System Design Life Cycle Flashcards

Question

Discuss system elements to be tested: **Devices**.

Answer 1

**Devices** include input devices, such as keyboards, mouse, microphone, stylus, webcams, and output devices, such as terminals, printers, projectors, and screens. The informatics nurse specialist must understand the system architecture and how all of the devices are interconnected as well as how the operating system interfaces with the devices. Other necessary information includes the configuration of the individual devices and software access as well as the manner in which to add individual devices to an existing system. Different operating systems use different naming protocols for similar devices and display information about devices in different manners. Devices can be in four different states when connected to a system: * Undefined: The system does not recognize the device. * Defined: Information about a specific device is present in the database but not available to the system. * Available: Information about a device is present in the database and configured to the operating system. * Not available/stopped: Information about the device is present in its driver, but the device is not available.

Answer 2

**System integration testing (SIT)**, part of software/hardware testing, determines if hardware or software applications can work together. Integration testing is done after unit testing and before system and acceptance testing and involves testing how all the units function together. This is a type of black box testing that should not require knowledge of code or inner product design. The purpose of the testing is to identify problems or faults within the component parts (assemblages) or within the entire information system that affects performance. SIT may include load, volume, and usability testing. SIT involves development of an integration test plan that outlines what will be tested and how the tests will be conducted as well as pass/fail criteria. Test cases may be developed to identify transitions and present end-user scenarios. Test data should be developed to use in the test cases. Approaches to integration testing include big bang (includes all components), top down (higher level components before lower level), and bottom up (lower level components before higher level).

Answer 3

The **systems environment** is assessed through analysis of the internal environment (e.g., staff, physicians, board) and external environment (e.g., vendors, patients, agencies). A needs assessment may be required to determine the type of data required. Data may be derived from the following: * Published materials (e.g., journal articles, reports) * Vendor materials (e.g., pamphlets, specifications) * Organizational input * Regulatory requirements * Accreditation requirements * Marketing t rends * Interviews and questionnaires * Technological trends Data are analyzed to identify trends, needs, and expectations. Once potential actions or solutions to problems are identified, they must be further analyzed and comparisons made, considering the needs of endusers. After implementation of a system, ongoing testing, analysis, and feedback are necessary to ensure that needs are met and that the system functions effectively.

Answer 4

**Load, or volume testing**, is a type of nonfunctional reliability testing that evaluates the system's ability to function under different loads, such as during normal use times and peak times with multiple users to determine maximum capacity and problems that might be encountered. This test involves evaluating the effect of volume on the system to determine limits. Testing tries to determine at which exact point problems arise. This can include static and dynamic testing of the system at the safe working load (SWL) and above the SWL. Volume testing may include testing the ability of an application to handle a certain volume of data, such as in a database. Volume testing should always be concluded before a system becomes live to prevent crashes and loss of data if limits are exceeded.

Answer 5

Information systems provide a number of different types of reports, and these should be assessed for accuracy. Some reports are generated automatically, and others require manual input to define the type of report and information needed. Types of reports that may be available include: * **Configuration**: These reports contain data about the system itself, including hardware and software, as well as workstations and servers. Configuration reports may be generated by systems or data sets. * **Informational**: Often informational reports include built-in templates and provide fact-finding to glean information from databases. * **Change**: Usually change reports are automated, showing changes that occur in the system over a period of time. * **Baseline**: Usually baseline reports are automated to show how the system or elements of the system compare to a baseline. * **Summary/management**: These reports show summaries of actions, processes, and data. * **Periodic**: Periodic reports are issued at predetermined periods, such as monthly claims reports. * Error/exception: Error or exception reports are issued when faults occur or data are outside of normal parameters.

Answer 6

**Functional testing** verifies that a code is functioning properly and determines if users are able to carry out certain functions or whether features in the software work as expected. Functional testing may include manipulating data, conducting searches, using user commands, and accessing user screens. Integration testing is also conducted as part of functional testing. Functional testing should be completed on units during development and on the system as a whole after integration. Functional testing should also be conducted from the perspective of the end-user, so functional tests should always be designed to correspond to end-user requirements. Functional testing may include both manual and automated testing components. Functional tests should be able to identify system level faults and problems.

Answer 7

**Links** (i.e., highlighted words, icons, images) allow access of information at one point from a different point. For example, a link may allow the user to jump from one part of a document to another or one document to another. In some cases, links may be external, such as links to Internet websites. When the user clicks on a link, a transmission control protocol/Internet protocol connection is established between the user and server, resulting in a hypertext transfer protocol request of information. All links must be tested individually to ensure they function properly. Links may open in different ways, such as in a popup window or by replacing the content of the original window. Links may be generated automatically, such as with alerts, or accessed manually.

Answer 8

**Unit/component suitability testing methods:** **Black box** - This is a form of functional testing that determines if an input results in the correct output, using test cases focused on the system's operational profile. This type of testing does not require knowledge of code or inner product design. Testing may not include activation of all codes, so it may not detect all faults. **Fault injection** — This introduces faults into the system to show what happens to the system when the component fails to function properly. **Operational system** - This tests the ability of the system to function after introduction of a component. However, this may require a huge amount of testing to determine how the system will deal with component failures or problems. **Defense building** - Wrappers are used to limit the component software in some way; that is, the wrapper may check or limit input into the component or check or limit output to the system. Wrappers are often employed when commercial software is purchased that only partially meets requirements.

Answer 9

Performance improvement processes cannot occur without organizational change, and **resistance to change** is common for many people, so coordinating collaborative processes requires anticipating resistance and taking steps to achieve cooperation. Resistance often relates to concerns about job loss, increased responsibilities, and general denial or lack of understanding and frustration. Leaders can prepare others involved in the process of change by taking these steps: * Be _honest, informative, and tactful_, giving people thorough information about anticipated changes and how the changes will affect them, including positives. * Be _patient_ in allowing people the time they need to contemplate changes and express anger or disagreement. * Be _empathetic_ in listening carefully to the concerns of others. * Encourage _participation_, allowing staff to propose methods of implementing change, so they feel some sense of ownership. * Establish a climate in which all staff members are encouraged to identify the need for change on an ongoing basis. * Present further ideas for change to management.is common for many people, so coordinating collaborative processes requires anticipating resistance and taking steps to achieve cooperation.

Answer 10

A **user interface** (human-computer/machine interface) allows interaction between the user and the machine (e.g., computer, other electronic devices), permitting the user to make input and to see output as a result. The design of this interface must consider the needs of the user and ease of use. Types of current and new interfaces include the following: * **Touch screens and touch user**: Often used in simulations, the device has a combined use of input and output. * **Graphical user**: This allows an interface between devices, such as the keyboard and computer. It includes object-oriented user interfaces as well as application-oriented interfaces. * **Gesture**: This allows input from gestures and mouse/stylus movements. * **Zooming**: This allows changes in scale of output. * **Voice user**: Input is by keystrokes or voice commands, and output is by voice commands. * **Natural language**: This allows input by keystrokes in natural language (e.g., questions), and output is the response. * **Zero-input**: Input derives from sensors.

Answer 11

The following steps are necessary whenever an organization is **upgrading** or implementing an information system: * Planning and administration of the project: Establish the planning and project teams, and set the key milestones for the project * Delivery of hardware and software: Select the vendor and purchase the hardware and software. * Program installation: Provide time for installation and perform a qualification (system testing, interfaces to databases, etc.) of the newly installed components. * Policies and procedures: Develop and approve the relevant polices and procedures. * Training: Provide training for all relevant personnel. * Maintenance and support: Set up a maintenance and user support procedure.

Answer 12

**Features** are parts of a component with predictable properties. Systems have become increasingly complex because of the expansion in features. Feature creep is the term used to describe the addition of more and more features to a program. Features may relate to data, hardware, software, end-users, and telecommunications and facilitate the four primary functions of an information system: allowing input, providing storage, processing data, and providing output. Features may include the following: * Management of database (e.g., storage, retrieval, import, export) * Ability to generate reports * Ability to integrate with other components of a system and scalability * E-mail and other customizable alerts * Time keeping/login and logout times * Communication among different levels and multisite capabilities * Real-time processing * Ability to establish uniform procedures * Ability to provide feedback

Answer 13

The following steps should be followed when developing the **documentation** that will be used to operate the new information system: **Step 1**: The standard operating procedures and user documentation should be prepared and used to train users before the system goes live. **Step 2**: The documentation that was used to operate the old system should be evaluated for applicability (via editing) to operate the new system. **Step 3**: Disaster recovery documents should be prepared in the event the system "crashes" or goes down. A paper-based system should be readily available. **Step 4**: The vendor's user guides and support documentation should be reviewed to determine if the information could be incorporated in the organization's user documentation.

Answer 14

Before going live with a hospital information system, the system should be thoroughly tested to assure that it is operating properly. This is accomplished by performing a **system test plan**. The system test plan consists of the following four steps: **Step 1**: Develop the overall test plan. This includes the installation, operation, and validation of the new system. **Step 2**: Create the test scripts. These are the scripts that actual users of the system will use to "stress" the system to determine if it is working according to specifications. They should reflect real use as closely as possible. **Step 3**: Carry out the testing and troubleshoot and system's failings as soon as possible.

Answer 15

**Programming changes** are common with information systems because of updates, upgrades, and the addition of new features. Technolog,' is constantly changing along with user needs and regulatory requirements, so programming must accommodate these changes. Typically, software upgrades are released on an 18-month schedule, and often one upgrade can be skipped without a significant impact on productivity; however, by the third year, obsolescence is an issue, and upgrading and making necessary programming changes are usually necessary, so management must carefully assess the value of upgrades, needs of the organization, and associated time and costs in implementation when making recommendations. Changes in regulatory requirements may occur every year or 2, so monitoring requirements and making necessary programming changes are essential.

Answer 16

**Interface** is a computer program that allows two or more programs to exchange information. If the connection is direct, the interface is point-to-point and allows transfer of data only between two programs. Interface engine software allows information to transfer from one system to a number of different systems. In this case, translation tables move data from the clinical data repository (collective database) to each system. Because terms may vary from one system to another, mapping is required to associate terms in one system with comparable terms in other systems. The serial peripheral interface bus (SPI) is a de facto industry standard, although different vendors have different configurations. SPI allows master/slave communication from the master device to single or multiple slave devices. SPI is full duplex and facilitates communication in both directions simultaneously. Half duplex interfaces facilitate communication in both directions but only in one direction at a time. SPI is used to communicate with a variety of peripheral devices, such as sensors, clocks, liquid-crystal displays, universal serial bus ports, and communications (e.g., Ethernet, handheld devices).

Answer 17

A **feasibility study** will help to define the problem(s) that the new information system is expected to address. It will also answer questions regarding cost, goals, and specific outcomes. Some specific questions may include: * How will the outcome (e.g., meeting the pre-defined business requirements) be measured? * What research has been done to back up the proposal? * What are the risks in terms of people, money, and time? * How long will the implementation take and what will be involved? * Will the project require dedicated staff members, contractors, or a combination of both?

Answer 18

**Components** are software applications, such as those commercially available or prepared by third parties, which need to be integrated into the other software of the information system. Testing is completed to determine if the software meets specifications and functions properly and whether it meets interaction requirements of the system. Tests verify if specific areas of code work correctly. Factors to consider include the ease with which the software's functions can be observed, behavior traceability, the difficulty or ease of functions and operations, and the method the component uses to provide or present information. Components may be tested by the developer and by the user, but the user may lack the source codes necessary for effective testing. In some cases, if software is functioning well, further testing may not be indicated. In general, those components that should be tested include reusable and domain components. Commercial components are often reusable and should be tested and evaluated for liability issues. When possible, reusable testing strategies should be developed.

Answer 19

**Changes in policies, procedures, or working standards** are common, and the quality professional is responsible for educating the staff about changes related to processes, which should be communicated in an effective and timely manner. * **Policies** are usually changed after a period of discussion and review by administration and staff, so all staff should be made aware of policies under discussion. Preliminary information should be disseminated to staff regarding the issue during meetings or through printed notices. * **Procedures** may be changed to increase efficiency or improve patient safety often as the result of surveillance and outcome data. Procedural changes are best communicated in workshops with demonstrations. Posters and handouts should be available as well. * **Working standards** are often changed because of regulatory or accrediting requirements; this information should be covered extensively in a variety of ways: discussions, workshops, and handouts so that the implications are clearly understood.

Answer 20

The following **hardware infrastructure requirements** should be evaluated and satisfied before the new system is installed: * Network infrastructure: cable/wireless local area network (LAN) installation, available access points, and overall compatibility with the new system * The type(s) of user workstation interfaces (desktop computer, laptop computer, terminals, etc.) * The location of the workstations (portable or permanent) * The physical location of the hardware (servers) * The connectivity and location of printers and/or other output devices

Answer 21

The availability of **system enhancements**, such as software upgrades, new software, and new hardware, is almost constant, but constant changes to a system can result in changes in functionality and a need for increased resources and training. A committee that reviews requests for enhancements can help to determine which are needed by the organization and which are unnecessary. Enhancements should be evaluated in terms of impact on efficiency and cost-effectiveness. Introducing enhancements to a system that change functionality requires advance notice to staff and sometimes additional training, so holding the introduction of enhancements to a schedule, such as every 6 weeks, may be less disruptive than routinely updating software and equipment as updates become available. Testing the enhancement should be completed, when possible, before wide dissemination.

Answer 22

It is important when implementing a new information system into the clinical environment to have **representatives from all areas of the organization** that will be affected by the new system, including those listed below: * _Hospital Administration_: In order to assure that business processes are maintained * _Finance_: To assure that billing and patient records are maintained, in addition to establishing a budget. * _Nurse administrator_: To facilitate that nursing procedures are compatible with the new system. * _Director of the Information Systems_ department: To oversee that the system is installed properly. * _Medical records_: To assure that record keeping is accurate and follows all regulatory requirements (e.g., HIPAA)

Answer 23

The following steps are needed to form an **effective implementation team**: **Step 1**: Select a leader who will own the implementation process. **Step 2**: Form the team with representation from the various users of the system (e.g., IT staff, executives, and nurses) **Step 3**: To assure success, look for the following team member characteristics: * Good communication skills * Can multi-task effectively * Good cooperation in the team environment **Step 4**: Keep the team focused on the final goal of implementing an effective system.

Answer 24

**Assigning resources** involves understanding the types of resources available—educational, personnel, financial, and equipment—as each must be allocated, using different priorities; therefore, establishing a list of priorities for each category of resources is essential. Prioritizing may be done by the informatics nurse specialist alone or with guidance from an advisory committee. For example, educational resources, such as computerized modules, videos, and texts, may first be assigned to those in a particular unit where training is essential. Personnel should be assigned, according to need, in terms of actual number of staff, work time, and duration of time. Financial allocation includes ongoing costs of maintaining a system, costs of updates and enhancements, and contingency costs (e.g., when problems arise or equipment malfunctions). Equipment resources, such as handheld devices and biometric monitoring devices, are allocated according to need, which is often determined by an advisory committee.

Answer 25

**Return on investment (ROl)** refers to an accounting calculation used to determine the value and cost of an investment. A typical ROI calculation includes: * The yearly cost for an employee who will use equipment (in dollars), for example, $80,000 (A). * The percentage of time (in decimals) the employee will use equipment, for example, 25% = 0.2S (B). * The percentage of estimated increased efficiency over prior system (in decimals), for example, 30% = 0.30 (C). * Multiplying the three figures above (A x B x C) yields the productivity advantage in dollars, for example: $80,000 X 0.25 X 0.30 = $6000 (D). * Equipment (including software and training time) costs in dollars, for example, $20,000 (E). * Dividing E by D and multiplying by 12 (E/D x 12) yields the time in months needed for the new equipment to pay for itself, for example: $20,000/$6000 = 3.33 x 12 = 39.96 months While this is simplified and does not account for depreciation, upgrades, and other changes, this approximates the procedure.

Answer 26

**External customer-supplier relationships** are critical to an organization because these customers receive products or services supplied by the organization. External customers include patients and their families (although inpatients are sometimes considered internal customers), private physicians, vendors, insurance companies, government regulatory agencies, lawyers, and others in the community. As with internal customers, each external customer is both a receiver of products or goods and a supplier. For example, a regulatory agency provides regulations and guidelines as a supplier and then receives reports in return as a customer. This symbiotic relationship must be clearly understood because the external customer-supplier relationship is one over which the organization often has less direct control, so identification of the customers' needs through surveys, interviews, focus groups, research, and brainstorming can help to clarify and improve these relationships.

Answer 27

Both the **external and internal environments** should be examined when performing **strategic planning**. In terms of the external environment, the major item of interest would be the state of technology. Some questions to ask include: * Has the hardware and/or software been updated by the suppliers? * Do we as an organization need to move up to the new level? * What are our competitors or peers up to? * Would an update in technology become a competitive advantage? In terms of internal environment, this information should be readily available through feedback from the users of the current informatics systems. In addition, any changes in business processes that require new capabilities should also be examined.

Answer 28

**Internal customer-supplier relationships** in an organization must be identified and understood. Internal customers are those directly involved in product or health care delivery, such as those on the Board of Directors, clerical staff, administrative personnel, nursing personnel, medical support staff, physicians, human resources personnel, plant managers, pharmacists, and volunteer staff. In-patients may be considered internal customers. A customer is, by definition, a receiver. Internal customers need others in the work environment to provide some type of product or service so that they may function, and they, in turn, provide a product or service to others, so each internal customer is also a supplier. Vertical customer-supplier relationships, such as between administration and nursing staff, are sometimes more obvious than the equally important horizontal relationships, such as between floor nurses, which can involve cooperative measures to ensure that quality care is provided. Identifying customer-supplier relationships should be part of strategic planning to increase internal awareness and improve methods of meeting the various customers' needs.

Answer 29

**Cost-utility analysis (CUA)** is a subtype of cost-effective analysis; however, the results are more difficult to quantify and use to justify expense because a CUA measures the benefit to society (e.g., decreasing teen pregnancy). Often the standards used to quantify a CUA are somewhat subjective. A CUA compares a variety of outcomes (e.g., increased life expectancy, decreased suffering) in relation to the quality- adjusted-life-year. A scale is used with 1 being normal health and O being death. A health condition is assigned a number on this scale, which is referred to as its "utility." When calculating outcomes with a CUA, an intervention is evaluated on whether or not it increases the utility score and thereby increases life expectancy or improves life circumstances by x number of years. Thus, the results of this type of analysis are not expressed as monetary values but rather societal values.

Answer 30

**Request for information (RFI)** is used early in system analysis to gather information from vendors, often in conjunction with requests for proposal and requests for quote. The RFI is often done by letter, although some vendors now use e-mail or:accept RFI on websites. The person requesting should outline the type of information needed and give an overview of plans to purchase and install an information system. Many companies have brochures or websites that provide general information about their systems, so sending a list of specific questions may elicit better information. The primary purpose in sending a RFI to a variety of vendors is to help in the elimination and selection process. Topics for questions may include the following: * History and financial status of company * Lists of current users of company's product and numbers of sites * Information about system architecture * Hardware and software requirements * User support * Equipment support/maintenance * Ability of equipment to integrate with other systems

Answer 31

**Resource use** refers to the consideration of all factors related to the planning and delivery of quality products and activities. Resources may be allotted to the physical environment for building or remodeling, staffing, equipment, literature, training, and outreach programs. Use review requires consideration of individual safety, program effectiveness, and cost. Interventions should be safe, effective, and affordable for each individual. Decisions should take into consideration rising health care costs and how to maximize the use of resources while continuing to provide quality professional development activities. The goal of resource use is to provide quality, cost-effective programs while using the best-qualified staff and appropriate resources.

Answer 32

**Staffing management** involves both clinical staff (e.g., nurses) and nonclinical staff (e.g., housekeeping staff, office personnel). Important issues include the following: * Workforce size and distribution, including full-time equivalent staff members, needed * Educational resources, such as training programs, and availability of trained personnel, including professional staff and support staff * Staff training, ongoing need for staff development, and opportunities for certification or advancement * Demographics (e.g., age, economic levels, ethnic backgrounds, lifestyles) * Incentives for career advancement, including increases in income, promotion, and certification * Staff turnover, burnout, and an ongoing need for recruitment * Organizational structure * Financial resources available * Cost-effective staffing and billable provision of care * Reimbursement (e.g.. Medicare, Medicaid, health insurance, private pay) * Supervision/ feedback * Organization-wide strategies for staffing

Answer 33

A **cost-effective analysis** measures the effectiveness of an intervention rather than the monetary savings. For example, each year, about 2 million nosocomial infections result in 90,000 deaths and an estimated $6.7 billion in additional health costs. From that perspective, decreasing infections should reduce costs, but there are human savings in suffering as well, on which it is difficult to place a dollar value. If each infection adds about 12 days to hospitalization, then a reduction in infection by 5 days would be calculated as follows: 5 X 12 = 60 fewer patient infection days. **Efficacy studies** may compare a series of cost-benefit analyses to determine the intervention with the best cost-benefit. They may also be used for process or product evaluation. For example, a study might be done to determine the effective use of four different types of computers to determine which type resulted in the fewest errors that resulted in added costs, thus saving the most money. **Incremental cost-effectiveness ratio** is the ratio of cost change to outcome change.

Answer 34

System selection is the second phase of the system development life cycle. The following are the **three components of the system selection process**: * _Needs Assessment_: This first action takes place after the decision has been made to purchase a new system or upgrade an existing system. Information is gathered regarding the current state of the art and how the offerings in the marketplace meet the current defined needs of the organization, as well as future needs. Typically, a selection committee attends trade shows and sales meetings that are set up by the potential vendors of the systems. * _Request for proposal (RFP)_: Once the pool of potential vendors has been narrowed down (typically to three), RFPs are sent out. The resulting proposals are then evaluated, references are checked, and the system is evaluated in action (wherever possible). * _Contract negotiation_: The winning system is then selected and a contract is negotiated with the vendor. Once the contract is approved, implementation plans may proceed.

Answer 35

**Inventory** describes the amount of material or equipment on hand, which should be reviewed at least once a year. In many cases, reordering is done when the amount of a particular item drops to a certain pre- established level. Just-in-time ordering is done when stock is almost depleted. Automatic reordering of supplies is easy when inventories are computerized. In some cases, departments have open accounts that can be used for small purchases without bidding. For large purchases (especially in public institutions), the nurse should state exactly (i.e., include brand names when appropriate) which items are to be purchased on a bid form. The bids are then sent to prospective bidders (at least three) in a competitive bid process. Organizations vary in what bids are acceptable. Some only accept the lowest bid, while others accept the best bid (e.g., those supplying brand names rather than substituting with generics). Many organizations have private purchase plans that allow them to purchase directly without bids or lease equipment, which is less expensive initially.

Answer 36

A **cost-benefit analysis** uses the average cost of an event and the cost of intervention to demonstrate savings. Examples follow: * Computer repair overtime costs related to improper computer use are $125/hour. If the institution averages 20 hours of overtime a month ($125 x 20 = $2500) x 12 months ($2500 x 12), the annual cost equals $30,000. * If the intervention included staff training materials ($400), instructor costs ($2000), and staff costs ($10,000), then the total intervention cost is $400 + $2000 + 10,000 for a total of $12,400. * If the goal were to decrease overtime costs by 80% to 4 overtime hours a month, then savings would be calculated as 4 x $125 = $500 monthly costs x 12 = $6000 subtracted from the current annual cost of $30,000 = $24,000 savings. * Subtracting the intervention costs from the savings gives the annual cost-benefit: $24,000 - $12,400 = $11,600 annual cost-benefit.

Answer 37

The following items need to be evaluated when performing the **system selection** portion of the system development life cycle: * _Costs_ related to the hardware, software and network for the new system * _Facts_ about the vendor (e.g., reputation, knowledgeable staff, and financial stability) * _System capabilities_ in regards to ease of use, user friendly interface, ability to meet the organization's needs, security, expandability, and ability to interface with other systems

Answer 38

The following information should be included in a **request for proposal (RFP)**: * A description of the organization * The organization's mission statement, goals, and objectives * The organizational structure * The type of healthcare facility * The proportion of clients in each pay type * The patient and facility statistics * The overall system requirements * The criteria for evaluating responses to the RFP * The deadline for submission of the requested information

Answer 39

The following are the overall steps in the formation of a **steering committee**: _Step 1_: Form a steering committee to evaluate the current information system and begin the research process for the new system. _Step 2_: Staff the steering committee with representatives from all levels of the organization that will use the new system. _Step 3_: Establish a leader of the steering committee that will own the process and report progress. _Step 4_: Establish the steering committee's goals and objectives. _Step 5_: Determine if an experienced outside consultant is needed to handle complex technical issues, and/or save time.

Answer 40

The following is a list of important **attributes** to consider when **selecting a vendor**: * What is the company's history and financial stability? * Do they invest in the development of new technologies? * How many sites currently use the company's systems? * What other organizations use the system being evaluated? * What hardware/networking is required for the system architecture? * Is the company's technology state of the art? * What other systems and software are compatible with the system? * What methods of user support are available (phone, internet, etc.) and what is the average response time to a user support request? * Does the organization have any large upcoming changes for the system to adapt? * How (and how often) does the company distribute software updates?

Answer 41

The following information should be gathered when conducting a **site visit**: * The site's experience regarding the information system's reliability and vendor support services * The amount of downtime that has occurred and the primary causes * System backup procedures User experiences with the various interfaces to the system * Narratives regarding any customizations to the system * A log of the amount of hours of training that were required * System security performance * Overall satisfaction with the system

Answer 42

The following **tasks** should be carried out by the **steering committee** when researching a new information system: * Verify that the project fits into the organization's goals and objectives as stated in the mission statement * Reach a consensus on the business requirements that the new information system needs to satisfy * Scan the internal environment within the organization to assess where the current information system is not adequate * Look to the future to assess the longevity of the new system and how it can evolve to meet the organization's needs for the next three to five years

Answer 43

The following is a list of programmed expert systems advantages: * **Consistency in decision-making**. Given a set input, the returned answer is always the same. * **A central knowledge depository**. Expert systems can manage a larger database of information than most human experts. Additionally, the knowledge survives staffing changes (e.g., the loss of subject matter experts). • **Ability to review answers and generate reports**. This allows decision makers unfettered access to information they need at any given time. The following is a list of programmed expert systems disadvantages: * **The software lacks "common sense".** It may sometimes provide answers that are not accurate. * **The logic is "locked down"**. The user is unable to deviate from the program in order to be more creative. * **Programming difficulties**. Programming these types of programs can be difficult due to the need to incorporate high- powered business integrators. * **Not adaptable**. Once the program has been completed, it is not adaptable to change without major effort.

Answer 44

There are two types of systems: **open** and **closed**. They are defined as follows: * _Open systems_ do not have fixed or permanent boundaries but are instead constantly being re-defmed as they interact with the environment. An open system may be a subsystem (e.g., a nurse within a hospital) and can overlap other systems. In computing, an open source program allows access to the source code. This allows customizations and updates from users and programmers in an open environment. * _Closed systems_ are self-contained and isolated from the environment (including other systems). The boundaries of a closed system are distinct and fixed. With the exception of an external energy source, closed systems do not receive input from the environment and all output is contained within the system. A saline IV pump is an example of a closed system. In computing, when the source code is locked (by the vendor) the program acts as a closed system. All adaptations must originate from the vendor.

Answer 45

The system development life cycle is divided up into the following **four phases**: * _Needs Assessment_: The phase where business requirements are collected from the future users of the system. * _System Selection_: The phase where an information system is selected that can meet all of the gathered business requirements. * _Implementation_: The phase in which the system is scaled up and performance tested. * _Maintenance_: The phase where a help desk is set up (for troubleshooting user problems) and the system is regularly backed-up and updated.

Answer 46

**Expert systems** were designed by individuals working in the field of artificial intelligence. These systems are programmed with information that a human expert would use to handle a particular problem, use set rules to analyze the problem, and in some cases provide the user with a list of recommendations. Expert systems are widely used in healthcare to help diagnose and treat patients. The knowledge bases for expert systems are created by a group of individuals who are asked to give guidelines on how they solve very specifically defined problems. Next, the system is created and test cases are used to verify the accuracy of the outcomes. Expert systems may use simple true/false logic or more advanced fuzzy logic. Simple true/false logic design generally asks the user a series of questions to which they answer yes or no. Fuzzy logic attempts to include common uncertainties, but is generally not as accurate as systems designed on true/false logic.

Answer 47

There are **six elements necessary in the formation of a system**. They are: 1. _Interdependency_: There must be multiple components that interact with each other in a concerted way. 2. _Inputs_: Data that is placed (input] into the system from an external source (e.g., system users]. 3. _Process_: The overall functionality that the system contributes its various components towards achieving. 4. _Output_: The product of the system. The end result of the various interdependent components of the system. This is usually a distinct product that can only be achieved if the system is operating correctly. 5. _Control_: Operation that works to prevent or correct problems as they occur throughout the process. This is usually initiated through a feedback mechanism. 6. _Feedback_: An internal control mechanism that allows for the detection and correction of processing problems. This can also include the monitoring of the external environment for an open system.

Answer 48

A **network system** is a group of computers linked together to increase efficiency or distribute computing power. One key reason to use a network system in a healthcare facility is related to data. Patient data must be stored for long periods and accessed by different functional areas within the same facility. By storing patient data in a central server (accessible to all computers connected to the network), the process is made far more efficient and reliable. Another advantage of network systems is that all users share the same software making it easier for the users to share information. In addition, network software licenses are more affordable for the company to purchase. The network software packages are easier to upgrade since only one upgrade to the server is required. Finally, individuals can use the network connection to perform patient consults, proofread each other's work, and send electronic mail (e-mail).

Answer 49

When a new information system is going to be **implemented, the informatics nurse** (or business integrator) is in a particularly important position to support the process. For this role, the following items should be included in the implementation plan: * A statement of support from the upper management of the company. * An assessment on how the new system will impact the various jobs that will be within the scope of the implementation. * A complete overview of the implementation plan and the methods being used. * An assessment on how the new system will affect the company culture (particularly nursing). * A budget that includes where the money will come from and how this will affect finances.

Answer 50

**Project scope** defines the goals of an information systems project, describing those elements to be automated and outlining both the content and the complexity. As part of the project scope, alternate solutions should be identified and feasibility considered. The project scope statement, which outlines the **project plan**, is usually done in the later stages of development as a guide for the user or consumer. The project plan should include the following: * Objectives of the project and characteristics * Requirements (in terms of services and products as well as deliverables) * Acceptance criteria * Limitations, boundaries, and constraints * Assumptions * Initial organization and preliminary timetable and schedule, taking into consideration the people assigned to different tasks and their skill levels * Identification of risks and methods to attenuate risks * Initial work breakdown structure, dividing the project into organized sequential steps, such as with a Gantt chart * Estimated costs and resources and creating a resource plan * Management requirements * Approval processes and requirements

Answer 51

**Social media** are Web-based programs/technology that allow users to interact with others online. Social media sites, such as Twitter, Facebook, YouTube, and Linkedin, allow user-generated content (UGC), such as blogs, images, videos, and audio files, which are accessible by the public; however, many social media sites, such as Facebook, allow users to control access through privacy settings. PatientsLikeMe.com is a health-related website with interactivity. Web tools used for health related social media sites are often referred to as Health 2.0 or Medicine 2.0 and can include blogs, wikis, search functions, videocasts, and podcasts. Web tools are increasingly used for medical education, especially in nursing curricula. Facebook is increasingly used for promotion and education by medical practitioners and other health care providers. For example, Healthcare.gov provides links to other government organizations and articles and allows users to subscribe and comment.

Answer 52

**Wikis** are open databases that allow the user to access, edit, delete, or add material. Wikipedia, the online encyclopedia, is a well-known example of a wiki that is open to the public. Wikis can be open to anyone or can be restricted to specific groups of people; for example, a class may have a wiki to which students post information about a particular topic. Wikis may be designed for a narrow intent, such as for one class, or to manage content for a broad purpose, such as a program. Wikis may be designed with different levels of access so, for example, only certain people are allowed to delete or edit material. Wikis use simplified markup language (HTML, XML) or an online rich-text editor that allows WYSIWYG editing. Wikis support hyperlinks, and many wikis can include photos, videos, and audio files.

Answer 53

**SharePoint**, a Microsoft product, is a Web-application platform that is integrated with Microsoft Office tools (e.g.. Word, Excel, PowerPoint, Outlook) and can be used for content and document management, collaboration, social media, and development of websites and Intranets. SharePoint provides centralized storage of documents, which can be accessed through password-protected portals. SharePoint sites can store lists (e.g., a list of links or other similar items) and libraries (collections of documents). The SharePoint "wheel," or outcomes that SharePoint can facilitate include the following: * Creation of sites or work environments * Establishment of communities, such as for sharing information or collaborating * Management of documents, including storing, tracking, updating, allowing collaboration, and archiving * Inclusion of search functions, based on keywords as well as analysis of content * Provision of information and insights to promote effective workflow * Allowance of composites and data integration * Templates are available for the creation of sites and subsites, and navigation is similar to that of Office products.

Answer 54

**Weblogs/blogs** are essentially online diaries or documents that are laid out in reverse chronological order (last entry viewed first) to which a blogger can add information as desired. A blog may be maintained by one person or a group of persons with shared interests. Multiauthor blogs (MABs) are becoming common. Blogs allow people to register to view the blog and to comment on entries, although they are not able to edit the blog. Blogs may contain only text, but most also have images and videos as well as links to other sites (e.g., YouTube). Blogs typically focus on one primary topic of interest, such as exercise, and some serve primarily as advertisement for companies or products. Blog-hosting services are available, although blogs can also be maintained on regular Web-hosting sites with blog software.

Answer 55

**WebEx**, a Cisco company, provides applications that allow for Web-based videoconferencing and collaboration. WebEx products include the Cisco WebEx Meeting Center, Training Center, Support Center, and Event Center. WebEx provides a number of services, depending on the product used, including the following: * Face-to-face meetings via Web in real time * Notifications * Training for users: interactive Internet training with videos and a variety of interactive tools to allow learners to participate actively in learning, including chat rooms and question and answer threads * Live-streaming * Consultation * Business management * Instant messaging * E-mail management WebEx allows participants in Web conferencing to share content, such as images and videos, in real time; thus, it allows people to collaborate at any time and from any distance, reducing the need to travel and allowing immediate consultation and videoconferencing, such as during surgery. WebEx is used for both business and education, especially for delivery of online courses or supplementary material for more traditional classes.

Answer 56

**Data-flow diagrams** show how data flow into a system and from one process to another, presenting a graphic representation of a-system and its processes. The diagram is a simplified flow chart that uses only four symbols, which are labeled during diagramming: * _Square_: external entity or sources of data or external destinations. An entity is named. * _Rounded rectangle_: process in inputting and outputting data. This is named with verb and object (but does not include word "process," and there is no subject). Data flow is from left to right and top to bottom. Each rounded rectangle represents only one process (so "and" is not used). Arrow (line with arrowhead): direction of data flow. * _Arrows_ are named (but do not include the word "data"). * _Three-sided open rectangle_ (electronic or physical data storage): Open rectangles are named and numbered (but do not include the word "file.") If more than one system shares a data store, then a solid stripe is placed on the left side of the rectangle to indicate this.

Answer 57

A **Gantt chart** is used for developing improvement projects to manage schedules and estimate time needed to complete tasks. It is a bar chart with a horizontal time scale that presents a visual representation of the beginning and end points of time when different steps in a process should be completed. Gantt charts are a component of project management software programs. The Gantt chart is usually created after initial brainstorming and creation of a time line and action plans. Steps to create a Gantt chart include the following: * List the name of the process at the top. * Create a chart with a timeline of days, weeks, or months (as appropriate for process) horizontally across the top. * List tasks vertically on the left of the chart. Draw horizontal lines or bars from the expected beginning point to the expected end point for each task. These may be color-coded to indicate which individual or team is responsible for completing the task.

Answer 58

A **clinical flow chart** is a schematic representation of a process and is often used to analyze quality improvement, particularly when looking for solutions to a problem. Typically, the following symbols are used: * Parallelogram: input and output (start/end) * Arrow: direction of flow * Diamond: conditional decision (yes/no or true/false) * Circle: connectors with diverging paths with multiple arrows coming in but only one going out A variety of other symbols may be used to indicate different functions. Flow goes from top to bottom and left to right. Flow charts help people visualize how a process is carried out and to examine a process for problems. Flow charts may also be used to plan a process before it is used. Flow charts may demonstrate critical pathways to outline treatment options or paths related to findings.

Answer 59

Prolonged mouse usage can lead to pain and nerve damage in the wrist, hand, and fingers. Solutions known to help include: * Adhere to a break schedule that allows you to stretch and rest your hands and arms. * Alternate the hand that uses the mouse (e.g., if you are left handed, switch the mouse to your right hand). * Perform a wider variety of work that involves more than sitting behind a desk. * Use an ergonomically designed alternative to a mouse (such as a track ball). * Use keystroke substitutes to avoid repetitive motion. Prolonged sitting can place strain on the back that may lead to pain and nerve damage. The following is a list of solutions that are known to help: * Adhere to a schedule that allows you to stand up, walk, and stretch. * Use an adjustable chair to maintain a good posture. * Place equipment (such as a phone or printer) so that it forces you to get out of your chair. * Consider a workstation that allows you the flexibility to sit or stand and perform your work.

Answer 60

A **storyboard** is a visual representation of the actions of a team, including data analysis and decisions, during the performance improvement process. It is usually done on a firm poster board and may be 3-4 feet square. It is somewhat like a giant flow chart with arrows or lines connecting one piece of information to the next The storyboard may be used to present summary reports and is also a tool used in continuous quality improvement. The storyboard may include a variety of items or information, such as the following: * Charts * Diagrams * Pictures * Text * Illustrations * Statistics Because the storyboard is meant to provide easy access to information about team activities, text is usually minimal.

Answer 61

The 1992 **Americans with Disabilities Act (ADA)** is civil rights legislation that provides the disabled, including those with mental impairment, access to employment and the community. The ADA prevents discrimination against employees or potential employees for organizations with fifteen or more employees because of disabilities. The Equal Employment Opportunity Commission enforces these provisions. Employers are only allowed to ask applicants if they need accommodations, not if they have disabilities, and individual accommodations must be made. Accommodations can include the following: * Alterations in workstation * Speech recognition software * Screen magnifying software * Optical character recognition systems * Video captioning * Braille readers and screen readers * Adapted keyboards and on-screen keyboard * Teletypewriter or text display device * Amplification systems People who are disabled are entitled to assistive technology that will allow them to function but are not entitled to jobs that they are unable to do even with assistive devices or accommodations. Most computer operating systems now incorporate assistive technology (e.g., screen readers).

Answer 62

There are a number of alternative keyboards on the market: * **Supportive keyboards**. These keyboards have a built in wrist rest. While the wrist rest may help the individual user sit with a more comfortable posture, it may also allow fluid to build up in the carpal tunnel causing wrist pain. * **Scooped key arrangement keyboards**. These keyboards are designed in bowl-like shapes. This type of design has the keys set closer together which allows for an extra row of keys. The intent is to reduce reach fatigue. * **Minimum-motion keyboards**. These keyboards were developed to change the way the individual keys are operated. Rather than pushing the keys down flat (as is the case with traditional keyboards), the user only has to lightly touch them. This is meant to reduce muscle tension and finger pain. * **Straight column keyboards**. This keyboard places keys running straight up and down instead of in diagonally offset rows (as is the case for traditional keyboards). This arrangement helps to lessen stress on the left hand with little effect on the right hand.

Answer 63

The user of the ergonomic device has to be evaluated along with the equipment and setting. All humans are different and have different ergonomic needs. The best ergonomic solution for one individual may not necessarily work for another. It should also be noted that the workstation may not appear to be configured in the best way to the supervisor (or casual observer), but may indeed be the best for the user. There is no such thing as a true ergonomic chair. Chairs are manufactured with many adjustable features. Some of these are effective and some are not. Chairs should be chosen that would accommodate the widest variety of users (body types) that will be sitting on them. Additionally, chair parts and padding wear out very quickly. What may have once begun as a very suitable ergonomic chair could deteriorate into a poor choice in a relatively short amount of time. Used chairs should be refurbished or disposed.

Answer 64

There are three major types of ergonomically designed **keyboards**: * _Split keyboard_: This type of keyboard was designed to minimize the occurrence of the hand and wrist position that places pressure on the major nerves in the wrist. There are two types of split keyboard designs; one directs each keyboard half out toward the elbows while the other completely separates the keyboard so that the halves can be located in-line with the elbows. * _Tented keyboards_ are similarly split into two halves; however, they also allow the typist to angle their palms toward one another reducing the joint posture known as pronation. * _Negative-slope keyboards_ were developed to reduce wrist extension by allowing the user to tilt the keyboard to a flat or backward slope opposite of the more traditional positive slope keyboard. Ergonomic research results for these keyboards are mixed, with individuals who already have ulnar nerve damage receiving the most benefit.

Answer 65

**Repetitive stress injury**: Any injury resulting from performing a similar motion repeatedly. In the late 1990's, there was a large increase in repetitive stress (motion) injuries reported by healthcare workers due to the increased use of computers and other electronic devices. **Carpal tunnel syndrome**: This is the most well-known repetitive stress injury. It involves the compression of the median nerve located in the wrist. It is usually seen in individuals who spend many hours in front of a computer screen typing. Ergonomic keyboards and wrist rests have not been shown to significantly decrease the chance of developing carpal tunnel syndrome. Many sufferers do report relief when using wrist splints at night to rest their affected hand(s). One of the best ways to keep from developing carpal tunnel syndrome is to take frequent breaks from the keyboard or mouse and perform simple exercises designed to alleviate pressure on the median nerve. Once carpal tunnel syndrome has been diagnosed, it can be treated with steroid injections, anti- inflammatory medications, or (less commonly) surgery.

Answer 66

Due to the danger of repetitive motion stress injuries and other hazards of working with computers, designers have developed a number of **ergonomic enhancement products** to be used in the computer work environment. They are: * _Glare filter_: This helps reduce eyestrain from light reflecting from a user's monitor. * _Negative keyboard angles_: This allows the keyboard to be situated below the elbows and allows the wrists to be held at a straighten more natural angle. * _Document holder_: This holds documents at eye level so that the user may type and enter information without moving their neck up and down. * _Lumbar support_: This helps support the back more comfortably, and helps position the back with a proper curvature to alleviate stress. * _Footrest_: This helps to improve posture, increase blood flow to the feet, and prevent lower back pain.

Answer 67

Ergonomics is the study of the work environment and its effect on humans. There are three types of ergonomics: * **Physical**: Physical ergonomics deals with the interaction between a person's body and a machine. * **Cognitive**: Cognitive ergonomics (also known as engineering psycholow) deals with the interaction between the human mind and work. * **Organized**: Organized ergonomics (also known as macro ergonomics) deals with the culture of work including issues of safety and ethics. When implementing a new information system in a medical facility, it is important to consider all three types of ergonomics. First, the interactive devices (e.g., computer screens and keyboards) must be physically easy to work with and have a low risk of physical injury. Second, the staff must be psychologically willing to value the new computer system and use it effectively. Finally, the ethical use of the system must be defined and written standards put in place to assure consistency.

Answer 68

The following are main features of a good **ergonomic chair**: * The ability to _adjust the height_ of the seat. Preferably, this should include a pneumatic adjuster that allows a customized setting rather than a ratcheting mechanism. The user should be able to adjust the chair so that their thighs are parallel to the floor (with both feet flat on the floor). * The ability to _adjust seat pad front-to-back_. This will allow individuals of different heights to support their legs and feel comfortable. * The chair should have _padded armrests_ that are adjustable for both height and width. This will prevent arm strain by providing passive support of the elbows. The forearms and hands will then be in the correct neutral position for typing. * The chair should be able to _recline_ to transfer some upper body weight to the backrest. * The chair should have an _adjustable back support_ to prevent lumbar compression.

Answer 69

The following are some important **ergonomic factors** in regards to the design of computer workstations: * Deciding how it will be used: How will the user interface with the information system? * Finding out how long the user will be in place: How many hours will the user be stationed at the interface? Is the time continuous? * Configured based on the equipment to be used: Does the user have to turn or reach for various components of the information system during their routine operations? * Located in areas of low noise: Is the noise environment conducive to the tasks the user needs to perform? * Located in areas of good ventilation: Are environmental conditions appropriate for the users and equipment? * Use stable workstation furniture: Is the workstation furniture suitable for the equipment that it supports? * Educate users on proper usage: Do the users follow the proper ergonomic procedures for performing their job? * Choose chairs with proper back support: Is the user's chair appropriate for the user in terms of adjustability and back support?

Answer 70

**Biomedical devices**, such as physiological monitors (heart rate, blood pressure) and smart pumps, must **interface** between the patient and the device and then in digital form from the device to the information system, which must aggregate the data, which are then sent to an interface that converts the data to HL7 for transmission to the electronic health record. While standardization is occurring, there are at present many communication standards, and interfacing with older systems or modified systems poses problems. Additionally, interface requirements vary among devices. Elements that must be considered in determining interoperability of biomedical devices include the following: * Type of device, including manufacturer and specifications * Network connectivity capabilities and whether the device is part of the same or a different network * Wired (specifications) or wireless (Bluetooth, 802.11, others) * Transport, data, messaging, and certifications (Continua, ICE) * Type of data transmitted by the device * Extra equipment required, such as a dongle, for connection or cables * Security of data

Answer 71

When performing modeling studies to determine the **number of errors** that occur in human-computer interactions, the **types of errors** should also be considered. With input, errors may occur during intention to carry out actions, the sequence, or the execution. With output, errors may occur in perception, interpretation, or evaluation: * _Low level_: Errors in execution of steps interfere with outcomes, and misunderstanding of outcomes interferes with perception. * _Moderate level_: The sequence of actions results in input that is not compatible with the computer or the mode results in misinterpretation of input. Output is misunderstood or misinterpreted because of a lack of training or education. * _High level_: Interference with intention occurs because of an inability to make a decision regarding a correct action or an inability to evaluate and interpret outcomes correctly.

Answer 72

**Barcode medication administration (BCMA)** uses wireless mobile units at the point of care to scan the barcode on each unit of medication or blood component before it is dispensed. Scanning ensures the correct medication and dosage is given to the correct patient, eliminating most point of administration medication errors. The BCMA system can also be used for specimen collection. This system requires monitoring and input from the pharmacy, as each new barcode must be entered into the system. Additionally, some medications are received in bulk, so when they are dispensed in unit doses, barcodes must be individually attached. Staff must be trained to ensure that BCMA is used properly and consistently. The Food and Drug Administration has required that drug suppliers provide barcodes on the labels of medications and other biological product. BCMA increases safety for patients, integrates with the medication administration record, and the information system of the organization, providing data for assessment.

Answer 73

**Cognitive walkthrough** is one method to determine **ease of learning** of new technology or applications. A study to determine each step in a process to complete a task is completed. Cognitive walkthrough is one method to assess the user's ability to understand the model and its purpose, to produce the desired actions, and to determine if users understand which is the right action and system feedback. The 'think aloud" procedure is used while participants use a product and carry out the steps in a process, noting any usability problems, such as the ability to learn the process without formal training. Sessions may be audiotaped or videotaped for later evaluation. Cognitive walkthroughs are particularly useful with prototypes or early in a system to identify problems with design or usability. Users may also be assessed for knowledge retention over a period of time and their comprehension of the system.

Answer 74

Performance testing to assess for errors includes the following: * Time needed to complete tasks, including both the speed and reaction time * Percentage of completed and incomplete tasks and the percentage completed correctly * Number of errors and types of errors * Time spent in each component/option as well as frequency * Time spent in training * Overall quality of completed tests * Time needed for system setup or installation and ease or complexity * Users descriptions of problems encountered and "think aloud" comment during tasks * Degree of application usage in real work environment as opposed to testing * Observations of user responses and behavior, including facial expressions, actions, and eye tracking * Amount of time spent on the Web and the number of hits

Answer 75

An important aspect of human-computer interaction (HCI) is **usability or ease of use**, which may encompass a variety of elements, such as screen layout and navigation. The three primary goals of usability are effectiveness, efficiency, and satisfaction. Usability studies should address all of these goals. There are many different approaches to usability studies, but studies have indicated that large-scale studies can often be replaced with small-scale studies with five to eight participants. Practice with prototypes, even on paper, can yield valuable insights. Participants using the prototypes are encouraged to "think aloud" and talk through the procedures, while observers write down the observations. This can help to determine the ease of use of equipment or software and the amount of training needed for effective use. Evaluation by trained experts can also effectively highlight usability problems. Heuristic (rule of thumb) evaluation or inspection methods have been developed to help guide the evaluation process. Measures of user perceptions include asking participants to assign usability ratings, noting comments during use, and administering questionnaires about satisfaction and workload.

Answer 76

**Gap analysis** is a method used to determine the steps required to move from a current state or actual performance or situation to a new one or potential performance or situation and the "gap" between the two that requires action or resources: Essentially gap analysis answers the questions "What is our current situation?" and "What do we want it to become?" Gap analysis includes the determination of the resources and time required to achieve the target goal. Steps to gap analysis include: * Assessing the current situation and listing important factors, such as performance levels, costs, staffing, and satisfaction, and all processes. * Identifying the current outcomes of the processes in place. * Identifying the target outcomes for projected processes. * Outlining the process required to achieve target outcomes. * Identifying the gaps that are present between the current process and goal. * Identifying resources and methods to close the gaps.

Answer 77

There are three different factors that contribute to **software usability**. They are: * _Learnability_: The amount of time it takes to learn and figure out how to use the software program. This can be enhanced by the program's help features, documentation, and interface design. * _Memorability_ (or efficiency): The amount of time it takes the user to perform tasks without having to stop and look up the instructions or use the help feature. Software that has been intuitively designed will enhance memorability. * _Discovery_: The time it takes a user to find specific product features in response to the need for that particular feature. This may be enhanced by the similarity of a software product to one that was previously used. All three of these factors should be evaluated when determining whether to purchase a software program for an information system.

Answer 78

**Structured query language (SQL)** is a fourth-generation programming language (4GL) that differs from 3GLs, such as Java, in that SQL uses syntax similar to human language to access, manipulate, and retrieve data from relational database management systems, which store data in tables. Both the American National Standards Institute (ANSI) and the International Organization for Standardization have adopted SQL; however, because the language is complex, many vendors do not use the complete standard, and this limits portability between vendors without modifications. Despite many available versions, ANSI standards require that basic commands (e.g., UPDATE, DELETE, SELECT) be supported. Language elements of SQL include the following: * _Clauses_: from, where, group by, having, and order by * _Expressions_: produce scales and tables * _Predicates_: three-valued logic (null, true, false) and Boolean truth values * _Queries_: require a SELECT statement * _Statements_: includes the semicolon (to terminate a statement)

Answer 79

There are five steps for conducting a **usability study**: 1. _Defining Purpose_ - The purpose, which guides the choice of usability tests, should be clearly defined. 2. _Evaluating constraints_ - The constraints (e.g., time, staff, resources) may influence the type of testing and the design of the test. 3. _Refining components based on evaluation of human—computer interaction (HCI) framework_ - The HCI framework must be evaluated to determine each component and to whom or what it applies. This includes choosing the most appropriate staff, determining the most important step in a process, and choosing the setting. If testing involves comparison with older or more traditional practices, then measures of equivalency must be determined. 4. _Determining emphasis_ - Usability testing may focus on one or more aspects, depending on the overall purpose. 5. _Select methods_ - Methods must match purpose and take into account constraints and HCI evaluation.

Answer 80

**Likeability** of software programs is not the same as usability or utility. Usability is the _ease of which a human uses a software program_. Likeability is defined as how much an individual enjoys using the program. Products that rank high in usability tend to also get high marks for likeability. While it is difficult to pinpoint exactly why users prefer one software program to another, likeability is a leading factor in determining how much a person wants to use the software. **Utility** is the _usefulness of the program_. Utility does play a role in the likeability of a product. If the user perceives that the software will perform correctly, they are more likely to use it They may also be attracted to the cost saving potential of the software program. Both of these factors should be considered when purchasing system software.

Answer 81

A key factor in **choosing software** for a computer system is the software's usability. Overall, usability is based on "user-centric" design that incorporates the interaction of the human user from the start of the design process. The success (or failure} of the design is based upon measurements such as focus groups, interviews, or questionnaires with the targeted potential users of the software. For software developers, it is important to remember to balance usability with utility. The software must be able to collect the proper inputs and perform its primary designed function in addition to having the best possible human interface (in terms of usability). Once the software is installed, the targeted users should also test it for usability. This should include a variety of individuals from all areas of the organization. The data collected should then be shared with the software developer for usability enhancements in future versions.

Answer 82

There are five logical **steps involved in computer programming**: 1. _Problem definition_: also called function specification. The problem (or function) must be defined in detail. All contributing information necessary for solving the problem must be outlined. 2. _Program design_: Provide the functional specification: Identify what the program will do (inputs/outputs). Provide design specifications: Specific instructions for the programmer to follow. 3. _Program preparation_: The code is written in a programming language. Documents (including instructions for the user) are prepared. 4. _Program testing_: Alpha testing (also known as disk checking) is carried out by the programmers and system analyst. Beta testing (real world user testing) is carried out to check for accuracy and sufficiency. 5. _Program implementation_: Trained users test the full program (including all logical sub-routines). Programmers troubleshoot uncovered problems before the program is released.

Answer 83

The following is a **classification of programming algorithms** by the way they are **designed**. * _Divide and Conquer_: Separates the problem into smaller and smaller sub-problems until each sub-problem can be solved easily. * _Dynamic Programming_: Breaks the problem down into problems that have already been solved in order to find the answer more quickly. * _Greedy Method_: Makes sure of approximate answers to sub-problems and can be the fastest way to find solutions. * _Linear Programming_: Inputs are restricted based on a predetermined construct. * _Reduction_: Changes the problem into a simpler problem. * _Search and Enumeration_: Specifies rules in the form of a graph.

Answer 84

The **human-computer interaction (HCI) framework** developed by **Nancy Staggers** in 2001, applies concepts related to psychology and technology to explain human interactions with computers over a period of time in different contexts. The different contexts include the following: * Providers * Patients * Interactions between patients and providers Communication is the basic exchange of human-computer interactions. The basic tasks to accomplish this exchange include initiating interaction, responding, providing information, and exchanging information. _The primary focus of HCI is usability related to human performance during interactions with computers in different contexts_, such as overall ease of use, difficulty in learning, efficiency, satisfaction, the ability to carry out error-free interactions, and the ability of the computer system to match the tasks. _Another focus is the mental model of users, the idea that the response of users to computers is based on previous knowledge and experience_. In order to be successful in tackling complex computer tasks, the mental model should be consistent with the concept or design of the computer programs; thus, the goal is to find a design that promotes an effective mental model.

Answer 85

All computer software is written in a specific **programming language**. Programming languages have been divided into five separate generations based on how close they mimic human language. The first generation is binary. Binary is machine language made up of two symbols that signify off (0) and on (1). Assembler language is the second generation. Assembler language uses English letters and symbols but relates them directly to binary. For this reason, assembler language can be difficult to learn. FORTRAN, COBOL, Java, and Visual BASIC are examples of third generation programming languages. FORTRAN and COBOL are procedural languages that require the user to specify both the exact procedure to be carried out as well as the data involved. Third generation programming languages also include Java and Visual BASIC. Java is used for internet content and Visual BASIC is a visual programming language. Most people interact with computers today through fourth generation languages that allow users to choose procedures from a menu instead of having to specify them with code. In the future, it is hoped that people will be able to speak directly to computers and have them carry out the verbal commands. This will be the fifth generation of programming languages.

Answer 86

There are a number of **algorithms** that are used in programming information systems. The following is a list of common algorithms and how they are applied: * _Recursion_: Calls on itself repeatedly until a match is made. This type of algorithm is often used in functional programming. * _Iterative_: Uses constructs that repeat themselves many times with the possible addition of other information to find a solution. * _Logical_: Uses the controlled dedication of axioms. Algorithm = logic + control. * _Serial_: One instruction is performed after another. * _Parallel and Distributive_: Breaks up the algorithm into parts that can be solved on different machines and then brings the separate answers together for the results. * _Deterministic/Non-Deterministic_: Uses precise decisions or uses a heuristically designed system of guessing. * _Exact/Approximate_: Determines a concrete answer or determines an answer that is close enough.

Answer 87

**Text** is more tiring for the eyes on the screen than on the printed page because of the illumination of the screen, and some fonts may blur in browsers, so fonts especially designed for the web, such as Verdana and Lucida Sans/Grande, should be used for text that will be accessed by a browser. Using a variety of fonts and multiple sizes on one screen can be very distracting. Long paragraphs should be avoided, and information should be presented in small paragraphs with adequate white space to rest the eyes. Font size should be 12-14 for standard text with larger sizes for headings. Text against a colored background, especially a deep color, is difficult to read. When highlighting text, underlining is more evident than italicizing and holding because screens have different lighting and resolution. Colored fonts may be used sparingly to highlight different types of information. For example, a question or heading may be in a blue font and an explanation in a black font.

Answer 88

The following items need to be evaluated when performing the needs assessment portion of the system development life cycle: * Compatibility and connectivity of the hardware and software that will be incorporated into the system * Aniount of downtime required for system testing and installation * Set up of the test and live environments * System response time and number of concurrent users * User support system * Administration of the system * Security parameters of the system * Disaster recovery contingency plans * User interface and ability to retrieve reports * System routines used for business processes such as hospital registration, records, and billing

Answer 89

The following steps are required for **human-centered design**: 1. Define and understand the organization's _requirements_ and the requirements of the individual users. 2. Define and understand the _logistics_ of how and where the system will be used. 3. Perform a _functionality analysis_. Specific system tasks should be broken down by priority, duration, frequency, and probability of completion. 4. Define the _key system functions_. The system functions should be logical and intuitive to the end users. 5. Perform an analysis of the most common potential _errors_ that could occur during tasks. Minimize the likelihood of committing errors by optimizing processes. 6. Design _interfaces and workstations_ so that they will work best with the users. 7. Perform _system testing_ with actual users. Depending on the results of these tests, the system should be adjusted to create the best system for the users.

Answer 90

Developing screens for consistency and ease of use requires an understanding of the basic **layout** and text guidelines. Headings should be placed uppermost and in the same place on subsequent screens. The eye should move in a continuous line (usually top to bottom], so images and text should not be scattered about a page but arranged in an orderly vertical display. Bright colors are distracting, and red and green should be avoided because some people may be color blind to those colors. Complex images and illustrations are difficult to view on the screen, so simple designs are preferable. Menu and status bars should be in the same place on each screen (usually top or bottom] and should contain only essential items. Icons should be easily recognizable and consistent. Unnecessary lines on the screen, such as borders, should be avoided.

Answer 91

**Instructor led training** is one of the most popular types of training for information systems. The _advantages_ of instructor led training are: * Uniformity: All trainees are exposed to the same material at the same time. * Coaching: Trainer is able to interact one on one with trainees. * Question and answer period: Trainees can have their questions answered immediately. * Demonstrations: The instructor can demonstrate the use of the test information system (set up for the class). * Tests of proficiency can be used. The _disadvantages_ of instructor led training are: * The effectiveness of the training depends on the quality and knowledge base of the trainer. * Larger class sizes can make training experience less effective. * The trainer must keep the level of training in line with the average trainee's experience.

Answer 92

Advantages and disadvantages of **online multimedia and tutorials** include: **Online multimedia** _Advantages:_ * Interactive: The trainee can access live feedback. * Improves retention: Instructor may be asked questions. * Tests of proficiency can be used: Real-time evaluations may be conducted with the trainees. _Disadvantages_: * Instructor and trainees must be available at predefined times. * Technology related problems may cancel the session. * Trainees need access to a computer and network connection. **Online Tutorials** _Advantages_: * The tutorial is available to the trainees 24 hours a day (7 days a week). * The trainee can revisit the sections they are having trouble with or need additional time . * Off-line examinations can be administered. _Disadvantages_: * The success of a tutorial is dependent on the richness and functionality of the design. * The trainee may not be as focused on the materials as they would be in a live setting.

Answer 93

Although extensive training should be completed before implementation of an information system, **ongoing training needs** must be assessed and training instituted. Methods of assessing needs include the following: * _End-user questionnaires and interviews_: Determine perceptions of need and user acceptance/attitudes. Staff members often know where their training needs lie and appreciate input. * _Real-time observations_: Note efficiency of use, correct or incorrect use, and time needed to carry out activities to note where changes would improve functioning. * _Analysis of errors/repairs_: Note patterns of errors (e.g., frequency, time, units), such as increased input errors in a single department, which suggest the need for more targeted training. This type of analysis may be the most cost-effective as it trains only those who need improved skills. * _Reviewing staff changes_: Note new additions to staff because they may have no or little or no training in use of the system.

Answer 94

**Organizational goals** are set based upon a needs assessment. The first step is for management to agree on the upcoming needs of the organization. These needs may be long-term, short-term, or a combination of both. Once the needs have been determined, performance goals for individuals and teams should be set to meet the organization's needs. It is important that the individual goals are specific, measurable, and time based. The goals should be distributed across the organization to align efforts in meeting the core needs. Regular milestones should also be set to assure that progress is being made.

Answer 95

There are two major on-the-job training methods for conducting information system training: 1. **Super user:** The super user is a regular user of the system who has in-depth knowledge of the information system. _Advantages_ - Understands the clinical areas and the information system; Any user may apply for this position _Disadvantages_ - Must take time away from clinical position: Must attend information system meetings _Tips_ - Is a good assistant trainer; Can help other users on the job **2. Job aids**: Job aids are learning tools used at the workstation. _Advantages_ - Lessens the need to memorize large amounts of information; Lessens the amount of time needed for dedicated training _Disadvantages_ - Access must be complete; Aids must be up to date _Tips_ - User friendliness is key; All users must be given same information

Answer 96

An **information system training plan** should include the following elements: * A training _mission statement_ to demonstrate the organization's commitment to the training process. * A _needs assessment_ (who will be trained, what will be taught, what resources are necessary, how much time will be spent, and where training will occur). * The _training modes_ that will be used: self-paced, on-the-job, or instructor led. * Whether the trainers are _in-house staff or contractors_. * The _amount of training time_ needed before the staff is deemed competent. * The _amount of money_ that will be spent on training. * The _methods_ that will be used to determine training effectiveness.

Answer 97

For employees that have little or no computer experience, **remedial training** is required. These individuals may feel intimidated by the idea of working with a computer system for the first time. It is important to address their fears and make them feel comfortable in the training environment. It may be useful to introduce them to basic computer use with a game (or other skill building software) before moving on to something more complex. These individuals may need to be taught basic computer skills (e.g., how to use a mouse and how to print documents).

Answer 98

All healthcare information systems have a variety of **support personnel**. These are the people who work to keep the system updated and running well: * _The Super User_: A super user is an employee who has some advanced knowledge about computers (and computer systems) and is familiar with the work done at the department level. A hospital may have a super user in each unit or department. * _Help Desk Personnel_: These are the people who answer user questions over the phone or in response to e-mail. If the problem is too difficult to work out over the phone, they may send someone to the user's location. A hospital must have a 24-hour information system help line for the users. * _PC Specialist_: A PC specialist usually has a bachelor's degree in computer science and assists with training and system setup (including upgrades). They may also install software on individual devices (e.g., Pocket PC).

Answer 99

There are two basic methods for carrying out information system training: 1. **Peer Training**: This is a method in which new users of the system are trained by existing users (their peers). The new employee shadows the peer and is coached on the proper operation of the system. _Advantages_ - Training is tailored directly to the function needed Proficiency can be easily tested _Disadvantages_ - Trainer may not be knowledgeable in principles of education; Existing bad habits can be easily passed on _Tips_ - Trainer should be knowledgeable in adult education; Works well for lower level staff 2 . **Self-Directed Text-Based Courses**: This method is based on self-directed (and self-paced) training by use of the provided materials. The materials are usually in the form of workbooks that can be studied at home or during breaks on the job. There is very little interaction with the subject matter experts. _Advantages_ - Individual works at their own pace. Proficiency is easily tested; Hospital system does not need to be in place for training to go on _Disadvantages_ - Personal motivation has to be high _Tips_ - Materials must be highly structured

Answer 100

Training employees on a new computer system should take the user through each part of the system that they will be working with. They should be introduced to the exact steps needed to perform each function that is required by their job. Simulations of potential challenging situations should be practiced. Additional features such as basic troubleshooting help screens and online tutorials should also be introduced to the trainees. Specific **areas for training staff** on information systems include: * The basics of how the computer system works. This includes both the hardware and software. * How the system impacts their areas of responsibility. This should include some "hands on" training at the individuals' workstation. * The computer support resources should be painstakingly outlined so that the staff member knows exactly what is available to them and at what times.

Answer 101

The following **questions** should be asked when performing **strategic planning** for information systems: * Is the core operating system open or closed? Can programmers access the program's actual code? * What technology is the system built upon? * What is the user interface? Is it user friendly? * Does the system comply with required standards (such as HL7)? * How easy is it to access raw data and create reports? * How is the system performance measured? * Can users customize their views? * How many users can access the system simultaneously? * Is the system upgradeable? * Will the system reduce or eliminate paper? * What is the timeline for implementation?

Answer 102

Systems take in information (called inputs), process it, and then produce new information (called outputs). Feedback controls the processes that occur within a system. The functional parts of a system and its processes are interdependent. A change or problem in one part of a system can affect the system's overall processes and this may cause problems for other parts of the system down the line. A econdary malfunction is defined as a change in one part of a system due to a problem in another part of the system. Problems must therefore be corrected at the area of the primary malfunction in order to prevent a secondary malfunction. If a problem affects the system's functions, it can also affect the output. To simplify **systems theory**, a system is more than the sum of its parts and is not equal to the function of its individual parts.

Answer 103

1**. Web Based Training**: Web-based training delivers content directly to students via the Internet. _Advantages_: Accessible from any PC that is connected to the network, Available 24 hours a day _Disadvantages_: Highly trained webmaster needed, Intranet must already be in place _Tips_: Online learner assessment is included **2. On-the-job Training**: On-the-job training is delivered to the student in-person usually at the work site itself. _Advantages_: Can be tailored to the individual. Learning is applied immediately. Proficiency is tested by the trainer _Disadvantages_: Productivity is less during training time. Bad habits can easily be passed on. Interruptions are extremely bothersome _Tips_: Trainer should be knowledgeable in adult education. Works well for lower level staff

Answer 104

The following common **goals** are relevant to **strategic planning** in healthcare information systems: * Computer systems designed to support business and clinical decisions. * Stay abreast of current technology. * Using the organization's technological innovations as a marketing tool. * To meet regulatory requirements. * To aid efficiency and overall productivity. * To improve the accuracy and dependability of patient data (especially tracking}.

Answer 105

The following **major steps are used in strategic planning**: 1. Develop a _mission statement_. 2 . Determine _goals and objectives_. 3 . Create a _strategic plan to achieve the goals and objectives_ that includes: * Identify potential solutions. * Select a course of action. * Implement the chosen solution. * Conduct regular evaluations including feedback from those involved in the strategic plan.

Answer 106

**Enterprise-wide strategic planning** requires that an organization look at needs of the organization, community, and customers and establish both short- (2-4 years) and long-term (10-15 years) goals. Strategic planning must be based on internal and external assessments to determine the present course of action, needed changes, priorities, and methodologies to effect change. The focus of strategic planning must be on the development of services based on identified customer needs and then the marketing of those services. Enterprise-wide strategic planning includes: * Collecting data and doing an external analysis of customer needs. * Analyzing internal services and functions. * Identifying and understanding key issues, including the strengths and weaknesses of the organization, potential opportunities, and negative impacts. * Developing revised mission and vision statements that identify core values. * Establishing specific goals and objectives.

Answer 107

**Market analysis** is done to determine both the current status of the market for a product or service and the future potential. Market analysis includes assessment of the following: * _Size of the market and demand_: current data about sales from government, industry, surveys, and major producers of similar products or services * _Marketing trends_: regulations, social factors, environmental factors, innovations, and any factors that may affect sales * _Growth rate of market_: based on analysis of historical data, current sales data, and developments that may impact growth positively or negatively * _Opportunity assessment_: in terms of competition * _Profitability_: assessment of influencing factors (Michael E. Porter), including buyer and supplier power, barriers to market entry, possible threat of competitive substitute products or services, and company rivalry * _Cost structure_: determining value and costs * _Methods of distribution_: existing and emerging * _Necessary factors_: resources, access to distribution, and technology

Answer 108

When **reporting an analysis to stakeholders**, the first step is to _determine the factors that are most important to the specific stakeholders_. For example, management may be most interested in costeffectiveness while end-users may be most interested in ease of use. Thus, the report should focus on the areas of interest. While analysis may have involved many steps, a report is most concerned with the end result of the analysis: "This is what works" rather than "This is how we know what works." Data should be presented in a visual medium, such as in charts or diagrams, as much as possible so stakeholders can more easily comprehend. PowerPoint presentations may be used but should contain supporting charts or highlights, not the entire report, as stakeholders will focus on the screen rather than the presenter. The report should be outlined in advance, organized in a meaningful way (most important information to least important, or vice versa), and presented clearly, allowing time for questions.

Answer 109

**System failure** may result in the hardware freezing or software malfunctioning. In some cases, the system may reboot, but in other cases, it may simply stop functioning. _Error messages_ may help to indicate the type of problem that is occurring and may guide troubleshooting efforts. _Policies should be in place to guide procedures during the time the system is not available_ (e.g., downtime planning). Common causes of system failure include user/operator error, power disruptions/disconnections, overheating, and equipment malfunction or failure. _Fast response to identify the cause_ of the system failure and repair to get the system up and running again are essential, but recovery, such as entering paper-stored data, must also be completed along with verification to ensure that data have not been corrupted and that the system is functioning properly.

Answer 110

The primary purpose of most end-user testing is to identify errors. Testing may be done to verify that the system functions as intended or to validate that the system functions in a way that meets the requirement of an organization. A number of different methods can be used to **analyze end-user acceptance** of systems. * User acceptance testing with scenarios in which users carry out representative tasks * Interviews with users regarding usability and other problems * Questionnaires for users to determine perceptions of usability * Comparative studies with users using different systems or methods * Direct observation of users carrying out tasks * Indirect observation of users carrying out tasks, such as by video * Analysis of computer-generated data to determine accuracy and numbers of errors

Answer 111

A number of different criteria must be considered for effective **system issues management:** * _Technical_: type of architecture, downtime necessary for maintenance, standards for connectivity, environments for testing, response times, and supporting technologies * _General/managerial_: security standards, data standards, options for storage, capabilities related to providing reports, integration with health information exchanges * _Registration_: correct client identification with unique identifiers across multiple registration sites and ability to track client's location and use of services * _Computerized physician order entry reporting_: indicates details about orders, provides notification of duplicate orders, produces audit trail, supports documentation, generates claims, provides clinical decision support, and displays results * _Integrated documentation_: pulls documentation (e.g., claims) from various departments * _Scheduling_: appointments, testing, and procedures * _Medical records_: provides automatic coding * _Billing_: provides summaries, insurance information, and charges.

Answer 112

Analysis of **end-user acceptance** of systems using human-computer interactions or **user-acceptance testing (UAT)** is done to determine the end-users willingness to use computer technology and software in the way in which it is designed. Without acceptance, users may avoid or misuse technology or remain dissatisfied, impacting job performance. For successful implementation of a system, user acceptance is critical. Analysis of end-user acceptance should begin during alpha (completed by developer) or beta (completed by end-users) testing before complete implementation of a system. Usability testing should help to determine ease of use and inherent problems in the system. While some organizations use surrogate end-users for testing, at least some participants should be actual end-users. Steps to analyzing end-user acceptance include: * Analyzing the basic requirements of the system and the organization. * Identifying the end-user acceptance scenarios. * Describing a testing plan, including different severity levels based on real-world conditions. * Designing the testing plan and test cases, considering the risks and the skills of the end-users. * Conducting the tests. * Evaluating and recording results.

Answer 113

**Product analysis** may be used to analyze one product or to compare a number of products. Product analysis may be conducted during the design of a product at any stage but may also be conducted to determine if existing products or prototypes meet desired criteria. Product analysis focuses on how products are made and used and their important features. Product analysis helps to identi& flaws or problem areas in a product and can identify possible changes needed for improvement. Steps in product analysis include: * Selecting product or products to be analyzed. * Determining the target market or user. * Establishing a list of criteria: cost, usability, user learning curve, user satisfaction, integration, product construction and materials, quality, dimensions, safety, life cycle, and recyclability. * Determining a scoring or ranking scale (e.g., 1 to 5, good to bad). * Evaluating the products in terms of each criterion and assigning a score or rank. * Assessing scores or ranks for problems or flaws. * Identifying changes needed in product.

Answer 114

**Exploratory**—This type of testing uses the results of previous testing to determine the types of additional testing indicated, based on user experience, and does not follow a specified pattern of testing. This may be done after conclusion of other tests to verify that no significant defects remain. **Graphical user interface (GUI)** —The GUI, which allows users to interact with devices through the use of images, such as icons, rather than text, must be tested to ensure it meets specifications. This is done by developing test cases that use all the functions of the GUI. GUIs usually have a large number of operations, so size and sequencing of actions are important considerations. Open source and commercial testing applications are available for GUI testing. **Installation**—This tests procedures needed to install, uninstall, and upgrade applications. All configurations should be tested, including installing on various types of equipment.

Answer 115

During the implementation stage of a new system and conversion of data, a number of **common problems** may occur, including the following: * Inadequate allocation of time and resources needed to implement a new system * Frequent changes that require programming revisions and result in both scope creep and feature creep with added costs in terms of time and finances * Underestimation of the amount of customization required to implement a system and convert data (One solution is to resist all customization and another, to fully customize.) * Failure to budget or plan for service contracts, updates, technical support, power needs, and ongoing operating costs * Inadequate testing of all components and the system, resulting in problems with conversion * Failure to understand the need for training and inadequate resource allocation for training and training materials * Failure to assess user resistance accurately or build support for system changes

Answer 116

Systems testing for **performance effectiveness** is completed after integration testing and involves testing the system as a whole to determine if it meets requirements, functions as needed, and meets expected outcomes. Numerous tests are involved in systems testing. **Accessibility**—Testing is completed to ensure that the system is in compliance with the Ada requirements. This includes testing speech recognition software, screen magnifying software, video captioning, braille readers, amplification systems, alternative keyboards, and screen readers to determine if they function properly through various actions. Technical compliance with requirements of the Federal Electronic and Information Technology Accessibility and Compliance Act (1997) must also be tested where applicable. Testing should also be done to ensure that Web access is in compliance with standards set by the World Wide Web Consortium's Web Accessibility Initiative (WAI), which provides guidelines to allow those with disabilities to access the Web and create Web content.

Answer 117

**System maintenance** activities encompass both the hardware and software aspects of keeping the system "caught up" in terms of maintenance. Hardware activities revolve around the consumables and physical storage requirements associated with printing and backing up system data. Software activities are associated with the updates of system software and the related testing/change control procedures. Specific system maintenance tasks include: * Troubleshooting hardware and software problems. * Keeping an adequate supply of replacement hardware (e.g., printers, cables, and monitors) and consumables (e.g., toner and ink cartridges). * Performing system back up procedures according to a predefined schedule. * Making sure the system has enough storage capacity. * Applying system upgrades and software patches. * Making sure disaster recovery plan is in place and ready for implementation.

Answer 118

In order to integrate computer systems, two major items of importance are the data dictionary and a master patient index. These two items need to be recognized by the various systems that make up the integrated system. In computing, recognition means that the data have to be similar in structure and characters. * **Data dictionary**: A data dictionary lists commonly used terms, their definition, and their synonyms. It should also list the term that should be used by all departments as the de facto standard in order to facilitate integration. * **Master patient index**: The master patient index (MPl) lists all patients and their demographic information. It is important that each individual be listed with several different pieces of data including: first and last name, social security number, and date of birth. The MPI should be set up so that new fields of information can be added easily and that it can be scaled up (without slowing down system performance) as the business grows.

Answer 119

**Sanity**—This is rapid run-through testing to determine if results seem reasonable and the system appears to work correctly. This type of testing may be done during development and before more rigorous testing to find obvious faults. **Scalability**—This tests the ability of the system to function under increasing loads (scaling up) or under increasing nodes (scaling out), such as adding computers or servers to the system. Scaling may be strong or weak. **Security**—This testing is done to determine if data security is adequate in protecting confidentiality. It also tests authentications, access controls, availability of information, and nonrepudiation (ensuring a record remains of messages sent and received). Steps include discovery, scanning for vulnerability, assessing vulnerability, assessing security, conducting penetration tests to simulate an attack on the system, auditing, and reviewing.

Answer 120

**Ad hoc**—This type of exploratory testing is usually done once, and the user attempts to identify problems in an unstructured way by trying various means to elicit errors. This is essentially a form of error guessing in which the user bases testing on previous experience with software. **Compatibility**—This may include certification testing to determine if the application functions properly in a target operating system or database. Compatibility testing, focusing on user experience, can encompass a wide range of tests, such as testing the system in different Web browsers, evaluating the bandwidth handling capacity, determining if peripherals (e.g., printers) function properly, evaluating the function of tools (e.g., messaging), and testing access to databases. **Exception handling**—This type of error testing is done to determine if there are errors resulting from incorrect programming, coding, or resource failures, how the system responds, and whether errors result in negative effects, such as corrupted data. Exception handling may involve hardware and software.

Answer 121

The role of **system support** encompasses all of the activities required to make sure the system is operating as it was designed to perform. Performance issues (e.g., a slow system response time) may indicate that the system is about to crash. Detection of problems is as important as troubleshooting items that have already broken. Specific system support activities include: * Fielding all requests made during the implementation period. * Establish ongoing communication between the system administrators and the system users. This may take the form of a printed newsletter, e-mail updates, or an in-house focus group. * Establishing a 24-hour telephone help desk. * Performing follow-up to all completed help requests to verify that the problem was adequately resolved.

Answer 122

Within a company, the need for an **integrated computer system** is necessary. Companies may choose to switch from many separate systems to one integrated system, or may invest in a computer interface program that will decode information between separate systems. The advantage of having an integrated system is that information is automatically transferred between the various independent systems that make up the parts of the integrated system. This results in a more robust, less error prone, combined system. There are two major types of interfaces: 1. _Point-to-point_: The point-to-point interface connects two separate systems directly to each other. 2. _Software reliance systems_: For systems that need to interface with more than two entities, it is best to use an interface engine software. This results in a more flexible network. Interface engine software can process information in real-time or in batches. Real-time processing means that information is transferred from one system to another immediately. Batch processing occurs at the end of the day when all information is transferred at one time.

Answer 123

**Smoke/power on**—This involves attaching an electronic device to power and observing the result ("smoke"). This identifies overloads or overheating. In computer applications, this refers to initial testing to identift failures ("smoke"). Smoke tests -may be functional (testing the entire program) or unit (testing specific functions). **Software performance**—These tests are used to determine the ability of the system to perform under specified workloads. Software performance testing may include load testing, stress testing to determine upper limits, endurance testing to determine the length of time a system can function under an anticipated load, spike testing to determine if the system can function with a sudden dramatic increase in load, configuration testing to determine if the system functions with changes in configuration, and isolation testing to repeat tests that resulted in failures or system problems. **Usability**—This tests the ability of end-users to use the system and applications adequately. This may involve observation and "think aloud" to evaluate performance, accuracy, ability to recall steps, duration of time spent on tasks, and personal response.

Answer 124

During the conversion and go-live process, a **command center**, comprised of a director and support staff, can coordinate and monitor all operations (e.g., applications, user support, vendor support, communication, documentation, technical operations). The command center should be established as part of the preliminary planning, Three primary functions of the command center include: * Providing communication to all parties and evaluating intelligence regarding problems. * Exercising control over the process of conversion, allocating resources appropriately, and demonstrating leadership in advocating for change. * Coordinating all activities and maintaining documentation. Members of the command center should be in the same area or adjacent areas to allow for fast and effective communication. Vendor representatives may be at the center and at off-site locations and are often critical during the go-live procedures.

Answer 125

**Maintenance**—This testing is done to identify problems requiring maintenance with equipment or applications or to evaluate the effectiveness of repairs. Maintenance testing is often done on software already in use when it is changed in some way or installed in other hardware. **Recovery**—This involves purposely crashing the system and evaluating the system's ability to recover. Techniques include restarting the computer in the middle of an action, unplugging the device during data retrieval, and restarting a browser after accessing a number of different windows to determine if memory and access to the windows remain intact after restarting. **Regression**—This tests the system after a change, such as installation of a patch or a change in configuration, to determine if the change has introduced faults into the system.

Answer 126

**Phased implementation** of a new system may involve _phasing by module, unit, or geography_. In phased implementation, the system may go live in one or more units initially with units added on an extended phased schedule until all units have switched to the new system. This has the advantage of allowing for evaluation and revision on a small scale. Additionally, those initially using the new system may subsequently serve as trainers and resources for those who receive the system at a later time. In some cases of phased implementation, some aspects of a new system may be used throughout the organization with other aspects added in phased steps. For example, all units may be able to retrieve data but only some to enter data. Careful consideration should be given to which units should receive the new system first. It is usually best to begin with people with computer skills or those who support the new system. Disadvantages include disruption of operations, difficulty in accessing complete data, and staff confusion.

Answer 127

Systems often contain large amounts of obsolete legacy data; however, keeping an old system running to allow access to the data is expensive, but moving all data to the new system may result in huge amounts of data posing problems in translation. A cost-effective solution is to **archive legacy data** to archive appliances, which offload data from the main storage system in an accessible format [online or offline). When determining which data are to remain active and which are to be decommissioned, the processes include: * Evaluating and auditing the data to eliminate redundancies. * Determining what data are important for business/legal reasons. * Evaluating data to determine what should be active and inactive. * Evaluating legal requirements in relationship to data. * Reviewing the organizational policies regarding data retention. * Developing a plan for archiving and decommissioning data. * Validating the integrity of the data.