TigER INITIATIVE

Tiger INITIATIVE Group membersAshlyn Johnson w036amj@pilot.wright.eduAmy Vanbuskirkw015amv@pilot.wright.eduAmy Wileyw064amw@pilot.wright.eduBethany HanenKratw137bmb@pilot.wright.eduJessica Akemonw106jkp@pilot.wright.edu

Kathleen Owensw005kao@pilot.wright.eduShawn Kisew025sek@pilot.wright.eduShelley Thiebeauw023skt@pilot.wright.eduWhitney Dunbarw105wld@pilot.wright.eduObjectives1. Understand the background of how the Tiger Initiative got started. 2. Know the 9 collaborative teams of the Tiger Initiative.3. Be able to state goals of the Tiger Initiative.4. Know where to access information on the Tiger Initiative.

3TIGER INITIATIVET TechnologyI InformaticsG GuidingE EducationR Reform

Executive SummaryFocused awareness with nursing stakeholders in three areasDevelop a U.S. nursing workforce capable of using electronic health records to improve the delivery of healthcareEngage more nurses in the development of a national healthcare information technology (NHIT) infrastructureAccelerate adoption of smart, standards-based, interoperable technology that will make healthcare delivery safer, more efficient, timely, accessible, and patient-centeredTIGER: Background2004: President Bush supported adoption of electronic health records2005: Small group of nursing leaders and advocates met and resolved to strengthen the voice of the nursing profession in the transformation of healthcare for 21st centuryOrganized TIGER Initiative (2005)TIGER: Background- Nursing Engagement2006: Interactive summit, Evidence and Informatics Transforming NursingCreated a vision for the future of nursing that bridges the quality chasm with information technology, enabling nurses to use informatics in practice and education to provide safer, higher quality patient careTIGER: Background Cont.Focus on nursing, however recommendations apply to interdisciplinary health professionsAim to develop a nursing workforce in the US capable of using electronic health records (EHRs) with hope to improve care delivery2009 Obama signs American Recovery and Reinvestment Act- $19 billion for health information technology (HIT)Funding by Dept of Labor and Dept of Education to increase HIT workforce8TIGER: Background Cont.Capital, technology, resources, and people needed to create an informatics-aware healthcare workforce Healthcare provider competency with EHRs (requires basic computer skills, information literacy, and understanding of informatics and information management)Education reform- 3 million currently practicing nurses may not be competent with HIT

9TIGER VISION Our vision is toenable nurses to use informatics tools, principles, theories, and practices to make health care safer, more effective, efficient, patient-centered, timely, and equitable by interweaving enabling technologies transparently into nursing practice and education, making information technology the stethoscope for the 21st century.

TIGER Expected Outcomes

Publish a Summit report, including Summit findings and exemplars of excellence. Establish guidelines for organizations to follow as they integrate informatics knowledge, skills, and abilities into academic and practice settings. Set an agenda whereby the nursing organizations specify what they plan to do to bridge the quality chasm via information technology strategies.

7 KEY PILLARS 1.) Communication2.) Education3.) Informatics Design4.) Information Technology5.) Culture6.) Management and Leadership7.) PolicyTIGER: Summary ReportProvides executive summary of activities through 2008Synopsis of findings and recommendations of the nine teamsAvailable at www.tigersummit.com

9 collaborative teams1.) Standards & Interoperability2.) National Health Information Technology Agenda3.) Informatics Competencies4.) Education & Faculty Development5.) Staff Development6.) Usability & Clinical Application Design7.) Virtual Demonstration Center8.) Leadership Development9.) Consumer Empowerment & Personal Health Records

1.Standards & InteroperabilityStandard-A definition or format that has been approved by a recognized standards organization or is accepted as a de facto standard by the industry. A standard specifies a well-defined approach that supports a business process and is:

1. Derived by a group of experts2. Examined and evaluated3. Provides rules, guidelines, or characteristics4. Helps to ensure that materials, products, processes, and services are fit for their intended purpose5. Ensures that it is in an accessible format6. Is in a continuous review and revision processThis collaborative group was designed to create standardization of nursing data. This will help to improve sharing of information throughout an organization as well as other healthcare providers. The goal is for the ability to share information across regional/national databases. Standards harmonization is a process where the terms used to describe nursing problems, observations, actions, goals, outcomes and interventions are standardized in order to share with others.

Benefits are: 1. accurately describe the care delivered by nurses and facilitate communication among nurses and other healthcare providers; 2. enable the comparison of nursing data across clinical populations, practice settings, time and geographic regions, 3. allow measurements of the impact of nursing interventions in relation to patient outcomes, 4. provide timely access to evidence based knowledge during patient care15Standards & InteroperabilityInteroperability-the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data such that clinical or operational purpose and meaning of the data are preserved and unalteredIn 2006 President Bush gave an Executive order mandating the Federal Government use interoperable standards.

Interoperable systems will assist clinicians in delivering safe, effective, efficient patient-centered care. Clinical data standards are the building blocks towards interoperable systems, including electronic health records, electronic medical records. It is important that nurses understand these standards and their impact on care delivery. 16Standards & Interoperability Goals:Integrate industry standards for health IT interoperability with clinical standards for practice and education.Educate practice and education communities on health IT standards.Establish use of standards and set hard deadlines for adoption. Work groups were created for the development of tools and resources for the promotion of these goals.

The first work group created a compilation of nursing standards, standard organizations, and initiatives required for the development of the national electronic health record framework.

The second group developed a series of web-based tutorials to educate nurses on the benefits of interoperable systems and the standards adoption process required to achieve interoperable healthcare.

The third group focused on a strategy for how the information was to be distributed. An awareness campaign was designed to stress the importance of adopting the standards of interoperability.172.National Health IT AgendaDecrease healthcare costsReduce medical errorsNational disastersThreat of terrorismWhy Do We Need Reform?National Health IT Organizations that Need Nursing ParticipationNational eHealth CollaborativeHealthcare Information Technology Standards PanelCertification Commission for Healthcare Information TechnologyHIT Policy Committee and HIT Standards CommitteeInstitute of Medicine(IOM) created a series of reports identifying information technology as key to healthcare reform. The escalating cost of the U.S. healthcare system and the need to improve patient safety and reduce medical errors, coupled with national disasters, terrorism, and other unsustainable healthcare trends, has necessitated major healthcare reform in the United States. Focusing on the adoption of electronic health records as a priority within the U.S. National Health IT Agenda is the key driver cited to achieving the transformation needed.

As a result of TIGERs strategic plan, the National Health IT Agenda Collaborative was formed. The purpose of this collaborative was to identify the most relevant health IT agenda and policies that are important to the TIGER and the nursing professions mission and to assist in closing any representation gaps on said policy issues.

This collaborative was created to identify the most relevant health IT agenda and policies important to TIGER and the nursing profession. They identified 3 areas where the nursing profession needs greater visibility. clinical standards and policy initiatives generated by the AHIC/National eHealth Collaborative and the ONC. In the standards harmonization and interoperability efforts of the ANSI-HITSP 3. In the certification process for HIT products

President Bush established a goal of 2014 for Electronic health records. Since the passage of the American Recovery and Reinvestment Act of 2009, momentum and activities to-date in the areas of governance, policy, technology, and adoption have accelerated in both the federal and private sector. Nursings involvement in the national HIT agenda, as the largest sector of the U.S. healthcare workforce, is even more urgent and critical today.

183.TIGER Informatics Competencies ModelBasic Computer Competencies

Informatics Literacy

Information ManagementModelStandard/SourceEuropean Computer Driving License/European Computer Driving License Foundation

Information Literacy Competency Standards/American Library Association

Electronic Health record Functional Model-Clinical Care Components/Health Level Seven(HL7)International Computer Driving License-Health/European Computer Driving License FoundationThis collaborative was created to establish the minimum set of informatics competencies for all practicing nurses and graduating nursing students. They reviewed over 1,000 competencies and narrowed the scope to describe the minimum set for nurses.

In order to provide safe, competent, and compassionate care nurse need to have basic computer skills in order to navigate with in the electronic health record. Nurses need the ability to access information and apply the knowledge appropriately to provide high-quality nursing care.

Following the review of literature the team developed this model to establish informatics competency. TICC established frameworks to expand for specialty practices, different environments, and advanced degrees or practice such as leadership roles.

Nurses are expected to provide safe, competent, and compassionate care in an increasingly technical and digital environment. Yet technology has changed the role of the nurse and significantly altered the interactions between the nurse and patient and the nurse and healthcare provider. Nurses that do not have the basic skills to communicate within an electronic health record or other electronic medium will be significantly disadvantaged as we work to achieve 100% electronic health record adoption by 2014.

The TIGER Informatics Competencies Collaborative (TICC) was formed to establish the minimum set of informatics competencies for all practicing nurses and graduating nursing students. The work of this team was foundational to all TIGER work related to preparing the nursing workforce for EHRs, and preceded the work of the TIGER Education and Faculty Development, Staff Development, Leadership Development, and Virtual Demonstration Center Collaborative teams.

194. Education and Faculty Development Recommendations forAssociate Degree ProgramsState Boards of Nursing State InitiativesHuman Resource Services Administration Curriculum Development

20Education-Focused OrganizationsNational League for Nursing (NLN) and American Association of Colleges of Nursing (AACN) support TIGER InitiativesChanges to curriculum to include HIT and EHRs21Education-Focused OrganizationsNLN23 recommendations for nursing schoolsNursing School AdministratorsInfrastructure, faculty development, student access to HIT in clinical experience, inclusion of informatics in curriculum FacultyInformatics education, a champion in every nursing school, provide hands on experience to students NLNFunding for think tank, minimal informatics competency for all nurses, create faculty development programsAACNInclude informatics in Baccalaureate and Doctor of Nursing Practice education 225.Staff Development Official TIGER Staff Development Collaborative Team report not yet availableStaff Development Collaborative TeamAim to help staff communicate and manage information effectively Research suggests that HIT can improve patient safety If used improperly HIT may be detrimental to patient safetyHealthcare OrganizationsEducate practicing nursesAdopt new technologies to improve patient safety 23Goals for Staff DevelopmentStaff Development Collaborative 3 GoalsEducation/programs in practice settings for ITContinuing education/training in informaticsCollaborate with industry, service, and academia to promote HIT education and improve use of HIT in practice 24Staff DevelopmentWorkforce Readiness-Prepare nurses already in the workforceNurses are the most frequent users of clinical information systemsOrganizational ReadinessKnowledge readinessTechnical readinessOperation readinessFunctional readinessResource readinessInternal environmental readiness25Staff Development Cont.Technology can improve patient safetyHealthcare Settings (implementing HIT)Staff preparation and trainingProcess changesContinuity of patient careIT administrative support26The Informatics for Advanced Arial Bold Program at ColumbiaInformatics Competency developmentPatient safetyEvidence-based care

27The Informatics for Advanced Arial Bold program at ColumbiaApplications to support nurses in various roles Student use of handheld devices for clinical documentationClinical practice guidelines for depression, obesity, and tobacco cessationA patient safety website for reporting hazardsAccess to National Cancer Institute information for tobacco cessation 286.Usability and Clinical Application DesignCurrent information systems may not meet workflow demandsCurrent technology was not designed with nursing workflow or thought process in mindSystems with designs appropriate for daily nursing practice are needed29Usability and Clinical Application DesignRecommendations provided for HIT vendors as well as practitioners Improve HIT productsEfficiency EffectivenessSatisfaction Better HIT designs Greater productivityReduction of errorsFitting to workflowImprovement of accuracyEasy to learnIncreased satisfaction of healthcare providers30UsabilityUsability PrinciplesFocus on the product usersMatch designs to users, tasks, and environmentsEvaluate products (users and metrics)Usability GoalsEvidence-basedPatient-centeredAllow interdisciplinary collaboration at point-of-care

31Usability & Clinical Application DesignHuman FactorsUsabilityErgonomicsHuman-computer interactionClinical application designUsability EBP interdisciplinary collaboration knowledge discoverySystems thinkingIndividual competencyEBPScope of practiceKnowledge discoveryIntegrated competency32Collaborative GoalsUsability GoalsNursing informed and helpful for nursing workflowKnown principles and processes drive systems designImprove system effectiveness by working with developersClinical Application Design GoalsSupport EBPCollaborative and interdisciplinary careProvide access to literature and knowledgeSupport knowledge-discoveryEnable research to practice translation

33Clinical Requirements Define user needsUnderstand nursing role and appropriate system actionsProvides recommendations to both health care practitioners and vendors 34Clinical Requirements Recommendations for VendorsClinician representationClear requirements for developers (non-clinicians) who hard-code designsRequirements of different skill levels (nurses choose level of system support)Work with organizations analysts and users to validate requirements during development/customization of the productPartner with customers to meet the needs of end-users35Clinical Requirements Recommendations for Health Care PractitionersSelect the team (interdisciplinary team to define clinical requirements)Analyze the systems impact on workflow of each deptUse standardized terminology for organization (allow free text, support EBP, end-users to review)Customization of systemLegal considerations (electronic signature, audit trail)Tools (system setup and maintenance)

36Usability and Clinical Application and Design Recommendations Safety and usability recommendations for vendorsFor healthcare practitionersUsability EvaluationsDesign prototype then evaluateProduct designUserEnvironmentHuman Factors recommendations Understand human capability and limitationHuman errorsTechnical errorsJudgmental errors Monitoring and vigilance failures37Collaborative 6: Case StudiesCase studies have identified key factors for successUser and key stakeholder involvementInvolved early onInvolved with requirements development and selectionClinicians + developersCreate design which fits workflowVendors understand workflow of end users 387: Virtual Demonstration Center (VDC)Created to develop a dynamic Internet Create a physical destination to demonstrate high effective and efficient, technology-enabled, solutions of exemplary health care delivery systems

VDCGoal: Encourage innovative and disruptive approaches to improving health care delivery with the use of technologyAllow access to the Center from anywhereExpand current thinking about healthcare

VDCHeld two virtual conferences in 2008Provided Gallery Walk to nursesProvided exemplars of best practice for technology utilization, contact resources, and virtual networkingInteractive experience

Interoperability and security were among the principles highlighted in all demonstrationSecond conference offered real-time presentations, interactive displays, and videos41VDC GoalsProvided visibility to the vision of ITDemonstrated future IT resourcesDemonstrated collaboration between industry, healthcare organizations, academic institutions, and professional organizationProvided universal accessibility to this demonstration for all nursing stakeholdersVDC GoalsUsed practice exemplars from different practice environments Demonstrated how integrated IT systems impact nurses and the quality and safety of patient careUsed practice exemplars from different practice environments to demonstrate best practices, results of research, case studies, and lessons learned by partnering with nursing professional organizations43Benefits and VDC Outcomes for 2008Nurses who can visualize the benefits of an It-enabled future will be more likely to use EHR in their practice settingMost exposure to IT capabilities are site-specific, except nursing informatics resourcesProvided a vision of how to partner with colleagues to widen the availability of resources due to limited accessibility

Benefits and VDC Outcomes 2008Provided an example of how education can be made more widely available Universal adoption of informatics competencies for all nurses

-Provided an example of how education can be made more widely available through virtual resources and environments d/t most IT education occurs in a specific field setting when a new system is implemented and focuses on system mechanics vs. user benefits and impact on patient care-Universal adoption of informatics competencies for all nurses will require access to informatics resources at anytime from any site. The goal of VDC was to support this outcome through innovative examples.

45Future OpportunitiesDevelop a virtual environment- Second Life3D interactive avatars that allows interaction with the programSocial networks and virtual technologyGoal: secure funding to help build out a virtual island that will support the TIGER missionImprove patient care and outcomes-3d- allows participant to interact with the program to increase their knowledge and familiarity with current and future technology- The goal is to secure funding to help build out a virtual island that will support the TIGER mission of educating nurses about the possibility and benefits of IT with the goal if improving patient care and outcomes.468: Leadership DevelopmentTransform organizations values, beliefs, and behaviorsTechnology changing but adoption of technology will not happen without leadershipRequires vision, influence, risk taking, clinical knowledge, and a strong expertise related to professional nursing practice Technology is an underpinning to support the needed changes, but adoption of technology will not happen without leadership that is educated and prepared to lead future technology initiatives47LeadershipLeaders: Model the WayInspire a Shared VisionChallenge the ProcessEnable Others to ActEncourage the HeartThe most significant contribution leaders make is not simply to todays bottom line; it is to the long-term development of people and institutions so they can adapt, change, prosper, and grow.

Resource: Kouzes, J.M., & Posner, B.Z. (2007). The leadership challenge (4th ed.). San Francisco: Jossey-Bass.

48LeadershipDevelop revolutionary leadership that drives, empowers, and executes the transformation of health careRequires nursing leadership to understand, promote, own, and measure the success of health ITEnsure development of informatics competencies at the beginning management role or the charge nurseLeadership- ExecutiveInformatics competencies should focus on: budgetary, regulatory, safety, security, and privacy policies Expected to fully understand and articulate goals and benefits of technology implementationRemain engaged throughout the lifecycle of system selection, implementation, and optimizationLeadershipResponsible for developing a culture that is innovative and ready to embrace changeThe Magnet Program TIGER collected examples of how organizations used HIT to demonstrate aspects of their Magnet journeyMagnet Program exemplifies a model for change, and recognizes healthcare organizations that provide nursing excellence in the delivery of quality patient care, and demonstrates innovation in professional nursing practiceThese examples help to illustrate how technology can achieve each of the 14 forces of magnetism as well as transform the nursing organization to use technology for their benefit. Examplars are meant to demonstrate the creativity and flexibility to transform the practice of healthcare delivery 51Leadership: RecommendationsDevelop programs for nurse executive and faculty that emphasizes the value of IT and empowers those to use HIT Expand and integrate informatics competencies into Nursing Leadership Development ProgramsLeadership: RecommendationsPromote sharing of best practices using HIT effectively to improve the delivery of nursing carePromote alignment with the Magnet Recognition Program as a mechanism to demonstrate nursing excellence in usingCriteria for Leadership DevelopmentMaintain knowledge of cutting edge practice and for management of clinical teamsAreas of focus: EvidenceContentTechnologyStandardsEvidence: Addresses improvement of quality, safety and value-added healthcare delivery professionals to identify care practices derived from scientific evidenceContent: Builds evaluation of care practices for technical and content gapsTechnology: Manages life-cycle change consistently to close the gaps with technology and knowledge resources found through evaluationStandards: Formal educational structured program, including Advisory Board Leadership Programs, AMIA 10 by 10 Program, AONE leadership programs for AACN accredited academic programs for nursing service administration549: Consumer Empowerment & Personal Health Records33% of adults are confident in their physicians an other HC providers having a complete and accurate picture of their medical historyNeed for consumers to take a more active role in their health carePersonal Health Record (PHR)- internet based

Need for consumers to take a more active role in their health care, starting with a comprehensive personal health record controlled and maintained by the consumerPHR- set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it55Consumer Empowerment & Personal Health RecordsPHR: promotes patient empowerment and supports the patients engagement in their own health careNurses obligated to become families with the technologyObjective of TIGER: make information available to nurses about PHRs and to encourage inclusion of this content to nursing curricula Consumer Empowerment & Personal Health RecordsWays nurses can impact the adoption and use of consumer empowerment strategiesPHRs: easy to use and accessible to consumersDeveloped an inventory of usability principles for patient-focused applicationsBarrier of PHRs: lack of interoperability with other systemsNational Health IT activities have focused on identifying and supporting the adoption of standards for PHRsPHRS must be easy to use and accessible to consumers. Applications do not always take into account the needs of consumers, who may suffer from disabilities, lack of computer expertise, and poor health literacy.57Consumer Empowerment & Personal Health RecordsPresident Obama supports greater use of technology in healthcareIncluded significant funds in the economic stimulus package to increase adoption of PHRsHigh prospect of achieving PHRs that are complete, accessible, interoperable, and secureReducing Medication Errors with Electronic Medical Records and Bar Coding TechnologyBar Coding Video

59Reducing Medication Errors with Electronic Medical Records and bar coding technology.http://www.youtube.com/watch?v=QnqdS26RohU&feature=relmfuhttp://www.youtube.com/watch?v=fjnyDNZE3RY&feature=relmfuReducing Medication Errors with Electronic Medical Records and bar coding technology.http://www.youtube.com/watch?v=QnqdS26RohU&feature=relmfuhttp://www.youtube.com/watch?v=fjnyDNZE3RY&feature=relmfu

While caring for a premature neonate the nurse administers many intravenous medications throughout her shift, including heparin 10 units/mL. The adult dose of heparin 10,000 units/mL is in similar packaging and labeling. The two very different doses of medication are easily confused due to similar labeling and packaging. To prevent medication errors we observes the 5 Rights of Medication administration: checking:Right PatientRight MedicationRight Dose Right RouteRight Time

But, to err is human. We increase patient safety and lessen the risk of medication error with preventative strategies, such as electronic medical records, medication bar coding, unit dose labeling and smart (programmed pumps).

Discussion Points

Informatics CompetenciesReview

The Informatics Competencies as outlined in the TIGER initiatives is a plan for all practicing nurse and students to have the necessary skills to practice nursing in the high-technology environment emerging in all avenues of healthcare. (Hebda and Calderone, 2010)

For All Nurses

Entry and retrieval of data in electronic medical records

Analyze and interpret information as part of care plan

Use informatics applications designed for nursing practice

Implement policies relevant to best practice

For Students and Beginning NursesBasic computer literacy and desktop applications such as e-mail

Access data and document using computerized patient records

Access and apply evidenced based practice

Support patient safety using information technology

For Experienced NursesBuild upon informatics knowledge gained

Become content expert in system designs

Appreciate relationships among data patterns

Exercise clinical judgment based on observed data trends

Safeguard access to patient data

Work toward improving information management and communication

As a student seeking degree and certification as an Advanced Practice Nurse

What are some of the ways we support patient safety initiatives while integrating informatics technology? In what ways do nurses or physicians resist change in patient care?

How can we work toward safeguarding patient data and health information in electronic medical records? What challenges does this present in your nursing practice?

References

Hebda, T. Calderone, T. (2010) What Nurse Educators Need to Know About the TIGER Intiative. Nurse Educator, (35) 2, 56-0

Saba, K. & McCormick, K. (2006) Essentials of Nursing Informatics, McGraw Hill

TIGER: ImpactStructured as programRelied on the participating organizations to distribute informationCollaborative approachOrganizations and nine collaborative teamsNursing Informatics CommunityPresentations and meetings at several national, regional, and international conferences

- TIGER was comprised of representatives from nursing specialty organizations that could work through the action plan within their own organizations. The 9 collaborative teams helped to increased the collaboration across the participating organizations. They developed their own wikis to share information. By the end of 2008 over 1400 individuals had joined the TIGER effort and help achieve the TIGER vision. 67TIGER: ImpactPractice Specialty Community: ANA & STTIPresented on TIGER at regional and national conferences, & conferences within organization Published articles in member newsletters or journalsNursing Leadership CommunityEnhanced visibility and access to nursing executivesExecutives contributed articles and presentations r/t technology and the TIGER effortTIGER: ImpactEducational Community of leaders and participants came from the academic communityAcademic partnerships proliferatingState-Wide CollaborationMinnesota developed a state approach: bringing together stakeholders in an annual Minnesota TIGER conferenceOther states have brought together the key organizations to discuss issues r/t technology adoptionVendor Community: GE Healthcare, Mckennson, Cerner, CPM Resource Center & othersDeveloped an interactive Gallery WalkPresented TIGER at their user group conferences or via webinarsThe vendors sponsors of the TIGER Summit developed an interactive Gallery Walk to demonstrate technology capabilities to the attendees and supplied demonstrations and presentations to the TIGER Virtual Demonstration Center. 69ReferencesKouzes, J.M., & Posner, B.Z. (2007). The leadership challenge (4th ed.). San Francisco: Jossey-Bass.McCormick, K. A, & Saba, V.K. (2006). Essentials of nursing informatics (4th ed.). New York, New York: McGraw-Hill The T.I.G.E.R. Initiative. (2011). Retrieved July 6, 2011, from Tiger Summit: http://www.tigersummit.com/Home_Page.phpThe TIGER Initiative. (2007-2011). Designing usable clinical systems: Recommendations from the TIGER usability and clinical application design collaborative team. Retrieved from http://www.tigersummit.com/uploads/Tiger_usability_Report.pdfThe TIGER Initiative. (2007-2011). Staff development and continuing education programs that support technology adoption. Retrieved from http://tigerstaffdev.pbworks.com/w/page/22250544/FrontPage

ReferencesThe TIGER Initiative. (2007-2011). Transforming education for an informatics agenda: TIGER education and faculty development collaborative. Retrieved from http://www.tigersummit.com/uploads/Educ.Tiger.Report_final4.pdfYou Tube. Computerized Health Records Reduce Medical Errors (2008). Retrieved from http://www.youtube.com/watch?v=fjnyDNZE3RY&feature=relmfu .