child which I agree. “Frequently families will not talk or express feelings about the user’s behavior in an effort to maintain a general sense of stability (Clinton & Scalise, 2013, p. 73). They would rather pretend that it’s not happening. “Also, they are often told not to trust anyone else with the problem because there is power in holding on to the “secret” (Clinton & Scalise, 2013, p. 73). It is quite the opposite that when we share our problems the load is lessen which is a good thing. I realize that in counseling that every client situation may be different and therefore the solution cannot be generalized to everyone.

It was inspiring to see young people come to AA and during one meeting an older member shared that he wished he had the been introduced to AA when he was their age, instead of when he was 62. I get that, my hope is that the younger members stick around to recover maintaining sobriety. I think that most of what I witnessed in meetings attendance has been reflected on and gives so much more meaning to what I saw and heard from the members. Matthew 6:33 King James Version (KJV) But seek ye first the kingdom of God, and his righteousness; and all these things shall be added unto you.


STEP 3: Reply to this post below (200 words) J. Hudson

Since I began walking this path to become a counselor, I have experienced and learned a many new thing.  As my initial motivation and inspiration for pursuing this career was based on both my own past experiences with substance abuse and seeing the plight of this affliction on our society; this area of counseling has been a distinct interest of mine during my studies.  All that being said, it would be easy to say that I have had a lot of experience with most aspects of addiction, including self-help groups.  Having been to a few different types of meeting and different Alcoholics Anonymous groups, I felt that there was not much that would surprise me.  I was delightfully incorrect.

            What surprised me most with my experience with AA, was the commitment that this particular group has to the spiritual aspect of the program.  As Hester and Miller (2003) note, the core principal of Alcoholics Anonymous is surrendering your addiction to a higher power, often some sort of spiritual entity (i.e. God).  Despite this being a keystone of the process, there are many groups that try to avoid this topic, glossing over it or taking the time to note all the non-spiritual things that can represent the higher power in a person’s life.  Unfortunately, this has been something I have witnessed first hand in some of my past encounters with Alcoholics Anonymous.  That being said, you can imagine how surprised and impressed I was to hear nearly every member (particularly those with the longest tenure with the organization) testify to the importance of this step and the impact it had on their life and sobriety.

            I firmly believe that this spiritual aspect also facilitates the support portion of the process.  The group process can prove invaluable to most people, due largely to the fact that the person is surrounded by people who are going through the same troubles and are supported by them fully (Hester & Miller, 2003).  This is an aspect of the program that I have understood, but it carried so much more affect to see it happen in front of me.  This group would freely offer help of any kind to one another at all times of the day and night for phone calls or meeting up for coffee, all in the name of being supportive and helping the individual resist the temptation to drink.  In the end, that support is not only valuable to the person who is fighting the temptation; but, it is also valuable to the person or persons providing support, as it makes them feel like they are giving back some of the support and love that they have received over time.  Again, this is a pillar of the program that often gets overlooked and under-appreciated.

            Finally, I have to admit I was somewhat reluctant to undertake this part of the course.  As I said, I have attended AA in my tenure as a counseling student and have had some experiences that were not all that favorable.  After seeing Alcoholics Anonymous groups that avoid steps, skirt issues and break down to infighting and negative thought process, it was a breath of fresh air to be part of one that embodies the core principals of the group.  Furthermore, I feel like knowing what we know about the history of the organization and its founders, the core of Alcoholics Anonymous has always been in Christ; and not some vague, nebulous spiritual concept.  I realize that the idea is put in place to be inclusive and to help underscore the necessity for people to understand that there is something greater than themselves in this universe; but at the end of the day, that power needs to be recognized for who and what it is:  God, the creator of the universe, who sent forth the son, Christ, to sacrifice His life so that we may all be free from the bondage of all sin, including addiction.



STEP 1: Initial Discussion Board Post (600 words)

For the Unit I Assignment, you will be writing responses to questions on concepts you learned in this unit reading (sociological imagination, sociological perspectives, and research design) based on your decision to attend Columbia Southern University.  For this assignment, complete both Part A and Part B as follows: 


 Part A:  Apply the concept of sociological imagination while answering the following question. What are at least two specific groups that you belong to (family, race, age, gender, ethnicity, class, level of education, work, etc.) that influenced your choice to pursue a degree at Columbia Southern University.  


Describe how relevant the functionalist view, conflict view, and interactionist view were in making your choice to attend college? Please make sure to address all three of these sociological views in your assignment. Hint: pp. 15-16 and 21 of the textbook explain the three different sociological views and p. 16 in the SOC THINK box provides specific questions students can use to apply the three sociological views to their choice to attend college.  


Part B:  Imagine you are a sociological researcher studying academic dishonesty at Columbia Southern University. Identify at least one research question you would address. What type of sociological research design method that recognizes patterns of behavior would you use to study academic dishonesty at Columbia Southern University? Identify and explain at least one advantage and one disadvantage of the research method type you chose.  Hint: A table of research design methods are provided on p. 36 of your textbook. For this assignment, ensure you follow the requirements below:  

  1. Answer ALL questions listed in both Part A and Part B of your essay.  
  2. Please answer the response questions in essay style format. You will not rewrite each question and answer it. You  will create an essay that addresses the response questions.  
  3. Use sociological terms and concepts from the textbook reading in your essay to demonstrate you understand and can  apply the concepts.  
  4. Cite the textbook at least one time in the assignment. The essay should contain one or more APA style in-text  citations showing how the course textbook was used. Other sources may be used in addition to the textbook. An APA style reference list containing the textbook and any other sources cited in the essay is also required. The following tutorial from CSU’s Writing Center on in-text citations is a great helpful resource. Click on the link to view this tutorial:  

The assignment should be a minimum of two pages and should use the following APA style components: APA style title page, double-spaced, 1-inch margins, and 12-point font.  Note: The rubric for this assignment contains a task section. Your task score is based on the following: (a) the page requirement is met; (b) whether unit terms and concepts are directly identified and specifically labeled; (c) all parts of each question are directly answered and clearly demonstrated; and (d) whether the textbook was cited.  The rubric grading criteria involves relevant, informative, and on-topic content. The criteria are based on whether you use in- depth critical analysis and remain on the topic of the questions being asked in the assignment instructions.  Please contact your instructor if you have any questions about the assignment or the unit’s course material.    

Unit I Scholarly Activity (My Educational Journey)

Posts should be at least 200-300 words each and reflect critical thought. Whenever possible, please try to relate the course content to real-world applications from your work experience. Be sure to cite all sources as well.


1. Why is it important that we understand the history of the counseling profession and that we stay updated on the current trends in our profession?


2. Why is it important that we understand the history of the counseling profession and that we stay updated on the current trends in our profession?


3. Why is it important that we understand the history of the counseling profession and that we stay updated on the current trends in our profession?


Responses to classmates post should be at least 100 - 200 each words and reflect critical thought. Whenever possible, please try to relate the course content to real-world applications from your work experience. Be sure to cite all sources as well.


Jean Miller - 

Excellent discussion so far! You all shared relevant examples of historical trends, including techniques that are no longer used (thankfully!) When I think about current trends, I think about the concept of wellness. Recent trends in holistic health have emerged in our profession. These trends often come from an Eastern tradition of medicine and even spirituality. Techniques such as yoga, meditation, breathwork, aromatherapy, acupuncture, and herbal therapies, etc, are more commonly used in mental health support and programs. They may even replace tradition therapy and medication for some clients. More commonly, I see these techniques used in combination with traditional therapy. Class, what are your thoughts about wellness and the current trends and techniques that I mentioned? Are they beneficial? Can you think of any more examples?



I believe it is essential to know the history of counseling because history repeats itself and we need to keep in mind what may be occurring now that will need to change. For instance, many treatments at the time were considered humane but are today seen as cruel. We need to look at standard therapies now and ask ourselves what may be regarded as inhumane in the future? There is a lot of heated debate on genetic therapy and if patients should be aware of what future health complications may arise. I can see where it can be positive because many issues may have a cure or preventative. Those health issues that are not will lead to added stress to the patient without benefit. It is so important to stay current in the field because treatments have changed dramatically over a short period in history and we as counselors should want the best for our clients. Staying current will assure that we are not using old and outdated treatments that do not work. I am sure that we will all have different styles and techniques for healing clients from the start to the end of our careers in an attempt to ever change for the best. 



It is very important that we understand and know the history of counseling as it is the basis for future research and treatment. Methods have changed over time and it is important to know the progress. Ethics have changed, levels of care, the way a client is treated, ,everything. The career field is evolving all the time it seems and while practices from years ago may not be viewed as ideal now, some may possibly be reviewed again in order to create something new or bring about new methods of treatment for clients. The mental health field, especially dealing with developmental disabilities and mental illness, used to be institutionalized and pretty much forgotten about. Now there are doctors and counselors who treat the individuals and come up with treatment plans that benefit the individual specifically and is tailored to meet their goals and encourage progress in order for them to be productive in society and be able to feel confident as well as function and cope with every day life. A lot of mental illnesses have gone overlooked in the past and even some now that go overlooked can result in negative results and actions from the individual who is in need.


Carolan Dickinson - 

Some of the potential trends I see in the counseling profession is the continued growth in the holistic approach to counseling. Rather than be restrictive in scope I see it as an expansion. I do believe we are headed in this direction and will be addressing the "whole person" and other aspects of people's lives as ways to cope, managing, and heal the things they are addressing solely through counseling. One of the ways that I have seen this in action is with the military and their program for treatment of post-traumatic stress disorder. While they do address the traditional aspects of counseling, they are also addressing other ways that have been proven successful in treatment like Yoga Warriors International, (March 13, 2018), Retrieved from There are studies and evaluations going on all the time on the advantages of mindfulness programs including this one from the National Center for Post Traumatic Stress Disorder, that discusses "The Potential of Mindfulness in Treating Trauma Reactions", (Niles, Pietrefesa, Potter, Schmertz, & Vujanoivc), March 13, 2018), Retrieved from The increased use of technology in our profession creates challenges in patient confidentiality and as well as creating accepted practices in term of that technology, and makes us look at the other parts of our profession. For example, the company Talkspace, Online Therapy (March 13, 2018) Retrieved from is what it sounds like. For a certain amount of money, people can call in and connect with a licensed therapist. On the surface, it sounds good to me, convenient, with little to no overhead and processing of claims, etc. However moral and ethical questions would come up for me. I would wonder how effective I'm being, is this addressing the issue, or is it a band-aid approach? I'm not sure how I feel about this service yet, however being able to provide counseling in technology is going to be around for awhile and will grow with the needs of our society.


Beca - 

There are upcoming potential tends coming up in the mental health field that  are still in development and not always popular. First is the prevention of mental health issues in the prenatal stages of  brain development. The factors involved are the mothers well being, substance abuse and access to food.  This theory  can possible change the prenatal care given to young mothers. I have seen copsing groups protection this new trend. The idea that a child with mental health issues is undesirable is horrible. Another new trend is the belief that psychical and mental disorders intertwine. A high mortality rate from cardiovascular disease has been documented in patient that also have bipolar, schizophrenia and major depression .Patients with obesity suffer from a higher rate of psychiatric disorders. This trend looks at the whole person  verses just their symptoms. The goal is to eventually have   a collaboration of care between psychiatrists and family physicians. The increase of technology in society has begun to change all professions, in counseling the new trend is on line counseling. The new websites for  counseling like My Therapist, Regain and  Better Help have the client pay weekly to have access to over 1000 councilors.  In this new age of convince  thousand of clients log on daily. The client can use what ever is easiest phone, skpe or on line connection to speak to a counselor at all hours of the day. The website gunslinger's happily explains the overview and positives to using this new service, yet where are the negatives.  Even though the ACA d does have ethical rules to one line counseling  I am concern that the client is not unprotected understand that clients are less inhabited while speaking in a safe place behind their computer or phone. When technology evolves and changes new issues evolve. What if I spoke on the computer to one of these websites and a third party like my ex husband got a hold of the conversations? There are always the intelligent computer people that can "hack" anything.

Posts should be at least 200-300 words




Due Week 10: 200 points

By now, you have practiced and should understand the sociological research process. You also have a good handle on how the major sociological theories explain social issues. Now, it's your turn to apply this knowledge. For your final assignment, you'll review a research article to identify the research conclusion. Then, you'll take another look at that conclusion from the perspective of one of the major sociological theories.

Instructions: Complete all three parts of the assignment by following the instructions below.


1) Article Review:

a)        Prepare to complete your assignment by reviewing the articles below. Select one for the focus of your assignment.

·    Money, Not Access, Key to Resident Food Choices in 'Food Deserts' https:!/­food-deserts-2017 I



·       'The narrowing, but persistent, gender gap in pay"­tank/2017/04/03/gender-pay-gap-facts/

·       "Bridging a Digital Divide That Leaves Schoolchildren Behind" technology/fcc-internet -access-school. html

b)       Review your selected article several times to familiarize yourself with the content before going to the next step of this assignment.

2)       Learn: Use the research information in the article to answer the questions below. You should write at least one paragraph for this step. Refer to Chapter 2 of your webtext as necessary.

a) What were the key findings of the research?

b) What conclusion was drawn from the research?


Remember: The four major sociological theories are Functional­ism, Conflict Theory, Symbolic Interactionism, and Rational Choice Theory. For more information, review Sections 1.8 - 1.12 in your webtext.

Use one of the four major sociological theories to explain the key findings in the research article you reviewed in Part A. You should write two paragraphs, one for each question.

a)        How would this theory explain the key findings or conclusion of the research in the article?

b)       What limitations does this theory demonstrate in addressing the problem examined in the research article?




Use your article to help answer the questions below. You should write two paragraphs, one for each question.

a)        What would you suggest to address this problem?

b)       What additional research would you conduct to help address the problem examined in the research article?

Your assignment must follow these formatting requirements:

·         Use Times New Roman font (size 12), with one-inch margins on all sides.

·         Use section headers (Learn, Theory, and Solution) and write left indented paragraphs under each correspond­ing section.

·         References are not required for this assignment as you will use one of the assigned articles and your webtext.

·         Include a cover page containing the title of the assign­ment, the student's name, the professor's name, the course title, and the date.




Grading for this assignment will be based on the following rubric:





Meets Minimum











Below 60 - F

60-69 - D

70-79 - C

80-89 - B

90-100 - A

1. Describe the

Does not de-


Partially de-



key findings of

scribe the key

describes key

scribes key

describes key

describes key

the researchers

findings and/or

findings or con-

findings and con-

findings and

findings and

and the conclu-

conclusion and

clusion and sup-

clusion but some

conclusion and

conclusion and

sion drawn from

does not pro-

porting details

of the supporting

includes support-

includes sup-

the research.

vide supporting

are sparse.

details are miss-

ing details.

porting details.







Weight: 20





strong under-






standing by using






sociology terms






and providing






logical, accurate,






and concise infor-







2. Use a major

Does not use a


Partially uses

Accurately uses

Accurately uses

sociological the-

major sociolog-

uses a major

a major socio-

a major socio-

a major socio-

ory to explain

ical theory to


logical theory

logical theory

logical theory

the key fmdings

explain the key

theory to explain

to explain the

to explain the

to explain the

or conclusion,

findings or con-

the key findings

key findings or

key findings

key findings

and address any

clusion and does

or conclusion,

conclusion, or

or conclusion,

or conclusion,

limitations of

not address the-

or inaccurately

partially address-

and addresses

and addresses

the theory.

ory limitations.

addresses theory

es theory limita-

theory limitations

theory limitations



limitations and

tions, but some

with supporting

with supporting

Weight: 40


supporting de-

of the supporting


details. Demon-



tails are sparse.

details are miss-


strates strong






understanding by






using sociology






terms and provid-






ing logical, accu-






rate, and concise













Meets Minimum











Below 60 - F

60-69 - D

70-79 - C

80-89 - B

90-100 - A

3. Propose a

Does not pro-

Proposes a solu-

Proposes a

Proposes a

Proposes a

solution and

pose a solution

tion that isn't

solution that isn't

solution that is

solution that is

additional re-

or does not pro-

fully aligned with

fully aligned with

aligned with the

aligned with the

search ideas.

vide additional

the key findings

the key findings

key findings of

key findings of


research ideas.

of the research,

of the research,

the research, and

the research, and

Weight: 30


or the support-

or the additional

provides addi-

provides addi-



ing details for

research ideas

tional research

tiona I research



the additional

are missing

ideas that in-

ideas that in-



research ideas


clude supporting

clude supporting



are sparse.



details. Demon-






strates strong












by using sociolo-






gy terms.

4. Write in a

Writing does not

Writing meets

Writing is satis-

Writing is profi-

Writing is ex-

skillful manner

meet minimal

minimal stan-

factory. Appro-

cient. Tone is ap-

cellent. Tone is

using stated

standards. Tone

dards. Tone is

priate and/or

propriate. Shows

appropriate and

formatting and

is not appro-

not appropri-

consistent tone

logic, clarity,


correct gram-

priate. Wholly

ate. Lacking

is developing.

and stated

excellent word

mar and spell-

lacking in logic,

one or more

Shows moder-

formatting. May

choice. Shows


clarity, and/or

of logic, clarity,

ate logic, clarity,

contain few or



stated format-

and/or stated

and/or stated

no spelling and/

logic, clarity, and

Weight: lO

ting. Contains

formatting. May


or grammatical

stated format-


many spelling

contain many

May contain


ting. Contains no


and/or grammat-

spelling and/

more than a few


spelling or gram-


ical errors.

or grammatical

spelling and/


matical errors.




or grammatical












1000 words 

document attached for all the details.

David Emile Durkheim: "The Division of Labour in Society"


·        Who is Durkheim?

·        What is his major contribution to social science?


·        Why division of labour is beneficial for the society?

·        Discuss mechanical solidarity and organic solidarity.

·        Discuss repressive law and restitutive law

·        What is "anomie"?

·        Critical analysis: Conflict between different moral principles? Is solidarity enough for the regulation of the society?


·       Express your personal ideas on the book

(The conclusions cannot be a simple summary of the essay!!!)

eight references (Harvard Style Referencing)

The Domains of the Health Administration Leadership Competency Model

The history, definition, and use of Leadership Competency Models were addressed this week in Chapter 2 of your course text. The Health Administration Leadership Competency Model was specifically tailored to include interdisciplinary effectiveness. It consists of seven interrelated domains of competencies.

To prepare:

  • Review the Health Administration Leadership Competency      Model on pages 26-29 of your text.
  • Identify someone with whom you have worked in the past      who served as a leader.
  • Evaluate that person's leadership skills according to      the criteria identified by the seven domains of the model, i.e., Charting      the Course, Inspiring Commitment, Developing Work Relationships,      Structuring the Work Environment, Influencing, Communicating, and      Self-Management.

The history, definition, and use of Leadership Competency Models were addressed this week in Chapter 2 of your course text. The Health Administration Leadership Competency Model was specifically tailored to include interdisciplinary effectiveness. It consists of seven interrelated domains of competencies.

To prepare:

  • Review the Health Administration Leadership Competency      Model on pages 26-29 of your text.
  • Identify someone with whom you have worked in the past      who served as a leader.
  • Evaluate that person's leadership skills according to      the criteria identified by the seven domains of the model, i.e., Charting      the Course, Inspiring Commitment, Developing Work Relationships,      Structuring the Work Environment, Influencing, Communicating, and      Self-Management.

Post a comprehensive response to the following:

  • What characteristics made that person an effective or      ineffective leader? Please explain with reference to the Health      Administration Leadership Competency Model.
  • What conflicts and challenges arose during your work      together?
  • How did the leader assist in working through it?
  • Did you play a role in resolving the issue? If so,      describe the situation
  • __________________________________________________________________________________________________
discussion board 1 (250-300 words) due Thursday