How to Make a Turkey Sandwich

Anyone can make a turkey sandwich and, truth be told, anyone could make The Best Turkey Sandwich Ever. Really, the only thing standing in anyone's way is that they probably don't yet know how. This is where this guide comes in. I will try to provide thorough instructions for making The Best Turkey Sandwich Ever.I discovered The Best Turkey Sandwich Ever by accident one night while living in New York City. For you see, I was unemployed at the time and didn't have too much money to throw around on food. As fate would have it, on that night, much like on a myriad of countless other nights that had preceded it (and subsequently on many nights thereafter), I happened to be very hungry. In a sad, strung-out, state of desperation, I languidly scavenged my apartment for something to hold me over until breakfast. I found some deli meat, cheese and half a loaf of unwanted challah bread that my sister gave to me last time I bothered to go uptown to visit her. Confronted with such limited suppli es, the solution seemed rather obvious; cobble these culinary elements together and make a sandwich. Although, looking back upon it, I can only attribute this particular chance arrangement of sandwich materials to the benevolent hand of some archaic pantheon of gods; perhaps viking. I like vikings.Anyhow, I crafted the sandwich to my preference and took a bite. By some happy accident of the cosmos, I, in my pathetic desperation not to scrounge together some pocket change and walk a block and a half for a slice of sicilian pizza, had chanced upon The Best Turkey Sandwich Ever.I've kept this to myself for too long. For the greater good of humanity, I am going to share my process with you today. If you follow these directions carefully, you too can live the rich prosperous life that can only come with The Best Turkey Sandwich Ever.

The Hunters: Moonsong Chapter Twenty-Nine

â€Å"You should be proud.† The Vitale Society pledges were lined up in the underground meeting room, just like they had been the first day when they removed their blindfolds. Under the arch in front of them, the Vitales in black masks watched quietly. Ethan paced among the pledges, eyes bright. â€Å"You should be proud,† he repeated. â€Å"The Vitale Society offered you an opportunity. The chance to become one of us, to join an organization that can give you great power, help you on your road to success.† Ethan paused and gazed at them. â€Å"Not al of you were worthy,† he said seriously. â€Å"We watched you, you know. Not just when you were here, or doing pledge events, but al the time. The candidates who couldn't cut it, who didn't merit joining our ranks, were eliminated.† Matt looked around. It was true, there were fewer of them now than there had been at their first meeting. That tal bearded senior who was some kind of biogenetics whiz was gone. A skinny blonde girl who Matt remembered doggedly grinding her way through the run wasn't there either. There were only ten pledges left. â€Å"Those of you who remain?† Ethan lifted his hands like he was giving them some kind of benediction. â€Å"At last it is time for you to be initiated, to ful y become members of the Vitale Society, to learn our secrets and walk our path.† Matt felt a little sWellof pride as Ethan smiled at them al . It felt like Ethan's eyes lingered longer on Matt than on the others, like his smile for Matt was just a bit warmer. Like Matt was, among al these exceptional pledges, special. Ethan started to walk through the crowd and talk again, this time about the preparations that needed to be made for their initiation. He asked a couple of pledges to bring roses and lilies to decorate the room – it sounded like he was expecting them to buy out a couple of flower stores – others to find candles. One person was assigned to buy a specific kind of wine. Frankly, it reminded Matt of Elena and the other girls planning a high school dance. â€Å"Okay,† Ethan said, indicating Chloe and a long-haired girl named Anna, â€Å"I'd like you two to go to the herb store and get yerba mata, guarana, hawthorn, ginseng, chamomile, and danshen. Do you want to write that down?† Matt perked up a little. Herbs were slightly more mystical and mysterious, befitting a secret society, although ginseng and chamomile just reminded him of the tea his mom drank when she had a cold. Ethan moved on from the girls, his eyes fixed on Matt, and Matt prepared to be sent in search of punch or ranch dip. But Ethan, locking eyes with Matt, inclined his head a little, indicating that Matt should join him a little apart from the rest of the group. Matt jogged over to meet Ethan, slightly intrigued. What couldn't Ethan say in front of the others? â€Å"I've got a special job for you, Matt,† Ethan said, rubbing his hands together in obvious pleasure at the prospect. â€Å"I want you to invite your friend Stefan Salvatore to join us.† â€Å"Sorry?† Matt said, confused. â€Å"To be a Vitale Society member,† Ethan explained. â€Å"We missed him when we selected candidates at the beginning of the year, but now that I've met him, I think – we think† – and he waved a hand at the quietly watching masked figures on the other side of the room – â€Å"that he would be an ideal fit for us.† Matt frowned. He didn't want to look like an idiot in front of Ethan, but something struck him as off about this. â€Å"But he hasn't done any of the pledge stuff. Isn't it too late for him to join this year?† Ethan smiled slightly, just a thin tilting of his lips. â€Å"I think we can make an exception for Stefan.† â€Å"But – † Matt began to protest, then instead smiled back at Ethan. â€Å"I'l cal him and see if he's interested,† he promised. Ethan patted him lightly on the back. â€Å"Thank you, Matt. You're a natural for Vitale, you know. I'm sure you can convince him.† As Ethan walked away, Matt watched him, wondering why the praise felt sour this time. It was because it didn't make sense, Matt decided, walking back to his dorm after the pledge meeting. What was so special about Stefan that Ethan had decided they had to have him pledge the Vitale Society now instead of just waiting til next year? Okay, yes: vampire – that was special about Stefan, but no one knew that. And he was handsome and sophisticated in that ever-so-slightly European way that had al the girls back in high school fal ing at his feet, but he wasn't that handsome, and there were plenty of foreign students on campus. Matt stopped stock-stil . Was he jealous? It wasn't fair, maybe, that Stefan could just waltz in and be immediately offered something that Matt had worked for, that Matt had thought was only his. But so what? It wasn't Stefan's fault if Ethan wanted to give him special treatment. Stefan was hurting after his breakup with Elena; maybe it would do him good to join the Vitale. And it would be fun to have one of his friends in the Society. Stefan deserved it, real y: he was brave and noble, a leader, even if there was no way Ethan and the others could have known that. Firmly pushing away any remaining niggle of not fair, Matt pul ed out his cel phone and cal ed Stefan. â€Å"Hey,† he said. â€Å"Listen, do you remember that guy Ethan?† â€Å"I guess I don't understand,† Zander said. His arm around Bonnie's shoulder was strong and solidly reassuring, and his T-shirt, where she had buried her face against him, smel ed of clean cotton and fabric softener. â€Å"What were you and your friends fighting about?† â€Å"The point is, they don't trust my judgment,† Bonnie said, wiping her eyes. â€Å"If it had been either of them, they wouldn't have been so quick to jump to conclusions.† â€Å"Conclusions about what?† Zander asked, but Bonnie didn't answer. After a moment, Zander reached out and ran one finger gently along her jawline and over her lips, his eyes intent on her face. â€Å"Of course you can stay here as long as you want to, Bonnie. I'm at your service,† he said in an oddly formal tone. Bonnie looked around Zander's room with interest. She'd never been here before; in fact, she'd had to cal him to find out what dorm he lived in, and how weird was that for a girlfriend to not know? But if she'd tried to picture what his room would be like, she would have assumed it would be messy and very guyish: old pizza boxes on the floor, dirty laundry, weird smel s. Maybe a poster with a half-naked girl on it. But, in fact, it was just the opposite. Everything was very bare and uncluttered: nothing on top of the school-issued dresser and desk, no pictures on the wal s or rug on the floor. The bed was neatly made. The single bed. That they were both sitting on. Her and her boyfriend. Bonnie felt a flush rise up over her face. She silently cursed her habit of blushing – she was sure that even her ears were bright red. She'd just asked her boyfriend if she could move into his room. And sure, he was gorgeous and lovely and kissing him was probably the most amazing experience of her life so far, but she'd just started kissing him last night. What if he thought she was suggesting something more? Zander was eyeing her thoughtful y as Bonnie blushed. â€Å"You know,† he said, â€Å"I can sleep on the floor. I'm not – um – expecting – † He broke off and now he was blushing, too. The sight of flustered Zander immediately made Bonnie feel better. She patted him on the arm. â€Å"I know,† she said. â€Å"I told Meredith and Elena you were a good guy.† Zander frowned. â€Å"What? Do they think I'm not?† When Bonnie didn't answer, he slowly released her, leaning back to take a close look at her face. â€Å"Bonnie? When you had this big fight with your friends, were you fighting about me?† Bonnie shrugged, wrapping her arms around herself. â€Å"Okay. Wow.† Zander ran a hand through his hair. â€Å"I'm sorry. I know Elena and I didn't real y hit it off, but I'm sure we'l get along better when we get to know each other. This wil al blow over then. It's not worth it to stop being friends with them.† â€Å"It's not – † Tears sprang into Bonnie's eyes. Zander was being so sweet, and he had no idea how Elena and Meredith had wronged him. â€Å"I can't tel you,† she said. â€Å"Bonnie?† Zander pul ed her closer. â€Å"Don't cry. It can't be that bad.† Bonnie began to cry harder, tears streaming down her cheeks, and he held on to her. â€Å"Just tel me,† he said. â€Å"It's not that they just don't like you, Zander,† she said between sobs. â€Å"They think you might be the kil er.† â€Å"What? Why?† Zander recoiled, almost leaping across the bed away from her, his face white and shocked. Bonnie explained what Meredith thought she saw, her impression of Zander's hair beneath the hoodie of the attacker she chased off. â€Å"Which is so unfair,† she finished, â€Å"because even if she did see what she thought she saw, it's not like you're the only person with real y light blond hair on campus. They're being ridiculous.† Zander sucked in a long breath, his eyes wide, and sat stil and silent for a few seconds. Then he reached out and put a gentle hand under Bonnie's chin, turning her face so they were gazing straight into each other's eyes. â€Å"I would never hurt you, Bonnie,† he said slowly. â€Å"You know me, you see me. Do you think I'm a kil er?† â€Å"No,† Bonnie said, her eyes fil ing with tears. â€Å"I don't. I never did.† Zander leaned forward and kissed her, his lips soft against hers, as if they were sealing some kind of pact. Bonnie closed her eyes and leaned into the kiss. She was fal ing in love with Zander, she knew. And, despite the fact that he had run off so suddenly last night, just before Samantha's murder, she was sure he could never be a kil er.

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Joseph Conrads Heart of Darkness Which social groups are marginalized, excluded or silenced within the text - Essay Example Africa, as portrayed in this book, is the direct opposite of the civilised continent of Europe where civilised human beings live. In writing his book, Conrad makes use of Marlow’s character to give voice to his own feelings about the inhabitants of the Congo. He compares the civilisation of Europe to the ‘uncivilised’ existences of the Congo’s inhabitants and shows Marlow moving into an oasis known as the ‘Outer Station’ to lend further meaning to this subject. The Outer Station is situated in the coast of Africa, and is administered by white Europeans who force African natives to perform most of the drudgery connected with running the outfit. Once Marlow reaches the oasis’ shores, he glimpses the darkness in the atmosphere of the place as well as in its inhabitants. The African natives whom Marlow encounters are depicted as sub-humans or animals. They are marginalised by the author in that they are not given a chance to explain their pr edicament. Nor are their feelings on being forcibly pushed to work away from their homes expounded upon. Rather than seeking to invoke pity for the wretched creatures that have been turned into slaves, the author strives to provoke apathy in the reader by stating that the natives ‘sat near the same tree in acute angles. ... In essence, the writer succeeds in changing Africans into irrelevant entities in such a way that the reader learns to adopt the position of the writer in ignoring the fact that they are human beings. In places in the novel where the derogatory names are not being used, there is a patronising tone used by the colonialists towards the natives. The author appears to try and convince the reader of the stupidity or idiocy of Africans in asserting through his European characters that the Africans had to have simple concepts explained to them in very childish ways, such as an analogy of the boiler tender, to understand matters such as the European work ethic. Naturally, the author neglects to mention that Africans worked in their own plots of land and fully understood what work was even before the White man reached their shores. The author also neglected to mention that the Africans may have been reluctant to work for the White man because they were being forced to do it for hardly any real wages. All through the book, the African natives are identified as savages. This is done without explaining to the reader what would make an entire ethnic group savages; apart from the refusal to work when they are told, as they are told, in their colonial masters’ lands- which had been stolen from the natives. In truth, it is the white people in the book who proved to have even more qualities of savagery than they accused the African natives off. To further encourage the perception of African natives as semi-human creatures, the colonial masters would often fire their rifles into the jungle for no apparent purpose. The reader is also informed that the natives had revolting customs

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Management and Leadership in Higher Education - Essay Example To be able to achieve this, it is necessary to have a way to measure the quality of service in order to ensure that this can be used in order to compare how quality of service is improving. Above all, the most important thing in implementing continuous quality improvement as a way to achieve overall quality of service is to educate and sensitise the employees about the need for quality management. While most medical staff has an inherent desire to take care of their patient. In this regard, the issue is not about the employee’s duty to serve the customers but actually the fact that the quality of service has to be continually increased. According to McLaughlin and Kaluzny (2006)4, the nature of quality is that if it is not improving, it is deteriorating and, therefore, it is necessary to make sure that the quality of service in any healthcare institution is well monitored and continually improved. Once all the players understand this, it becomes even easier for quality to be m anaged and made easier. As Chalice5 (2007) says, using the continuous quality improvement strategy is the best way to guarantee that the hospitals will be able to benefit from the improved quality in patient care delivery. Using Software to manage collaboration and quality management Just like many other businesses healthcare organisation are realizing the need for using software technology as a way to improve the quality of service and also increase customer service6. There are a number of dentistry software, which is geared to help dentists and their staff to be more productive, to better manage their finances and to increase the quality of care to their patients. In a modern world, software is not a choice for many businesses... This paper approves that this means, only one important thing, that the department should be able to have a good priority settings in order to help in making sure that it is able to utilize the resources in the most economical way. This will, however, also require the leader to collaborate closely with employees in order to understand their needs. Leaders should not just assume that they know what is best for their department and what the priority is; they should work with their juniors in order to understand what their juniors need and what they want in order to make sure that every need is well captured. Doing this will also motivate the employees and make them feel that they work environment issues are being addressed in the right way. Managers should combine a number of leadership strategies in order to make sure that they are able to achieve the highest quality. This essay makes a conclusion that many have turned to strategies such as continuous quality improvement in order to overcome the various challenges and hurdles, which are present in the industry especially due to the nature of the industry. This combines together with other strategies such as working together with the community and collaborating with patients and their families will be a good way to make sure that the dentist department is able to serve the needs of their patients and those of the community at large in a way that guarantees quality. The most important thing to note is that in managing quality in a hospital setting, the issue at stake is not how to maintain quality, but how to continually improve the quality.

Juvenile Runaways Essay Example | Topics and Well Written Essays - 1750 words

Juvenile Runaways - Essay Example Sometimes police deal with juvenile runaways in cases pertaining to child abduction, child abandonment, child abuse or neglect, underage drinking, child sexual exploitation, prostitution, shoplifting, drug dealing, murder and many such illegal activities. 'According to data compiled by the Substance Abuse and Mental Health Services Administration, 4.5 million children "regularly" use tobacco products, and 20 percent use alcohol.'(Daniel Macallair) The example of a thirteen year old girl, Helen who has already killed a man is frightening. She ran away from her aunt's house to stay with a gang. 'I was with my homies and we saw one of the MS scum who had killed my homegirl,' Helen recalls. 'I stuck this knife into his back and he fell. We kicked him and crushed his head with a brick. Then we pushed his body into a ditch. I was covered in blood. Revenge is sweet,' she said. Her friends smiled. (Sandra Jordan, 2002) Another example is of two juvenile runaways who were trying to illegally immigrate to the US along with a kidnapper. 'Yuma Sector Border Patrol agents rescued two juvenile runaways and arrested an alleged kidnapper Monday after they entered the United States without having been inspected at a port of entry.'(Yuma news) These sorts of incidences are not uncommon these days. The term 'runaway' is specially identified with juveniles when they are absent from home or substitute care, for example placements, such as foster care or group homes without permission. Runaways were once believed to be juveniles seeking adventure or rebelling against mainstream values and the authority of their parents. But more recently, runaways have been regarded as victims of dysfunctional families, schools, and social service institutions. Runaways are usually running away from a problem they do not know how to solve, rather than "running to" an environment they imagine being more relaxed and exciting. "There were approximately 1.7 million juvenile runaway episodes in 1999. In 1999, 150,700 juveniles were arrested for running away. Only about one-third of these juveniles were actually "missing," meaning that their parents or caretakers did not know where they were and were concerned about their absence. Only about one-fifth of all runaway episodes were reported to police. Most runaways are older teenagers, ages 15 to 17, with only about one-quarter ages 14 and younger. Juveniles of different races run away at about the same rates and boys and girls run away in equal proportions. Although juveniles from all socioeconomic statuses run away, the majority are from working-class and lower-income homes, possibly because of the additional family stress created by a lack of income and resources. Blended families also experience additional stress, which may explain why juveniles living in these settings are also more likely to run away. Runaway rates are similar for juveniles in urban, suburban, and rural settings." (Kelly Dedel, p1) The law enforcement officers encounter runaways, whether reported missing or not, through a number of activities, for example while patrolling areas where runaways congregate or while investigating missing persons reports, or during criminal investigations in which juveniles were either perpetrators or victims. Despite their interest in protecting children's safety, police often assign a low priority to

AN INQUIRY INTO THE EFFICIENCY OF CELEBRITY ENDORSEMENT AS A MARKETING Dissertation

AN INQUIRY INTO THE EFFICIENCY OF CELEBRITY ENDORSEMENT AS A MARKETING COMMUNICATIONS STRATEGY IN MORDERN SOCIETY - Dissertation Example Furthermore, factors such as the gender and age of the focus group were also taken into consideration as it greatly affects the findings of the study. On the basis of this study, it was observed that findings regarding the effect of celebrity endorsements as a marketing communications strategy could be divided into three key areas, namely – the perception of consumers with regard to a particular celebrity and his /her association with a brand / product or service; key factors which must be taken into consideration while choosing a celebrity for endorsing a particular brand or product; and finally develop a strategic model for Data Analysis: In order to measure the attitudes and perception of consumers towards a product celebrity endorsements various variables will be studied such as - their views on the advertisement; perception of the brand based on that advertisement; and the influence on their purchase decision. The differences in their perceptions with regard to the celebr ity endorsements will be measured on the basis of their attitudes towards single celebrity ads (i.e. a product endorsed by one celebrity) and multiple celebrity ads (i.e. same product endorsed by multiple celebrities). The data will be then analyzed on the basis of percentage of respondents in accordance with these variables such as gender, age, educational background etc. On the basis of the literature review, and the observations likely to be made on the basis of the personal interviews, it could be stated that the success or failure of any celebrity endorsement is a result of several attributes, which will be presented in the questionnaire. This includes - match between the product and the celebrity endorsing it; the choice of celebrity and the target audience; the popularity of the celebrity; the credibility or image of that celebrity in the industry; the values they endorse; their physical appearances; their appeal i.e. locally as well as globally; the likelihood of the risk of them (celebrities) getting involved in a conflict or a controversy; and the number of brands endorsed by the said celebrity. These attributes play a key role in influencing the consumer’s purchase decision and hence must be taken into consideration by the marketers / organizations prior to associating themselves with a celebrity. This information will be presented in the form of graphs, for better clarification the same is depicted in the figure below: Figure 1: Factors taken into consideration while selecting a celebrity for endorsing a given brand / product: The rating will be shown on the x axis while the attributes will be shown on the Y axis. The numbers 1 to 9 indicate the attributes mentioned above, which are taken into consideration by marketers while endorsing a product. The findings in this chart will be based on the observations made as well as on the findings observed in literature review section. In recent times, the global business has become highly complicated and hence the choice of a right celebrity for the product is extremely crucial for the organizations. Their decision strategy may

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Nursing administration Research Paper Example | Topics and Well Written Essays - 4500 words

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Food Inc. Essay Example for Free

Food Inc. Essay 1. Incorporation (Inc. ) means to form a legal association of individuals, created by law or under the authority of law, with a continuous existence independent of the existences of its members, and with powers and liabilities distinct from those of its members. Therefore, Food Inc. implies that food system of the modern day has become more of a combination of monopolized businesses, whom only care about their profits, rather than the farmers from the obsolete agricultural system. 2. Walking through a supermarket many food items are plastered with images of farms and pastures creating a facade to the true factory farming that’s occurring in today’s society. These images are creating a pastoral fantasy of the agrarian America of the 1930’s. 3. Using Monsanto’s soy beans for this timeline all seeds begin in a lab. Seeds are genetically altered (GMOs). They are then sold to farmers who have a contract with the Monsanto Company. Then they harvested in large amounts and shipped out to be processed, but some of the beans are used a feed for cattle and other livestock. At the factory they are packaged, and are shipped out to local supermarkets for national consumption. 4. The McDonald brothers revolutionized the fast food industry. They â€Å"brought the factory system to the kitchen. † Increasing profit, while decreasing costs, and with this came an increase in the unhealthiness of food by focusing on the three things humans’ desire most: sugar, fat, and salt. 5. Factory farming is the precise systematic farming of livestock in a factory setting an example being chickens. Today, chickens are often raised in huge metal buildings with no access to light or fresh air, confined together with thousands of birds in one building, and made to grow so quickly that often their bones cannot keep up and they can lose their ability to walk. 6. In Food Inc. the phrase â€Å"growing chickens† creates a negative connotation. It would seem that the process that’s usually referred to as raising chickens has become so systematic that there is no longer a personal connection between the farmer, and his chickens. They become property, which are only used for financial profit. 7. With all the diversity found in the supermarket, one would think there are hundreds of different companies that provide the different foods. Truthfully, about eighty percent of all products in the supermarket are produced, and distributed by four major companies. This creates an illusion of diversity which, unfortunately, most consumers are unaware of. 8. Monsanto Company, Tyson Foods, Smithfield Foods, and Perdue Farms were all asked to be interviewed for Food Inc. and all declined the opportunity. Declining the opportunity to explain their motives give many a reason for doubt. Showing they have secrets or motives that would not be explainable without legal confrontations. 9. Environmental contamination is a major result of the newly developed farming system. Manure mixed with run-off water can contaminate surrounding vegetable farms causing Salmonella and E. coli contamination in plants such as spinach and lettuce. In South America, a major beef producer, deforestation has become a huge problem which is created by companies trying to make space for factory farms. This deforestation causes the displacement of animals and ecosystems. Smoke produced by factories can lead to smog, and air pollution in concentrated amounts. 10. Not only does the modern food system have a negative effect on the environment it harms humans as well. With animal feed being treated with antibiotics any bacteria present has a chance to become immune. This bacteria can then be acquired by consumption of raw meat, and with it being immune to some antibiotics, it will cause an increase the difficulty of treatment, and may result in death. With the food system being based so highly on the consumption of fat, salt, and sugar, a major concern for humans is heart disease, obesity, and diabetes. Type two diabetes, acquired diabetes, used to only be contracted in adulthood, but now its arising as early as age seven. 11. There is a direct relationship between food and health. The major goal of the new industrial agricultural system is to grow everything faster, fatter, and bigger. We’ve grown right along with the companies who own these farms. Michael Pollan evaluates the problem by comparing it to the past: â€Å"Over the course of human history, we were struggling to make sure we had enough food and enough calories for a sizable percentage of the human race. Now the problem is too many calories. † 12. GMO stands for Genetically Modified Organism. Companies such as Tyson may use GMOs to produce more efficient and more profitable livestock. GMOs should be clearly labeled when present in food. Although not all GMOs are harmful, a customer should be privileged to know what their food contains. Labeling the presence of a GMO may also prevent a lawsuit against the major corporations if anything was to happen. 13. The documentary Food Inc. , being very factual, used many different sources to acquire all the information needed. Sources such as first-hand accounts on what occur, hidden cameras, accredited websites, other documentaries, classical farmers, award winning authors familiar with the topic, and many well educated informants. 14. Food Inc. is sectioned into chapters. Each chapter pulls the veil away from the consumers eyes on somewhat different, but connected topics: fast food, food contents, food safety, right to healthy food, meat industry, chicken industry, major companies, lives lost, and what consumers can do to change the system. 15. Being a documentary the main purpose of Food Inc.is to educate people on the problems of food production, and to persuade consumers to make healthier food choices. It may also be trying to inspire change in the everyday persons eating habits. 16. Food Inc. is directed towards middle class citizens who shop at the supermarket without really knowing what they are eating. 17. The strategies used throughout Food Inc. covered a wide range of tactics. Rhetorical questions, hidden camera footage, creditable statistics, personal anecdotes, music, religion, and the most heart wrenching strategy used was on location filming of the factory farms. 18. Food Inc. had a very informative, and cautious tone. There were many facts, and just as many warnings. 19. An interesting revelation made in the duration of Food Inc. is how naive people can ben to their surroundings. Maria Gonzalez believed that â€Å"everything was healthy† which justified her family visiting Burger King for almost every meal. It would be understandable to know that she couldn’t afford anything healthier, but to not know that the food she was consuming was unhealthy, it just shows how manipulative large corporations can be.

Patient Healthcare Using SMS Technology Application

Patient Healthcare Using SMS Technology Application Chapter 1 Introduction to Patient Care Using SMS Application Patients travel longer distances for the opinion of consultant which is not possible either due to patient situation or due to distances. Enhancement of health care in different locations and other remote areas can be achieved using mobile phone applications [1]. 1.1 Problem Statement Development of mobile communication networks playing an important part in the enhancement of a mobile medicine. Patient Care Using SMS Application represents a feasible solution of patient care such as text messaging and booking appointments using mobile phones, which are best aspects of mobile medicine. The main idea is improve patient access to healthcare; encouraging patients to use mobile health application and supporting people with long term conditions [5]. 1.2 Objectives Incredible growth of mobile communication and recognition of new generation Wireless protocols has initiated the advance SMS based medical applications. Following that facts Patient care using SMS based application for mobile application for patient is good solution [5 6]. * To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis-à  -vis Exchange Server etc * Main aim of this application is to achieve â€Å"greater quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patients care â€Å"[5 6]. 1.3 Scope The goal of Patient Care Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between General Practitioners and consultants care have to be provided. The second is sufficient exchange of patients information have to be provided. Additionally, privacy of communication and stored information has to be guaranteed. Both ethical and technical aspects are equally important [7]. 1.4 Existing Systems The existing system of treatment consists of two different systems. They are as follows: * Traditional or manual system * Online application 1.4.1 Traditional or Manual system The present system of treatment consists of manually consulting a doctor by taking prior appointment or else registering at that instant of time, waiting to get register themselves and then consulting the doctor which is a time consuming process. 1.4.1.1 Drawbacks * Time consuming * Patient need to stand in long queues to make appointments * Patients not follow prescription directions once they leave the surgery or hospital. Research has showed that more than 50 percent of patients not follow the management advised by their doctors may be due to lack of time and interest. 1.4.2 Online System Online application is also available where the user is provided a login and password through which he can access the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. The online systems are discussed below are: * EMIS * VISION System 1.4.2.1 EMIS System EMIS ® stands for Egton Medical Information Systems Limited. EMIS provides a service that enables you access to your healthcare online [9]. After registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their practice and update personal information if practice has set up these features online [10]. This example has been explained in detailed in chapter 2. 1.5.2 Example 2: Vision System Vision [14] is the most famous system in use UK, within the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP practices which are using Vision system across the UK each day. â€Å"Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, proven and reliable. The strong product-base has allowed other features such as advanced-scanning, PDAs support and incorporated voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third party systems† [14]. In this project we are more concentrating on EMIS rather than Vision system. Key Features Messaging Incorporated External system Appointments Consultation Manager Problem Orientated Views Community Caseload Search and Reporting 7. Clinical Audit Vision and the National Applications [14] Few of the above features are explain below [14]: 1. Messaging This system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patients data from number of external sources including the NHS Spine or local CPRs to be easily accessed and used within Vision, supporting the requirements of the NHS IT-strategy. Vision also manages a range of clinical messages from third party systems to support the patient care as follows: * Choose and Book Referrals (electronic booking) * E- Discharge Summaries * Radiology reports and Encrypted pathology reports * OOH Summaries With a powerful XML event and messaging engine, Vision is designed to ensure the performance of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message types are managed. 2. Incorporated External System In the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be seamlessly from the Vision desktop. The patient is automatically recognised in the target system, when the required data is passed to the third-party application. For integration into the patient record when required, important data may also be written back to Vision 3. Patients Appointments This Vision system allows user full access to the appointment screen. â€Å"Using session templates developed by the practice† the appointment books are defined in advance. The view of appointment book can be defined by user: all significant doctors and other Healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctors room or leave the surgery, their status is recorded. Our evaluations are based on EMIS system, its features and limitation which have been explained in later chapters. 1.5 Thesis Organisation In chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages. The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained. In the chapter 4 we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter. The chapter 5 focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions. The chapter 6 is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained. Advance system and its features are discussed in this chapter 7. Waterfall Models activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations. The chapter 8 explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter. Chapter 2 Egton Medical Information Systems EMIS ® and EMIS intellectual technology are trading names of â€Å"Egton Medical Information Systems Limited†. EMIS had begun 18 years ago in a rural area dispensing practice in Egton near Whitby in North Yorkshire [11]. EMIS ® head-offices are based in Leeds, including Development and Support departments. Training for general practices is localised and headed by Provincial Operations Directors [11]. 2.1 Practice Care System Enterprise Due to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMISs Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at many levels and ease safe access 24/7 by the wider health care-community [11]. PCS Enterprise for PCTs has been designed with capability of future technological and keeping development in mind, such as sharing data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 Version 3 the patient data is transferred between dedicated health care systems directly [11]. 2.2 An overview of PCS Enterprise This edition has been designed to develop EMIS provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with shared EPRs and seamless data exchange. This system is based on three-tier architecture, while utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to scale to thousands of instantaneous user connections [11]. EMIS Primary Care System Enterprise edition is designed to meet GP needs as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system: 2.3 EMIS Primary Care System Practice edition Health information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has been designed to meet GP needs, combining functionality with simplicity of use [11]. Key features of EMIS PCS * Complete patient record management * Quick and good prescribing * Formulary managements * Incorporated consultation mode * Incorporated appointments * Mentor Library * Integrated with MS Word support * User defined templates * Drug Explorer 2.4 EMIS LV Version 5.2 In the PCS market, EMIS Live Version [11] is the main text based medical system. Approximately 5000 GPs currently using EMIS LV system (which is shown below) in the UK. The system offers GPs consultation mode option, medical record, search and reports option, prescription and booking appointments. 2.5 Population Manager This system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Population Manager [11] has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy and standardised information entry. Population manager is an incorporated part of EMIS LV system. 2.6 Version 5.2 features This is the most recent release of EMIS LV. This LV offers users the following key features [11]: 2.6.1 MS Word incorporation Patient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to create patient related letters in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS. 2.6.2 Referral template for Cancer patients If cancer is suspected GPs requires produce and fax or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks; hence these referrals are named as â€Å"two week rule referrals†. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2. 2.6.3 Electronic Insurance reports One of the most common and time taking medical information requests for GPs is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system. 2.6.4 Scanning and attachments This module enables to scan corresponding or images and attaches them directly to a patients record in consultation mode. These documents are instantly available during consultation. 2.7 EMIS Clinical Communication Modules The following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care [11]. 1 Online Referrals with Booked Admissions 2 Electronic Referrals 3 Incoming Reports including Electronic Discharges 4 Online Results Ordering With an approved list of suppliers this Clinical Communication Modules work. Using the common set of messaging standards currently being developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the further testing of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below [11]: 2.7.1 Online Referrals and booked admissions Traditionally referring patients from doctors at general practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and occasional loss. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding patient demographics and clinical information and in some cases booking an appointment. Requirements: Each EMIS practice must have: * EMIS LV 5.2 * NHS Net connectivity * Router access for EMIS * Version 2 clinical terms (5 byte Read Codes) The Secondary Care Provider will need: * An EMIS approved website 2.7.2 Electronic Referrals This module enables us to create a referral letter within EMIS LV and transmit it electronically to a secondary care consultant [11]. The way electronic referrals work You can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission: answer ‘Yes and the referral letter is placed in the Communications outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter immediately or wait until the next scheduled transmission. Upon receiving the referral letter, the secondary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen. Requirements Each EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS Support * SMTP or DTS mailbox * MS-Word Integration The secondary care provider will need: * SMTP or DTS mailbox * Suitable software capable of sending and receiving XML messages and acknowledgements * SMTP/DTS and EDI code addresses of the practices involved the trust should obtain these from the health authority or national tracking database 2.7.3 Incoming Reports including electronic discharges Use this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hours services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider [11]. How does the Incoming Reports module work? Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the incoming report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider. When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for viewing, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL function in Consultation Mode. Requirements To use Incoming Reports, an EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS * A DTS address To use Incoming Reports, a secondary care provider must have: * A DTS address. * The DTS addresses and EDIâ‚ ¬Ã‚   codes for all required practices this information is available from the health authority or from the national tracking database. * Software to create and send XML messages and receive acknowledgements 2.7.4 Online Test Ordering Requesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service. The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a secure NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results [11]. Online Test Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current patients demographic and GP details are transferred to the laboratory system when you request the required tests. After you have ordered the tests, the test information is transferred to your EMIS system and filed in the patients record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can print a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as soon as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before [11]. Requirements Each EMIS practice must have: * EMIS LV 5.2 or EMIS PCS * NHSnet connectivity * Router access for EMIS * Version 2 clinical terms (5-byte Read codes) Support issues The overall Online Test Ordering process relies on different services and software all working in conjunction with each other: the EMIS software, the laboratory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to resolve issues with the two areas; therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities. 2.8 Storage area network (SAN) Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run [11], on which EMIS stores data [Detail explanation in later chapter]. Chapter Summary The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. Chapter 3 Drawbacks of Online systems Although online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example. 3.1 Patient Record  ¨ Time required to put all relevant information onto system  ¨ Possible security issues  ¨ Doctor can focus too much on patient information onscreen which could intimidate the patient  ¨ Scanning and entry of data is more time consuming. Important information lost can when overlooking the record.  ¨ Medical record print-outs are frequently of poor quality and difficult to understand necessary information  ¨ In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable.  ¨ Often using computer and paper records together will make patient data look very difficult.  ¨ Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data[16] 3.2 Appointments  ¨ Patients have to be checked into appointment system by receptionist  ¨ Problematic if patients cant read, or unable to view sign (e.g. blind people) 3.3 Prescriptions  ¨ Relies on drug information being up to date  ¨ Aptitude of doctor in using computer effectively  ¨ Some times doctors issue hand written prescription; they may not be available on computer. The acute and repeat prescribing registers can make it more confused. Printouts of Pharmacy still required [16]. 3.4 Email  ¨ Relies on doctor checking their mail daily  ¨ Troublesome patients abusing the system  ¨ Hospital letters not emailed (would be preferred) 3.5 Security issues  ¨ Doctors have to go to bother of signing on and off EMIS  ¨ Forgetting passwords  ¨ Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be absolutely in-operable  ¨ Leaving computer on  ¨ Locum doctors  ¨ Experts are need to show computer frauds and misuse [16] 3.6 Internet connection  ¨ Continuous internet connection required  ¨ The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. 3.7 Backup  ¨ System backed up every night onto tape  ¨ Two copies:- Fireproof safe Remote location 3.8 Read codes Maintenance of enormous clinical expressions or codes is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the principle because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility [17]. The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2 The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems arise from different uses and from the different views of Healthcare professional. [17]. Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its diagonal section closely mirrors ICD9, even though this doesnt always reflect a clinicians view, and correct hierarchy placement of a concept according to ICD9 rules may appear anomalous to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map correctly to ICD9 [17]. Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated [17]. Read/SNOMED Codes Read/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. â€Å"Unlike the principal of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical activity to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners† [24]. Read codes has been explained more clearly in chapter 4. 3.9 GP2GP Record transfer The experience of the GP2GP record transfer and the clinical involvement are explained this section. 3.9.1 The underlying principle for electronic GP-GP record transfer The vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable proportion of these practices use their computer systems for recording patient record information in whole or in part [33]. This results from a variety of causes whose main headings are: * Patient records that are an unpredictable mix between paper and electronic. * The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant (but un-quantified) resource implications for practices. There is also widespread anecdotal evidence of resulting adverse effects on patient care. The rationale for the electronic transfer of records is therefore: * As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities. * To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus reduce resource implications * To reduce the risks to patients arising from the transfer of confusing records. 3.9.2 The nature of electronic GP-GP record transfer Electronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of [33]: * Record encounters; what constitutes a single transaction with the record like a doctors consultation, a letter received from hospital or outside, an examination result etc * Names for these encounters; e.g. home visit, * Headings within these encounters * Complex clinical constructs * Read code mappings; such medication codes sets * Codes and associated text * Major modifiers of clinical meaning 3.9.3 The Problems of electronic GP-GP record transfer There are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below [33]. Medication information There are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are: * The multiple coding schemes used and * Failure of previous code mapping exercises (see chapter 5 on data transfer). 3.10 The Problem Oriented Medical Record (PMOR) Electronic health records (EHR) are more used in UK General Practice despite continuing improbability about its legality and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple sequential list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) [31]. 3.10.1 Limitations of the PO Medical Record The limitations of POMR are explain below [31] * It is very easy to pick up but very difficult to maintain. * In the strict way of the word not all headings are problems. For example, the heading of Immunisation is used usually to indicate where all the entries related to a immunization history may be found. * Many different problems may be discussed within a single consultation * To check scanned documents is very difficult especially when patient record is too big * Problems are frequently linked in a fundamental way. * The PO Medical Record only gives a basic measure of the state of a problem. * Different clinicians, view the clinical record, required different information from the medical record as well as with different views. * Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again. Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress [31]. 3.11 Other Disadvantages * Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms. * Many screen need to be changes to find results and mouse activity * Information can be hidden as only the informati Patient Healthcare Using SMS Technology Application Patient Healthcare Using SMS Technology Application Chapter 1 Introduction to Patient Care Using SMS Application Patients travel longer distances for the opinion of consultant which is not possible either due to patient situation or due to distances. Enhancement of health care in different locations and other remote areas can be achieved using mobile phone applications [1]. 1.1 Problem Statement Development of mobile communication networks playing an important part in the enhancement of a mobile medicine. Patient Care Using SMS Application represents a feasible solution of patient care such as text messaging and booking appointments using mobile phones, which are best aspects of mobile medicine. The main idea is improve patient access to healthcare; encouraging patients to use mobile health application and supporting people with long term conditions [5]. 1.2 Objectives Incredible growth of mobile communication and recognition of new generation Wireless protocols has initiated the advance SMS based medical applications. Following that facts Patient care using SMS based application for mobile application for patient is good solution [5 6]. * To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis-à  -vis Exchange Server etc * Main aim of this application is to achieve â€Å"greater quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patients care â€Å"[5 6]. 1.3 Scope The goal of Patient Care Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between General Practitioners and consultants care have to be provided. The second is sufficient exchange of patients information have to be provided. Additionally, privacy of communication and stored information has to be guaranteed. Both ethical and technical aspects are equally important [7]. 1.4 Existing Systems The existing system of treatment consists of two different systems. They are as follows: * Traditional or manual system * Online application 1.4.1 Traditional or Manual system The present system of treatment consists of manually consulting a doctor by taking prior appointment or else registering at that instant of time, waiting to get register themselves and then consulting the doctor which is a time consuming process. 1.4.1.1 Drawbacks * Time consuming * Patient need to stand in long queues to make appointments * Patients not follow prescription directions once they leave the surgery or hospital. Research has showed that more than 50 percent of patients not follow the management advised by their doctors may be due to lack of time and interest. 1.4.2 Online System Online application is also available where the user is provided a login and password through which he can access the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. The online systems are discussed below are: * EMIS * VISION System 1.4.2.1 EMIS System EMIS ® stands for Egton Medical Information Systems Limited. EMIS provides a service that enables you access to your healthcare online [9]. After registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their practice and update personal information if practice has set up these features online [10]. This example has been explained in detailed in chapter 2. 1.5.2 Example 2: Vision System Vision [14] is the most famous system in use UK, within the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP practices which are using Vision system across the UK each day. â€Å"Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, proven and reliable. The strong product-base has allowed other features such as advanced-scanning, PDAs support and incorporated voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third party systems† [14]. In this project we are more concentrating on EMIS rather than Vision system. Key Features Messaging Incorporated External system Appointments Consultation Manager Problem Orientated Views Community Caseload Search and Reporting 7. Clinical Audit Vision and the National Applications [14] Few of the above features are explain below [14]: 1. Messaging This system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patients data from number of external sources including the NHS Spine or local CPRs to be easily accessed and used within Vision, supporting the requirements of the NHS IT-strategy. Vision also manages a range of clinical messages from third party systems to support the patient care as follows: * Choose and Book Referrals (electronic booking) * E- Discharge Summaries * Radiology reports and Encrypted pathology reports * OOH Summaries With a powerful XML event and messaging engine, Vision is designed to ensure the performance of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message types are managed. 2. Incorporated External System In the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be seamlessly from the Vision desktop. The patient is automatically recognised in the target system, when the required data is passed to the third-party application. For integration into the patient record when required, important data may also be written back to Vision 3. Patients Appointments This Vision system allows user full access to the appointment screen. â€Å"Using session templates developed by the practice† the appointment books are defined in advance. The view of appointment book can be defined by user: all significant doctors and other Healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctors room or leave the surgery, their status is recorded. Our evaluations are based on EMIS system, its features and limitation which have been explained in later chapters. 1.5 Thesis Organisation In chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages. The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained. In the chapter 4 we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter. The chapter 5 focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions. The chapter 6 is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained. Advance system and its features are discussed in this chapter 7. Waterfall Models activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations. The chapter 8 explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter. Chapter 2 Egton Medical Information Systems EMIS ® and EMIS intellectual technology are trading names of â€Å"Egton Medical Information Systems Limited†. EMIS had begun 18 years ago in a rural area dispensing practice in Egton near Whitby in North Yorkshire [11]. EMIS ® head-offices are based in Leeds, including Development and Support departments. Training for general practices is localised and headed by Provincial Operations Directors [11]. 2.1 Practice Care System Enterprise Due to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMISs Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at many levels and ease safe access 24/7 by the wider health care-community [11]. PCS Enterprise for PCTs has been designed with capability of future technological and keeping development in mind, such as sharing data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 Version 3 the patient data is transferred between dedicated health care systems directly [11]. 2.2 An overview of PCS Enterprise This edition has been designed to develop EMIS provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with shared EPRs and seamless data exchange. This system is based on three-tier architecture, while utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to scale to thousands of instantaneous user connections [11]. EMIS Primary Care System Enterprise edition is designed to meet GP needs as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system: 2.3 EMIS Primary Care System Practice edition Health information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has been designed to meet GP needs, combining functionality with simplicity of use [11]. Key features of EMIS PCS * Complete patient record management * Quick and good prescribing * Formulary managements * Incorporated consultation mode * Incorporated appointments * Mentor Library * Integrated with MS Word support * User defined templates * Drug Explorer 2.4 EMIS LV Version 5.2 In the PCS market, EMIS Live Version [11] is the main text based medical system. Approximately 5000 GPs currently using EMIS LV system (which is shown below) in the UK. The system offers GPs consultation mode option, medical record, search and reports option, prescription and booking appointments. 2.5 Population Manager This system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Population Manager [11] has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy and standardised information entry. Population manager is an incorporated part of EMIS LV system. 2.6 Version 5.2 features This is the most recent release of EMIS LV. This LV offers users the following key features [11]: 2.6.1 MS Word incorporation Patient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to create patient related letters in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS. 2.6.2 Referral template for Cancer patients If cancer is suspected GPs requires produce and fax or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks; hence these referrals are named as â€Å"two week rule referrals†. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2. 2.6.3 Electronic Insurance reports One of the most common and time taking medical information requests for GPs is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system. 2.6.4 Scanning and attachments This module enables to scan corresponding or images and attaches them directly to a patients record in consultation mode. These documents are instantly available during consultation. 2.7 EMIS Clinical Communication Modules The following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care [11]. 1 Online Referrals with Booked Admissions 2 Electronic Referrals 3 Incoming Reports including Electronic Discharges 4 Online Results Ordering With an approved list of suppliers this Clinical Communication Modules work. Using the common set of messaging standards currently being developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the further testing of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below [11]: 2.7.1 Online Referrals and booked admissions Traditionally referring patients from doctors at general practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and occasional loss. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding patient demographics and clinical information and in some cases booking an appointment. Requirements: Each EMIS practice must have: * EMIS LV 5.2 * NHS Net connectivity * Router access for EMIS * Version 2 clinical terms (5 byte Read Codes) The Secondary Care Provider will need: * An EMIS approved website 2.7.2 Electronic Referrals This module enables us to create a referral letter within EMIS LV and transmit it electronically to a secondary care consultant [11]. The way electronic referrals work You can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission: answer ‘Yes and the referral letter is placed in the Communications outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter immediately or wait until the next scheduled transmission. Upon receiving the referral letter, the secondary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen. Requirements Each EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS Support * SMTP or DTS mailbox * MS-Word Integration The secondary care provider will need: * SMTP or DTS mailbox * Suitable software capable of sending and receiving XML messages and acknowledgements * SMTP/DTS and EDI code addresses of the practices involved the trust should obtain these from the health authority or national tracking database 2.7.3 Incoming Reports including electronic discharges Use this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hours services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider [11]. How does the Incoming Reports module work? Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the incoming report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider. When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for viewing, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL function in Consultation Mode. Requirements To use Incoming Reports, an EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS * A DTS address To use Incoming Reports, a secondary care provider must have: * A DTS address. * The DTS addresses and EDIâ‚ ¬Ã‚   codes for all required practices this information is available from the health authority or from the national tracking database. * Software to create and send XML messages and receive acknowledgements 2.7.4 Online Test Ordering Requesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service. The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a secure NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results [11]. Online Test Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current patients demographic and GP details are transferred to the laboratory system when you request the required tests. After you have ordered the tests, the test information is transferred to your EMIS system and filed in the patients record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can print a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as soon as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before [11]. Requirements Each EMIS practice must have: * EMIS LV 5.2 or EMIS PCS * NHSnet connectivity * Router access for EMIS * Version 2 clinical terms (5-byte Read codes) Support issues The overall Online Test Ordering process relies on different services and software all working in conjunction with each other: the EMIS software, the laboratory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to resolve issues with the two areas; therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities. 2.8 Storage area network (SAN) Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run [11], on which EMIS stores data [Detail explanation in later chapter]. Chapter Summary The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. Chapter 3 Drawbacks of Online systems Although online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example. 3.1 Patient Record  ¨ Time required to put all relevant information onto system  ¨ Possible security issues  ¨ Doctor can focus too much on patient information onscreen which could intimidate the patient  ¨ Scanning and entry of data is more time consuming. Important information lost can when overlooking the record.  ¨ Medical record print-outs are frequently of poor quality and difficult to understand necessary information  ¨ In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable.  ¨ Often using computer and paper records together will make patient data look very difficult.  ¨ Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data[16] 3.2 Appointments  ¨ Patients have to be checked into appointment system by receptionist  ¨ Problematic if patients cant read, or unable to view sign (e.g. blind people) 3.3 Prescriptions  ¨ Relies on drug information being up to date  ¨ Aptitude of doctor in using computer effectively  ¨ Some times doctors issue hand written prescription; they may not be available on computer. The acute and repeat prescribing registers can make it more confused. Printouts of Pharmacy still required [16]. 3.4 Email  ¨ Relies on doctor checking their mail daily  ¨ Troublesome patients abusing the system  ¨ Hospital letters not emailed (would be preferred) 3.5 Security issues  ¨ Doctors have to go to bother of signing on and off EMIS  ¨ Forgetting passwords  ¨ Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be absolutely in-operable  ¨ Leaving computer on  ¨ Locum doctors  ¨ Experts are need to show computer frauds and misuse [16] 3.6 Internet connection  ¨ Continuous internet connection required  ¨ The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. 3.7 Backup  ¨ System backed up every night onto tape  ¨ Two copies:- Fireproof safe Remote location 3.8 Read codes Maintenance of enormous clinical expressions or codes is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the principle because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility [17]. The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2 The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems arise from different uses and from the different views of Healthcare professional. [17]. Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its diagonal section closely mirrors ICD9, even though this doesnt always reflect a clinicians view, and correct hierarchy placement of a concept according to ICD9 rules may appear anomalous to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map correctly to ICD9 [17]. Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated [17]. Read/SNOMED Codes Read/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. â€Å"Unlike the principal of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical activity to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners† [24]. Read codes has been explained more clearly in chapter 4. 3.9 GP2GP Record transfer The experience of the GP2GP record transfer and the clinical involvement are explained this section. 3.9.1 The underlying principle for electronic GP-GP record transfer The vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable proportion of these practices use their computer systems for recording patient record information in whole or in part [33]. This results from a variety of causes whose main headings are: * Patient records that are an unpredictable mix between paper and electronic. * The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant (but un-quantified) resource implications for practices. There is also widespread anecdotal evidence of resulting adverse effects on patient care. The rationale for the electronic transfer of records is therefore: * As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities. * To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus reduce resource implications * To reduce the risks to patients arising from the transfer of confusing records. 3.9.2 The nature of electronic GP-GP record transfer Electronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of [33]: * Record encounters; what constitutes a single transaction with the record like a doctors consultation, a letter received from hospital or outside, an examination result etc * Names for these encounters; e.g. home visit, * Headings within these encounters * Complex clinical constructs * Read code mappings; such medication codes sets * Codes and associated text * Major modifiers of clinical meaning 3.9.3 The Problems of electronic GP-GP record transfer There are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below [33]. Medication information There are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are: * The multiple coding schemes used and * Failure of previous code mapping exercises (see chapter 5 on data transfer). 3.10 The Problem Oriented Medical Record (PMOR) Electronic health records (EHR) are more used in UK General Practice despite continuing improbability about its legality and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple sequential list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) [31]. 3.10.1 Limitations of the PO Medical Record The limitations of POMR are explain below [31] * It is very easy to pick up but very difficult to maintain. * In the strict way of the word not all headings are problems. For example, the heading of Immunisation is used usually to indicate where all the entries related to a immunization history may be found. * Many different problems may be discussed within a single consultation * To check scanned documents is very difficult especially when patient record is too big * Problems are frequently linked in a fundamental way. * The PO Medical Record only gives a basic measure of the state of a problem. * Different clinicians, view the clinical record, required different information from the medical record as well as with different views. * Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again. Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress [31]. 3.11 Other Disadvantages * Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms. * Many screen need to be changes to find results and mouse activity * Information can be hidden as only the informati

Origins for the Treatment for Tuberculosis Essay -- Biology Medical Bi

Origins for the Treatment for Tuberculosis Abstract Tuberculosis, also known as Mycobacterium tuberculosis, is a deadly bacterium that invades the respiratory system. This bacterium spreads rapidly from person to person by a simple cough or sneeze. Treatment for tuberculosis has changed over the years. In the beginning the most common form of treatment was the sanatorium, where patients infected with Tuberculosis were kept in an isolated environment. Now a days the treatment is straightforward and the patient is put on two standard antibiotics, isoniazid and rifampicin. These drugs are very effective at fighting tuberculosis, but recently a new strand has been developed, multi-drug resistant tuberculosis. This paper outlines the various treatments for tuberculosis from the beginning of the 16th century to the present and the changes that have occurred in the bacteria. Tuberculosis, often called TB, has been recognized as a dangerous illness for quite sometime. Although its incidence has greatly declined during most of the last century, there has been a significant increase over the last twenty years. The recent incidence rate has been relatively high among the homeless in inner city areas and among those infected with the AIDS virus. TB also remains a severe health issue for infants and the elderly. While the disease continues to be a source of concern among the more populated and less hygienic areas in Asia, it is also prevalent in certain areas of this country where it has been linked with the arrival of refugees from Asia and Central America. Tuberculosis is primarily a bacterial infection of the respiratory system. If bacteria, viruses, or fungi enter the lungs and become established there, they could cause several dise... ...he benefits that medical technology has brought to society over centuries as well as an awareness that the fight against bacteria is by no means over. The recognition that there are several forms of drug-resistant bacteria today should propel future generations to rededicate efforts to eradicate them. Further research and observations should be made in order to help suppress deadly strands of tuberculosis. TB Treatment 6 References: Carlomagno, Cathy. (April 2005). 100 years of Progress in Tuberculosis Treatment. www.medicalnewstoday.com/medicalnews.htm Davies, Peter. March 1999. Multi Drug Resistant Tuberculosis "http://www.priory.com/cmol/TBMultid.htm" Larson, David. (1996). Mayo Clinic Family Health Book. New York: William Morrow & Company. Padilla, M. (2005). Tuberculosis. Encarta. 7-27-05: http://encarta.msn.com/encyclopedia_761576449/tuberculosis/html.