Monday, February 15, 2010

NU501 - Final Feedback

NU 501, Nursing Informatics. Assignment 4, Grade A-; Course Grade A.

You did an outstanding job writing about blogging and demonstrating an understanding of the topic. You did a great job describing the history and how blogging is used. The assignment was interesting and well organized. You were able to thoroughly research the topic and present it expressing ideas clearly. You might want to review APA format as there were some abbreviations, citations, and formatting that did not meet APA standards. This paper was to be of a more scholarly type written in the third person narrative. Here is a website that can explain third person narrative.

I have enjoyed having you as a student, good luck in your studies!

I'm going to take a quick break, and figure out what's next. It looks like either a course on nursings' theoretical foundations, or one on research.

Tuesday, February 9, 2010

NU501 Assignment 4 - The Research Paper

OK, maybe it wasn't that bad

A Moby Dick analogy would also work. Call me Ishmael - that's all the Melville I know.

It was fun, but it was difficult. It's also done. Hooray, etc.

I'm gonna take a short break before picking up another course. I believe that I got off easy in NU501 - this was the only such paper for the course, and I got a very generous extension in order to complete it. I expect that I'll need to submit several for each of my subsequent courses. Gotta go find that cat, you know.

In the meantime, I'm truly open to any feedback and observations from those with much more experience with this sort of thing. I've actually tightened up the version you see here, compared to the one I submitted - not so much in the overall language or style as in some judicious copy editing. I'm sure there are plenty more mistakes where those came from.

- - - - -

Bloggers blogging blogs:
Who we are, what we’re doing, and what happens next.

by Jerry

Submitted to meet the requirements of Assignment 4,
NU510 Nursing Informatics
In the online Master of Science in Nursing program
at St. Joseph’s College of Maine
February 8, 2010

To contact the author, leave a comment

Abstract: Blogs, blogging, bloggers, and the blogosphere are information technology phenomena with roots in the earliest days of the Internet. The various technology developments that preceded blogging all share an important feature with the practice, namely the desire for collaboration and sharing.

Blogging is the convergence of multiple technologies and technology paths, which has resulted in greater capabilities available to more users for less cost and with less effort. Each development has made it possible for more people to engage with information technology, and to apply ever-more powerful tools to focus on their interests.

This paper concludes with a case study showing excerpts of how the author developed a blog post using Blogger, including examples of how that tool generated the html code required for external links and embedding video.

Section 1 – What exactly are we talking about?

The first question to address in a paper about blogs is simple: What exactly are we talking about?

I didn’t find the term blog and its many derivations (including bloggers, blogging, and blogosphere) in the large dictionary at my local library. It defines the term bloemfontein on page 236 as an adjective which describes a person or object “of or from the city of Bloemfontein, Union of South Africa.” The dictionary then promptly moves on to bloke, a chiefly British term “used informally and commonly implying mild disrespect when applied to a superior…” (Webster’s)

Of course, the absence of blog could also be attributed to this particular edition’s publication date.

Wikipedia, which according Brady is “…an online encyclopedia that is created and edited by everyone” (page 4) is more helpful. It’s a rich source of computer terms, particularly regarding the Internet. Wikipedia defines blog as: “…a type of website, usually maintained by an individual with regular entries of commentary, descriptions of events, or other material such as graphics or video…’Blog’ can also be used as a verb, meaning to maintain or add content to a blog.” (Wikipedia - blog)

So, a blog is a thing as well as a thing to do. A blogger is a person who blogs. He or she sits down at a computer to blog on their blog, and in so doing enters the blogosphere.

I hope that was helpful. May I stop now?

That’s not a serious question. Rather, it’s worth pursuing the more serious one, namely, “What exactly are we talking about?” as well as exploring how blogs may be used in health care, particularly in nursing education and clinical practice.

I’ve long suspected there are no neat or simple answers to these questions, and the research I’ve conducted in the course of developing this paper has reinforced my suspicion.

But we need to start somewhere, so let’s consider blogs as methods and technologies that exist within the context of other methods and technologies, all of which relate to computers, and to the communications that takes place between them.

This consideration places blogs in the broad realm of information technology, and establishes blogging as an activity engaged in by people who understand the various technologies associated with blogs, and who possess the skills needed to interact with these technologies.

In its simplest form, a blog is a way for people to develop stories, news, and commentary, which I consolidate here under the general term, “content.” Blogs are also a way to publish the content, making it available to readers throughout the world.

In this sense, a blogger is very much like a traditional author who writes a book, story, article, screenplay, or other similar work. However, unlike a traditional author, a blogger also acts as publisher, distributor, bookstore owner, and newsstand proprietor.

Blogging technology may seem complicated, but Karpf puts the technology into perspective when he says, "…a blog is a relatively basic technological artifact." (page 3).

A blog isn’t so much about the tools used to make it as it is about the kind of thought process associated with formulating and articulating an idea. The political blogger Suw Charman, quoted by Brady, says, “…(as a blogger) you’re trying to synthesize an original viewpoint from the different angles you’ve read (in other blogs)…” (page 10).

We can also think of blogging as the modern equivalent of placing a wooden soapbox in the middle of a busy sidewalk, climbing up onto it, and speaking for the benefit of anyone who will listen. We’re not interested in the wood the soapbox is made from. Our attention is directed to the speaker standing on the soapbox; to what he or she is saying; to how others are, or are not, listening and reacting; and to what happens next.

As Brady observed, “Blogs are merely tools…knowledge is synthesized by communication between people.” (page 13)

Still, it’s important to understand the hardware and software that make blogs possible. I address those components in the next section, along with some key developments that form the foundation upon which blogs rest.

Let’s conclude this section by considering the act blogging in ways that complement Karpf’s observation about blog technology. In 2003 Shirkey predicted, “…(blogging) technology will be seen as a platform for so many forms of publishing…that blogging will stop referring to any particularly coherent activity.”

Markos Moulitsas, founder of the political blog DailyKos is quoted in Rosenberg, “One of my biggest pet peeves is the way…blogging…(is) held up as some sort of end in itself – some sort of magic wand…(b)logs are a tool, an instrument, nothing more.” (page 142)

Confused? Good. That means we can continue.

Section 2 – Seriously, what exactly are we talking about?

“Blogging is about sharing.” (Brady, page 8)

I’ve touched on the idea that blogging uses information technology in ways that this paper has not yet addressed. I’ve also suggested that blogging is somehow related to public speaking, or writing for a publication.

There would not be much else to explore if blogging simply described a new way to tell stories - that’s been done since before the beginning of recorded history. The analogy that blogger = writer, or that blogger = speaker, is incomplete.

While a blogger may be considered a writer, a blogger also breaks through the traditional constraints imposed upon a writer, who generally has little or no control over whether his or her work is published.

Put another way, if every submission to the New Yorker magazine appeared in that publication, the New Yorker’s editorial staff wouldn’t need to send out rejection slips. Perhaps there would be no need for an editorial staff at the New Yorker in the first place.

Such a magazine would also be very thick with pages and, in the opinion of critics, filled with material of dubious quality. But as one blogger said, “…I had written a number of letters to the editor…and they never got published. So, that sort of irritated me a little bit…and (I) thought, ‘Why not start my own (blog)?’” (Concord Journal)

The blogger = writer AND blogger = publisher analogy is still incomplete because a blogger is not subject to the constraints of traditional print media distribution or sales.

IF blogger = writer AND blogger = publisher, THEN blogger ALSO = distributor, with the electronic equivalent of a network of trucks + vans + delivery boys; AND blogger ALSO = bookstore owner + newstand proprietor who’s always open for business.

If we further consider how other media such as images, audio, and video are broadcast, we can begin to gain insight into how blogging transcends any single form of content and distribution. We can even begin to answer that question, “Seriously, what exactly are we talking about?”

I’ll enhance the analogy further and add a component which is often directly facilitated by blogs, namely that blogger ALSO = researcher.

That last statement illustrates an important way blogging is fundamentally different from just writing or speaking or broadcasting, and shows how blogs reinforce the blogosphere as a new and unique media phenomenon.

Just as one blogger can readily publish his or her blog to make content immediately available throughout the world, every blogger is part of a vast distributed network of information and activity that is significantly larger than the sum of its parts. That network is readily accessible from a single location, and is an efficient and effective mechanism with which to support or challenge any of the information posted within it.

Brady examined collaboration and research among bloggers to explore if, and how, their tools and methods could be applied in more formal settings, such as academic and commercial research.

Among other findings, Brady concluded that, apart from a blog’s content, three common components of many blogs – permalinks, comments, and trackbacks – could enable bloggers to “meet the standards of research within the academic community,” consistent with rigorous peer review. (page 7)

To summarize our evolving understanding of what we’re talking about, let’s express it in a simple programming statement:

IF (blogger = writer) AND (blogger = publisher), THEN (blogger ALSO = distributor with the electronic equivalent of a network of trucks + vans + delivery boys); AND (blogger ALSO = bookstore owner + newstand proprietor always open for business), AND (blogger ALSO = television + radio + movie producer), AND (blogger ALSO = television + radio broadcaster + movie distributor); AND (blogger ALSO = researcher supported and validated by rigorous peer review).

Karpf noted that blogs represent “…a shift in the…use of the Internet, from static information repository to networked conversation tool.” (page 3). His comment begins to reveal the enormous potential power and value of blogs.

Section 3 – OK, wait – what were we talking about?

We were talking about blogs, but before we go much further, let’s take a step back to understand what came before them, and look at key developments in the history of information technology to see how the evolution of blogs makes sense.

In the beginning, there was the Internet. Well, in the early days of computer technology, starting back when the president of the United States was a guy named Ike, there slowly came to be conceived, and subsequently developed, the precursor to what we now take for granted as the Internet, or as some of my blogging colleagues like to call it, “the innertoobz.”

(digression) The term ‘innertoobz’ combines words uttered by two recent public figures, namely former U.S. President George W. Bush and former U.S. Senator Ted Stevens (R-AK).

In the case of Mr. Bush, he incorrectly referred to the Internet several times in the plural - Internets. This misstatement has since been used “to portray the speaker as ignorant about the Internet or about technology in general…The term gained cachet…following Bush's use of the term in the second 2004 presidential election debate on October 8, 2004.” (Wikipedia – Internets)

Mr. Stevens used an awkward metaphor to criticize a proposed amendment to a bill before the Senate Commerce, which he chaired at the time. “…(t)his metaphor was widely ridiculed as demonstrating Stevens' poor understanding of the Internet, despite being in charge of regulating it.” (Wikipedia – Series of tubes)

According to Mr. Stevens, “…the Internet is not something that you just dump something on. It's not a big truck. It's a series of tubes. And if you don't understand, those tubes can be filled and if they are filled, when you put your message in, it gets in line and it's going to be delayed…” (Wikipedia – Series of tubes)

So, (Internets + tubes) * casual phoeneticization of spoken language = innertoobz (/digression)

In their history of the people and events behind the development of the Internet, Hafner and Lyon note that the motivation for its development arose from the inconvenient fact that computers of the time were isolated entities. They write, “The computers themselves were extremely egocentric devices,” much like a monarch who only communicates with a servant when the monarch wants something. The engineers in their account had a different idea – namely that one computer should be able to tap another on the shoulder and essentially say, ‘Hey, I need to talk with you.’ (page 146)

And though that idea originated in a frightening Cold War event, Hafner and Lyon also note, “The project…embodied the most peaceful intentions – to link computers at scientific laboratories across the country so that researchers might share computer resources.” (page 10)

In practical terms, the Internet was needed because communicating among a far-flung community of computer researchers was tedious, when it was even possible. A person who wanted to connect to several different computers needed several different computer terminals. One participant observed to Hafner and Lyon, “It became obvious…that we ought to find a way to connect all these various machines.” (page 13)

Bilgil wrote, directed, and produced the 2009 animated documentary, “History of the Internet.” In it, he highlights the technological constraints that existed at the time of Hafner and Lyon’s history, as well as the developments that enabled them to be overcome. “(W)hat we take for granted today was only a vague idea fifty years ago.”

The original purpose of the Internet was very specific, namely to link the computers used by government-sponsored researchers. It’s more complicated than the “series of tubes” imagined by an octogenarian ex-senator. Still, it’s OK for our purposes to think of it as the capable soapbox upon which many people, including bloggers, stand.

One participant in Hafner and Lyon’s history provided this insight: “The process of technological development is like building a cathedral. Over the course of several hundred years new people come along and each lays down a block on top of the old foundation…(when an historian asks), “Well, who built this cathedral?’…you can con yourself into believing that you did the most important part. But the reality is that each contribution has to follow onto previous work. Everything is tied to everything else.” (pages 79-80).

And eventually, everybody ends up in the cathedral.

Section 4 – So, that’s why they call it ‘The Web.’

“Everything is tied to everything else.” (Hafner and Lyons, page 80)

I find that last comment as powerful as it is profound, because the idea that everything is connected to everything else describes a structure and process that each are web-like. The first iteration of the Internet in 1969 resembles a small web, or even just a portion of one, in its simplest form. As Hafner and Lyons described, “The (first) network was real, but with only 4 nodes clustered on the West Coast, its topology was simple, the experiment small.” (page 160)

Illustration 1 – Initial Internet topology in 1969, by the author, based on Hafner and Lyons. (page 160)

A subsequent schematic illustrates how that structure evolved into a more complex form with 15 nodes two years later.

Illustration 2 – Internet topology in 1971, from Gromov.

We may be inclined to believe that the only real physical connections in either of these webs are those defined by the straight line between two adjacent components. But the functional connections are more significant. In addition to acting as a gateway for the host computer to which it is connected in Illustration 2, each Interface Message Processor (IMP) – the computer developed specifically for communicating in the network - also passes along messages that are not intended for its host. In that way, the host computer in the upper left hand corner of the latter schematic is functionally connected to the host computer in the lower right hand corner, with every intervening IMP simply passing along the messages between them.

In that way, not only is everything tied to everything else, but everything is tied to everything else in multiple ways. Now that’s what I call a web.

This functional connection between computers is also the foundation of another web, and it is that web which we will next consider in our attempt to understand blogs.

The World Wide Web, or simply ‘the Web,’ was initially conceived and developed by a single person. Tim Berners-Lee was a researcher at CERN, the European high-energy physics laboratory located in Geneva. The Web is his most significant and enduring contribution. As he later noted, “The Web resulted from many influences on my mind, half-formed thoughts, disparate conversations, and seemingly disconnected experiments.” (Berners-Lee).

Berners-Lee observed that “…computers were good at logical organizing and processing, but not (at more intuitive) associations…(like) the human mind.” That observation led him to explore how computers could be used to make connections between seemingly disparate nodes of information, in much the same way that his engineering predecessors who developed the Internet sought to establish physical and functional links between the computers themselves.

Berners-Lee proposed his vision for connected information at CERN, saying that the “working structure of the organization is a multiply connected “web” whose interconnections evolve with time.” (Berners-Lee - proposal) According to Berners-Lee, this web was not limited to the scientific data and information scattered across multiple computer systems within CERN, or even at other similar labs; but also included the activities and interests of the many researchers themselves, as well as the relationships between members of research teams, and among the various teams whose interests might intersect or overlap at any time.

In contemplating the problem of isolated and disconnected information, Berners-Lee was also exploring ways to better enable the people behind that information to know about each other, and about ways to enhance their ability to connect.

Berners-Lee went beyond articulating general concepts, and developed the specific technologies that made the Web a reality. They include:
  • HyperText Markup Language (HTML): the programming language used to enhance the textual and other content components on the Web, and to establish links between information located on any computer attached to the Web.
  • Uniform Resource Locator (URL): the unique and specific address of any piece of information on the Web.
  • HyperText Transfer Protocol (HTTP): the rules that computers connected to the Web use to communicate with each other.
These technologies have become so ubiquitous and transparent that most of us give them no thought or attention, in much the same way that we simply get into our cars, turn the ignition key, and head off to our destinations. We know there’s a lot of engineering and technology that make driving possible, but we really don’t think about any of it.

The first iteration of Berners-Lee’s web became available to the public in 1991, when he connected the first computer, designated as a Web server, to the Internet. It was called a Web server because its purpose was to provide, or serve, information. He also released the first version of the tool called a Web browser, which is used to find and access that information. (Berners-Lee)

Section 5 – OK, now what?

Let’s review what we’ve got so far. First, there’s this thing called the Internet, which is a series of tubes…OK, not tubes exactly, but physical and functional connections that enable computers to communicate.

Then there’s this thing called the Web that runs on the Internet. We use the Web to point from something on a computer over here to something else on a computer over there.

Now, here is where it gets interesting. Once the basic Web information technologies were in place, people needed ways to develop content (authoring tools); ways to put it out there for others to see (publishing tools); and ways to find and display it themselves (browsing tools).

The earliest users of the Internet and the Web were comfortable with technology, and the tools they used to write publish, and access Web content met their needs at the time. However, the rest of us would find those tools difficult to use.

Consider the Web browser. Berners-Lee developed the first browser in 1990, and called it WorldWideWeb. It only displayed text, because Web pages did not initially include images. Berners-Lee’s browser was written specifically for the NeXT computer system, manufactured and sold by the company of the same name. (Berners-Lee) While Berners-Lee chose that system because it had the capabilities he required for the overall Web development project, the NeXT computer was never a commercial success. NeXT stopped manufacturing them in 1993, and the company was acquired by Apple. Notably, the software innovations that NeXT developed subsequently became the foundation for the current version of Apple’s Macintosh operating system. (Wikipedia - NeXT)

An online history of Web browsers by Lilly features a comprehensive list of the tools known to have been developed after Berners-Lee’s WorldWideWeb. Though there are now substantially fewer choices, current browser capabilities easily surpass those of earlier tools, and browsers have evolved in the same incremental fashion as the technology components that we have already discussed. According to Lilly, “No matter which browser you choose to surf the web with, the features you take for granted today are the result of nearly two decades of browser design.”

The best known early browser was Mosaic, which was initially developed in 1992 by Marc Andreeson and a group of classmates at the University of Illinois’ National Center for Supercomputer Applications (NCSA). The development of Mosaic is an important milestone for several reasons: it displayed both text and graphics, it was distributed for free, and it could be installed on computers running Microsoft’s Windows and Apple’s Macintosh operating systems. Andreesen and his colleagues believed “everybody should be using the Web…(and) their program proved an instant hit.” (Rosenberg)

Andreeson and several colleagues left NCSA to form Netscape, Inc. They sold several versions of a new browser called Navigator, starting in 1994.

When Microsoft entered the market with Internet Explorer (IE) in 1995, the company dedicated substantial resources to the product’s development, and included it as part of its widely used Windows operating system. Netscape was unable to compete, steadily lost market share, discontinued further browser development, and was acquired by America Online in 1998. (Lilly)

The majority of users now browse the Web with the latest versions of IE; a browser called Safari for the Macintosh; Mozilla’s open source Firefox; or Google’s open source Chrome. (Lilly)

Most of us give little thought to our browser. We simply expect it to be there. And while some Web users, then and now, simply want to find and read (or watch) Web content, others also want to develop and publish it. Those activities require additional tools, along with the skills to use them.

According to Rosenberg, Tim Berners-Lee activated the first website in 1990, when he designated his NeXT machine to serve at the Web address “As he proselytized for his new creation, enthusiasts at other universities would crank up their own Web servers, begin publishing sites, and email Berners-Lee to tell him...Berners-Lee would insert a listing for it – and a link to it – from a page at his site.” (page 9)

Rosenberg makes it sound easy, but most people still don’t know how to “crank up their own web servers.”

Just as with browsers, a market soon developed for Web content authoring and publishing tools. These tools also became easier to use as more, and less technically experienced, people took to the Web.

Microsoft entered this new market in early 1996 when it acquired Vermeer Technologies, Inc. (VTI). VTI developed FrontPage, a tool for authoring and publishing Web content. In the press release announcing their acquisition, Microsoft executives predicted that people using word processing and spreadsheet programs “will author web documents for…the Internet in the near future.” (Microsoft)

As one technology publication noted at the time, Microsoft’s entry “brings Web publishing technology within the reach of the average PC user.” (CNET)

We’ve accounted for the tools needed to author, publish, find, and view Web content, and now need to consider one last piece - the Web server, the computer used to store content and make it available to others. As previously noted, though Berbers-Lee and his contemporaries would simply “crank up their own Web servers,” that was not a viable option for the growing number of less technically-capable people who also wanted to develop and publish Web content.

This need for Web servers led to the development of another new industry - Web hosting. The basic concept behind Web hosting is similar to the market for real estate. People need places to live, just as Web sites need to be stored on servers connected to the Internet. Landlords operate apartment buildings, and tenants rent individual apartments. In the same way, Web hosting companies operate banks of Web servers, while organizations and individuals rent portions of these computers for their Web sites. This model is called shared hosting. (Loh)

But just as some people want to own the structures where they live, some organizations and individuals need their own computer resources to support large and busy Web sites. This model is called dedicated hosting. (Loh)

Section 6 – Can we talk about blogging now?

Based on the discussion thus far, we can consider blogs as the most recent set of blocks in our cathedral. They are conceptually layered directly on traditional Web technologies, which in turn are based on Berners-Lee’s original concepts, which itself would not be possible without the Internet as foundation.

The following illustration demonstrates that blogs are the functional convergence of each preceding tool and technique. All of them are held together in the framework of the browser.

Illustration 3 – The evolution of information technology, leading to blogs. By the author.

Where did this convergence first take place, who made it happen, and how? Rosenberg points to many events and participants, cautioning, “…efforts to identify a ‘first blog’ are comical, and ultimately futile, because blogging was not invented; it evolved…(it) arose in relative obscurity – it got no headlines as it emerged.” (p 81)

However, I will focus on a particular tool to keep the narrative concise, and based upon my own blogging experience. The tool is called Blogger with a capital ‘B,’ to avoid confusing it with a blogger, a person who blogs.

The two people who started the project that led to Blogger didn’t set out to build it. Evan Williams and Meg Hourihan had other plans. According to Rosenberg, their initial idea was based on their belief that “…the future belonged to software tools that worked across the Web and inside the Web browser. Services like Hotmail and Yahoo! Mail had already shown how this worked for email: to use them, you didn’t need to download an email program, install it, and run it in a separate Window – you just signed up on a website and sent and received your message there.” (page107)

In the course of building a complex product on that model, which they hoped to sell to other computer programmers and Web developers, Williams wrote a small, almost incidental piece of software to make the work easier. The simple tool he developed enabled them to quickly and easily post any information they found onto their own internal Web site, which they frequently used to communicate with each other.

According to Rosenberg, “Trivial as its actually technical details were, the little script…accomplished something important: it cleared the obstacles from the path between brain and Web page.” (p 110-111) This observation about Blogger’s technology echoes Karpf’s earlier one, "…a blog is a relatively basic technological artifact." (page 3).

Williams said that upon using his tool he “had an epiphany” and as a result the internal Web site he shared with Hourihan “changed from an occasional creative outlet that I would do when I had time, to much more of a linked outlet for my brain.” (Rosenberg, page 108)

Rosenberg also identified a broader implication. He wrote that Blogger, “…established the template for a whole new wave of web companies…(that) didn’t have to raise millions or spend millions to achieve something valuable; they could be built around an idea and sustained without any…trappings…As blogging spread beyond the technology industry, its new acolytes carried the seeds of this ethos into other fields. Maybe you could start a new publication without rounding up big money. Maybe your political organization or your marketing consultancy didn’t have to invest in a lease or fancy signage. In this way, blogging became not only a mode of expression but a way of thinking about guerilla-style organization-building.” (page 129)

In other words, blogging is empowering.

In her extensive online history of blogging, Blood notes, “The promise of the Web was that everyone could publish.” The term ‘everyone’ should more accurately be, “everyone with access to a computer hooked up to the Internet.” Still, Blogger and other tools like it enable many people who would otherwise be unable to publicly express their ideas. (Blood – online)

Blood points to Blogger as the final piece needed to realize “the promise of the Web” because at first “only those people who knew how to code a web page could make their voices heard. Blogger…(has) given people with little or no knowledge of HTML the ability to publish on the web: to pontificate, remember, dream, and argue in public.” (Blood- online)

Section 7 – Can we wrap this up?

Let’s try. My own professional interest is health care, specifically nursing education, and caring for patients and families at end of life. I blog to express my thoughts and opinions on these topics. I also blog as a way to learn and teach, and to build a network of like-minded professionals.

I doubt that I would blog, or that I would blog as much as I do, if the process was technically difficult or time-consuming. I’m willing and eager to develop my ideas, but I’m not interested in fiddling with computers any more than I have to. I also doubt that my blogging would be as useful or rewarding as it’s been if my blog’s reach was limited.

I previously described my blog in a report submitted as my final project (Soucy), and will now illustrate how I used Blogger to develop a blog post with text, links, and video. My blog is Death Club for Cuties. I developed and posted an essay on January 28, 2010 titled, “For J, her family, and her dad.”

Illustration 4 – Screen snap showing url and initial portion of referenced essay

The complete url for the entry is: is the main address for my blog. The portion of the address indicates that the blog deathclubforcuties is on a shared hosting server owned by Blogspot.

The portion of the address that reads /2010/01 indicates that this particular piece was posted in January, 2010, because I use Blogger to organize and archive my posts on a monthly basis.

The final address portion that reads /for-j-her-family-and-her-dad.html is based on the title I gave to the piece, with .html indicating that this is an html file type.

All components of the address were automatically generated by Blogger.

I added several links within the text of the essay. One was to a video showing the final pitches of Red Sox pitcher Clay Buchholz’s 2007 no-hitter against the Baltimore Orioles. The text ‘Clay Bucholtz’s(sic) no-hitter’ is highlighted in a different color than the regular text to cue the reader about the link.

Illustration 5 – Screen snap showing hypertext link for Clay Buchholz no-hitter

When a reader clicks on the highlighted text, their browser is connected to a different server hosting the target video, shown below.

Illustration 6 – Screen snap showing Clay Buchholz no-hitter video

The video’s full address is visible at the top of the screen in the url portion of the browser:

The ‘br’ portion of the address indicates that this server is located in Brazil. I located the video by searching Google with the term “Clay Buchholz no hitter” then copied its address. I developed the link by activating a form within Blogger, pasting the address into the form, and finally clicking OK to generate the html source code, as shown:

Illustration 7 – Screen snap showing method for building hypertext link in Blogger

In addition to developing a link to a video, I also embedded another video directly into the essay:

Illustration 8 – Screen snap showing embedded video in my blog

I was already familiar with this specific video, and located it within YouTube using the search term “Nessun Dorma Pavarotti:”

Illustration 9 – Screen snap showing source video at YouTube

YouTube provides the html source code to enable video embedding, located in the shaded box immediately to the right of the video player.

Finally, I copied the source code into another Blogger form, and clicked Publish Post:

Illustration 10 – Screen snap showing html code for embedding video in my blog

Conclusion - So, what have we proven?

I believe that question is best answered in an online review of Blood’s book, written by a reviewer who calls himself acleversheep (A Clever Sheep). The review appears at the online bookstore

acleversheep writes, “Blood demonstrates over and again that blogging is all about self-discovery. You will most likely not find a huge audience, she tells us, but you will find that you are a better writer than you were before you started blogging. You probably won't be a huge influence on public policy, but you will hone your reasoning and filtering skills by engaging the topics you care about. You may not ever make a penny from your blog, but you can improve your reputation and your standing in your industry by becoming a resource and a reference point.”

Blood also provides an answer in her online history of blogging: “We are being pummeled by a deluge of data and unless we create time and spaces in which to reflect, we will be left with only our reactions. I strongly believe in the power of weblogs (blogs) to transform both writers and readers from "audience" to "public" and from "consumer" to "creator." Weblogs are no panacea for the crippling effects of a media-saturated culture, but I believe they are one antidote.”

That’s a good place to start answering the question. It’s also a good one with which to finish this paper.


acleversheep (A Clever Sheep). Not a "How-to", but a "Why-to." 2002. Book review at Obtained at

Berners-Lee, Tim. Weaving the Web: The Original Design and Ultimate Destiny of the World Wide Web. New York, Harper, 2000

Berners-Lee, Tim - proposal. 1989. “Information Management: A Proposal.” Obtained at

Bilgil, Mehli. 2009. “History of the Internet.” An animated documentary obtained at

Blood, Rebecca - online. 2000. “weblogs: a history and perspective.” Obtained at

Blood, Rebecca. The Weblog Handbook: Practical Advice on Creating and Maintaining Your Blog Basic Books, New York, 2002.

Brady, Mark. 2005. ‘Blogging, personal participation in public knowledge-building on the web’, Chimera Working Paper 2005-02. Colchester: University of Essex. Obtained at

CNET News, 1996. “Microsoft details Vermeer buy.” by Jim Calhoun, staff writer. Obtained at

Concord (MA) Journal. “His take is on the Web.” Page 3, November 19, 2009 by Patrick Ball, staff writer.

Gromov, Gregory. 1995. “History of Internet and WWW: The Roads and Crossroads of Internet History.” Obtained at

Hafner, Katie and Lyon, Matthew. Where Wizards Stay Up Late: The Origins of the Internet. New York, Touchstone, 1998.

Karpf, Dave. 2008. “Stability and Change in the Political Blogosphere in the 2008 Election: An Institutional Approach” Doctoral Candidate, University of Pennsylvania. Fellow-in-Residence, Miller Center for Public Affairs. Obtained at

Lilly, Paul. 2009. “Surfing Since 1991: The Evolution of Web Browsers.” Obtained at

Loh, Andrew. 2007. “A beginners guide to web hosting.” Obtained at

Microsoft Corporation, press release 1996. “Microsoft Acquires Vermeer Technologies Inc.” Obtained at

Rosenberg, Scott. Say everything: how blogging began, what it's becoming, and why it matters. New York, Crown, 2009.

Shirky, Clay. 2003. “Power Laws, Weblogs, and Inequality.” Obtained at

Soucy, Gerard. 2009. “NU501 Leapfrog to Assignment 5.” Obtained at

Webster’s New International Dictionary of the English Language, 3rd Edition. Mirriam Webster, Springfield, 1986.

Wikipedia – blog. Obtained at

Wikipedia – Internets. Obtained at

Wikipedia – NeXT. Obtained at

Wikipedia – Series of tubes. Obtained at

Sunday, December 27, 2009

NU501, final project feedback

NU 501, Nursing Informatics, Assignment 5, Grade A
You did an excellent job with your Blog! The content is thorough and describes many aspects for nurses that deal with end of life issues. The appearance is well organized and easy to read. The font and color were also appealing and easy to read. Your content is provocative and through provoking in an area that needs much attention and gets very little. Nice job!

Why, thank you very much.

Now I just need to finish that paper for assignment 4...

Sunday, December 20, 2009

NU 501 Leapfrog to Assignment 5

Blogging about blogging...

It's been taking me much more time to finish assignment #4, which is a research paper that complies with the APA format. I'm writing about blogging, and though I've got the general structure and what I want to say pretty much established, along with the supporting material and sources, it's just a freaking slog.

So, last week I took a chance and wrapped up the report to accompany my final project, which was Assignment #5 -

I first proposed developing my other blog to complete the final project requirements back at the start of the course, and promptly got the go-ahead from Sharon, my instructor:

I can't help but chuckle now at my hubris - I really did think I'd be able to submit the first four assignments in a single month, and then coast to a finish sometime before Halloween with the assignment you're reading now.

Ah, ha ha ha!

I guess life just got in the way, and this course turned out to be more work than I anticipated. But I mean more work in a good way. It's really been a challenge and a lot of fun. I love this stuff, and it takes time to do things right. So, here we are looking at Christmas and I'm still tying up loose ends.


I even heard from my overall advisor the other day, wondering what was up:
On Thu, Dec 17, 2009 at 3:45 PM, Holly XXXXX wrote:
Hi Jerry,

I was just reviewing your course progress and noticed that Unit IV is missing….please contact me soon. We are also still waiting for your official transcripts the University of Mass @ Boston.


Holly XXXXX, Academic Advisor
Saint Joseph's College of Maine
Graduate and Professional Studies
Oops. Here's what I replied:
Jerry Soucy to Holly XXXXX, Sharon XXXXXX
Dec 17

Hi, Holly:
I submitted the Unit V assignment earlier this week, and noted to Sharon in the accompanying email that I had leapfrogged Unit IV to submit a written report to accompany my final project. I'm working on the Unit IV assignment - a research paper that complies with APA formatting requorements - but it's proven to be a long, hard slog.

Sharon approved my final project proposal early in the course, and since the project has been ongoing (see it here), I was in a better position to develop the project report quickly. I didn't want to be sitting here with two missing assignments at this point.

I haven't heard back from Sharon yet - either her feedback on the project report, or her response to my leapfrogging Unit IV.

I'll follow up with UMass/Boston and my transcript request after the holidays.

Thanks, Jerry
So, I'll let the chips fall where they fall, and will get back to wrapping up that APA-formatted paper right after I post this material.

- - - - -
Implementing Information Technology Into My Practice: A report on my blog, Death Club for Cuties


This report describes my experience to date with Death Club for Cuties (‘the blog’). It includes an analysis of the material I have written, as well as the visibility I have earned and the interactions I have had with others who share my interests.

This report also identifies potential objectives for the blog’s continued development.


I started the blog on February 15, 2009 as a way to explore several topics of personal and professional interest – nursing education, end of life care, and the use of blogging as an information technology tool for professional development.

I also planned to explore ways that the blog could support a project I am undertaking at work, namely to develop a core team of nurses skilled in providing end of life care to patients and families on our 20-bed neurosciences intensive care unit.

Summary – Blog posts, readers, and reader comments

As of this writing I have submitted (“posted”) 27 separate essays (“blog posts”). Eleven (11) of the blog posts have generated a total of 34 reader comments, 5 of which are mine. The remaining 29 comments were posted by 15 different readers.

Gail Rae has posted 9 individual comments, the most of any reader. Five (5) of Gail Rae’s comments were posted on the same day. The reader who signs herself ‘risaden’ has posted 5 comments, while Wounded Healer and Christian Sinclair, MD have each posted 2 comments. The remaining readers who have posted a single comment are: Jan Henderson; Karen; RB; LeighSW; Jessica Knapp; Sally; Øystein; Marty Tousley, CNS-BC, FT, DCC; JerseyRN; Eric Widera; and Angel.

The reader comments are most often expressions of support and encouragement. Some readers have also noted their own experiences and reflections, related to the tone or subject of my original blog post; and/or have highlighted their own material, or that written by others, related to the subject or tone of my original blog post.

The first reader comment was posted by risaden on June 4, 2009 in response to the very brief blog post “One small step at a time,” which I posted on May 30, 2009. Her comment was, “Yes, keep posting.”

Most of the people who have left comments at my blog are themselves bloggers who write about palliative care, end of life, health care policy, grief and bereavement, and other matters related to health care.

The following readers are also bloggers:

A review of blog posts, by month

My blog posts can be grouped into 3 general categories:
  • Meta – These are blog posts about blogging itself, and about the interests and motivations that led me to blogging. The purpose of meta posts have often been to explain and explore the status of my blogging efforts, as well as the status of the companion project to develop an end of life care team that I submitted to my manager, and that was subsequently approved. The general focus is one of self-reflection, processes, and relationships.
  • Topical – These blog posts explore one or more subjects or issues directly related to end of life care, nursing education, and general health care policy and delivery. They are based on original material that I have either developed specifically for the blog, or that I originally developed for some other purpose or audience, but have adapted to the blog’s format and purpose.
  • Links – These are blog posts that may contain little original material, but that reference material developed by others for online or traditional media which I find personally interesting, and which I wish to share with my readers.
Some blog posts combine characteristics of more than one catergory. In the following section, I identify and briefly discuss the 27 individual blog posts that I have developed to date.


2/15/09 meta, link, topical

I had already been planning to begin a blog on end of life care and nursing education for some time when I read a blog post, known as a ‘diary’ at DailyKos, by the blogger and community member memfromsomerville (‘mem’) about Ted Kennedy. mem’s diary, simply titled ‘Teddy,’ prompted me to first post a comment there in response. I subsequently took the opportunity to adapt that comment with very minor changes as the first post on my new blog.


3/28/09 meta, link

I posted my second blog entry a little more than one month after my first, again in response to a diary at DailyKos. This one was simply titled, ‘Wife,’ by the writer who calls himself ‘The National Gadfly.’ It’s a moving and deeply personal account of his visit to her grave, and a reflection upon her life. I also used the opportunity to post a brief meta reflection on my proposal and blogging.


4/23/09 meta, link

At this point, I was on a roll to post a single blog entry each month, the focus of which was to reflect upon the status of my proposal. In this particular post I also noted for the first time the existence of other bloggers writing about end of life and palliative care, and linked to them.


5/30/09 meta, link

Another month, another brief meta post accompanied by a link to related content that had been more fully developed by someone else. There was a twist this time around though – my first reader comment (by risaden)!


6/24/09 meta

Again, a single brief meta post as the only post for the month, though this one is a bit more developed and touches on the issue of humor.


7/8/09 meta, link

I didn’t know it at the time, but I had entered the first month where I would post more than a single entry. This started as another meta ‘I need to post more posts’ type of post, though I also referenced the recent sudden death of a colleague at work, and included a link to a site that I found largely as a result of my interest in the works of the artist Sheperd Fairey. The reader risaden also left a comment of encouragement in response.

7/11/09 link, topical

This was my first true non-meta blog post, based on a concept I had developed to help provide context for the family members of my patients. This post was selected by risaden when she hosted the August edition of Palliative Care Grand Rounds, a monthly summary of material in online and traditional media for end of life and palliative care profesionals.

7/21/09 meta, link, topical

This post directly references a series I developed at DailyKos that drew on poetry and wire service photographs associated with the invasion and occupation in Iraq as a way to explore and witness grief. This post was an attempt to establish a theme or structure that could be repeated as a regular feature in my blog.


8/4/09 meta, link, topical

Essentially identical to the previous post, though this one prompted a comment by Gail Rae.

8/21/09 meta, link, topical

Though I have never hesitated from expressing my personal political and policy views in strong, even confrontational, language in other blogs, I explicitly decided not to do so in this one. I think it’s because I want Death Club for Cuties to be regarded as a source of somewhat more objective, or perhaps less polarizing, information. This post comes the closest of any to contradicting my decision.

8/25/09 meta

More thoughts about, and descriptions of, the status of my proposed projectl at work. Hindsight is a funny thing, because though this blog post identifies the month of October as the official starting point for my project, here we are in mid-December and it still hasn’t happened. This post does note that I had established a connection with two other ELNEC trainers at work, and that I’d be contributing content to the course they were supervising. That event did happen, and the material I developed for my class was the subject for a subsequent post.

8/26/09 meta, link, topical

This was posted in response to the death of Ted Kennedy, and points back to my opening post in February. I also drew extensively from others commenting on Kennedy’s death, most notably colleagues at DailyKos, as well as several video links.


9/1/09 meta, link

Here I link to the first assignment I completed for NU501. Seems like a long time ago. Seems like yesterday.

9/3/09 link

I’ve followed the blog called ‘Bag News Notes’ for several years, and have had the chance to meet and talk with Michael Shaw, the clinical psychologist who developed the blog and writes much of its content. The Bag is dedicated to the analysis of visual media, and Shaw’s approach is unique and powerful. Here I feature an image and link to a photo essay at the Bag about end of life.

9/6/09 link, topical

I’m proud of this piece for several reasons, most notably because I wrote it carefully, to protect confidentialty, as a case based on personal experience. The post was selected for the October edition of Palliative Care Grand Rounds.

9/8/09 meta, link, topical

This is another piece that I’m proud of for its form, content, and focus.

9/10/09 meta, link, topical

This was another post associated with Ted Kennedy, as well as with the larger discussion of the current attempts to reform health financing policy.

9/15/09 meta, link, topical

This piece is probably best appreciated as a companion to one I developed for my other blog at about the same time. That post is called ‘This will probably come in handy later.’

Both pieces relate to the slow health decline most often associated with aging. It was influenced by the readings I had begun at the blog, GeriPal, which itself focuses most closely on end of life as it relates to aging (as opposed to terminal illness or sudden injury).

9/22/09 meta, link

This post represents a significant milestone in the life of my blog, because it marks the point at which I was asked to host December’s Palliative Care Grand Rounds. That moment was kind of like being brought up from a minor league team to play in the World Series.

9/28/09 meta

A long post that simply reproduced the lengthy email sent to my colleagues, inviting them to join the end of life care team I had proposed earlier in the year.


10/21/09 meta, link

Here, I try to explain why I’m not posting more frequently to my blog (and why it’s taken me so long to complete another NU501 assignment).

10/24/09 link, topical

This is another favorite post, because the original story that I linked to is very compelling, and because the subject of that story came by and left a comment. That’s precisely the kind of interaction and connection that blogging makes possible.

10/31/09 link, topical

I’m sorry that nobody left any comments, because I’m really invested in this piece. That’s as true now as when I originally developed it several years ago as part of an online course for first-year students in an associates’ degree in nursing program.


11/2/09 meta, link, topical

This post was featured in November’s Palliative Care Grand Rounds. I’m still waiting to hear if my proposal’s been accepted. Any day now…

12/20/09 Update: Sadly, No!

11/13/09 link, topical

This is the script and slides that I used in a class on the subject of ethics, which I presented to the participants at an ELNEC course conducted at my hospital by two colleagues. I also subsequently presented this same material to first year/first semester nursing students in an associates’ degree in nursing program. The class preparation took a substantial amount of time and effort, and is offered up as another excuse for why it’s taken me so long to complete my remaining NU501 assignments, and for why my pace of blog posts has continued to be so spotty.

This post also generated the most substantial response of any, both in the form of a detailed comment in my blog by Gail Rae, and in the form of a lengthy and well-thought out piece at her own blog.

11/26/09 topical

On Thanksgiving Day, it somehow seemed appropriate to recycle the eulogy I delivered at my mom’s funeral 9 years ago.


12/1/09 meta, link, topical

I worked as hard and as long on this post as I’ve worked on just about anything I’ve ever written. My first challenge was to compile worthwhile material developed by others. My next was to assemble that material into a cohesive unit, with a unifying theme and enough context to have it all make some sort of sense. I’m very pleased with the response it generated, and with the recognition I received as a result.

The rest of the blog – what’s on the right side?

These components include an assortment of original text, links, and other material of interest that supplement the posts and support my blogging objectives. Some of the material is relatively permanent, while other components are subject to change and revision as required.

  • This Blog is for… - This is a brief statement of purpose, an introduction to help new readers determine their interest in the subject matter, and in my perspective.
  • About me - A very brief biography to convey my perspective and establish credibility.
  • Important Note - Here I invite readers to participate, and ask for attribution in the event that anyone wants to draw upon my material
  • Guiding Vision – A companion to the statement of purpose that draws upon a quote which mirrors my own view of my profession.
  • What’s With the Name? - Just in case anybody’s wondering.
  • End of Life and Palliative Care Resources – A list of links to individuals and organizations where others who are specifically interested in end of life care and/or nursing education can obtain helpful tools and information.
  • End of Life and Palliative Care Blogs – Similar to EOL Resources, though the focus here is on a specific category of blogs and bloggers.
  • Life, Death, Healthcare, etc - A looser list of organizations, individuals, sites, blogs, and bloggers than the others, though still within a defined set of themes.
  • For Good Self Care – Blogs and bloggers who have nothing to do with end of life care, but that I enjoy and want to share with others – particularly with regard to enjoying a good time and having a laugh. We can’t be all death all the time.
  • I Support – This is where I direct my charitable giving.
  • Fair Use – I adapted this text from Michael Shaw at Bag News Notes, and use it along with the enbedded links to preempt charges of copyright infringement.
  • Confidential Health Information – In the same spirit, I developed this text and its embedded links to convey my adherence to HIPAA regulations.
  • Archive – For access to prior blog posts, organized in reverse chronological order.
  • My Other Blogging – It’s kind of like potato chips. Who can eat just one?
What the data shows – comments and illustrations on blog traffic and other useful parameters

After I had decided to blog about end of life care and nursing education, I had to ask myself – Who’s going to read this stuff?

I didn’t act in any concrete way to begin answering this and related questions until I embedded a small software program (‘code’) known as Google Analytics into the body of my blog template.

Important side note – I’ve intentionally stayed away from engaging in any form of ‘how to’ set up a blog. It would be very easy to conduct a quick search to locate and review materials that provide clear and detailed instructions.

More importantly, my own approach to such aspects of blogging, and one that the technology supports, is to simply get started and figure things out for myself as I go along. While this may seem careless to some readers, it’s an attitude very much in keeping with the form.

My interest is in developing the content and the relationships, not in the underlying mechanics that make them possible. In other words, a blog is like a paper-based form. The real challenge, in my opinion, is to fill out the form well enough so that others want to read it.

So, at the risk of provoking the question, “But how do you do that?” let’s just say that by following the simple instructions on embedding Google Analytics code, I’m able to look at who’s visiting my blog, where they came from, and how long they stayed, among other things.

I’ll just focus on a couple of basic metrics that provide useful insights into my blog to date, and that illustrate how establishing a credible blog within a larger network can generate activity.

Note also that though I began this blog with my first post on February 25, 2009 I did not embed the Google Analytics code until August 26th. That latter date marks the start of my ability to analyze my blog’s traffic and visitors.

This chart above shows blog traffic, as a measure of all visitors who’ve come to the blog during the identified date range. The large spike on the right labeled December 2 indicates the substantial boost in traffic as a result of hosting Palliative Care Grand Rounds for December. Those visitors were pointed to my blog by several other blogs. This chart also notes a total of 1,167 visits for the measured period, along with a calculated daily average.

This second chart also shows blog traffic, though this time as a measure of the unique visitors during the date range. The distinction is a subtle but important one, as it counts each unique visitor only once, regardless of the number of return visits any one visitor may have made in a given day. The large spike on the right labeled December 2 again indicates the substantial boost in traffic as a result of hosting Palliative Care Grand Rounds for December.

Here are the top ten (10) referral sources to my blog. The sources numbered 2, 3, 4, 7, and 10 are other blogs. Source #9 is the nursing student/faculty communication site at a local community college where I recently taught 2 classes. Source #1 is actually not a source, and indicates that 127 of the 528 tracked visits arrived directly at the blog without benefit of a referral. The 3+ minute average time on the site is a fair measure of site ‘stickiness,’ and indicates that visitors stay at the blog long enough to read the relatively short posts. The majority of the visits for this time period were by people who had not previously been to the blog, and the bounce rate indicates that the majority of readers did not explore multiple posts.

This chart shows the top 25 referring sites for a different time period.

Some conclusions

To restate the objectives I identified at the outset: I began this blog as a way to explore several topics of personal and professional interest – nursing education, end of life care, and the use of blogging as an information technology tool for professional development.

I also planned to explore ways that the blog could support a project I am undertaking at work, namely to develop a core team of nurses skilled in providing end of life care to patients and families on our 20-bed neurosciences intensive care unit.

I believe that I have met, or have at least begun to meet, these objectives. This project is far from over.

I have begun to explore end of life care and nursing education by writing original material and assessing materials written by others. I have learned more about blogging technology, and about the process of blogging, through this project.

I have also begun to develop and participate in a network of professionals with similar interests, and have seen where that network has helped to build readership at my blog. This blog has the potential to serve as a forum from which I can continue to build my professional knowledge and expand my credibility and reach.

It’s not yet clear to me how this blog can be used to support the needs of an end of life care team that I will be developing at work after the holidays.

I’m very glad that I started, and I look forward to whatever may lie ahead.

Wednesday, November 4, 2009

NU501 Assignment #3 Feedback

NU 501, Nursing Informatics, Assignment 3, Grade A

In this assignment you demonstrated an understanding of the information systems in your institution and how they are integrated. You described the systems involved thoroughly and in an organized manner. Isn’t it amazing the number of applications there are and how at least some of them are able to communicate and share data with each other? I really enjoyed reading about your previous experiences and the historical perspective of some of the IT activities in the Boston area. One of the best papers I have read!

I could not have said it better myself ;^)

Tuesday, October 20, 2009

NU501 Assignment 3

This one took a bit longer than I had planned, but I'm glad that I took the time.

Some personal context

I work as a staff nurse in the neurosciences intensive care unit at the Brigham and Women's Hospital (BWH) in Boston. My primary clinical interest is caring for patients and families at end of life. I am also very interested in how information technology can be used to support patient care and nursing education.

My professional experience is split between my clinical work, which has been spent practicing in a range of critical care settings, and with patients receiving hemodialysis for end stage renal disease; and my work with patient care information systems, and with systems used more broadly as tools for individuals and organizations.

Many key advances in health care information technology occurred in the Boston-area. I've met and worked with some of the people who have played important roles in this industry, and I have incorporated a few personal recollections and observations in this assignment.

Brigham and Women's Hospital (BWH)

BWH is a 747-bed nonprofit teaching affiliate of Harvard Medical School, and one of the two founding member of Partners HealthCare System (Partners), an integrated health care delivery network.

source 2008 AnnualReport, Partners HealthCare (pdf)

BWH provides medical and surgical services, and has established clinical centers of excellence for oncology, and women's and reproductive health, cardiovascular/thoracic, neurosciences, orthopedics, and arthritis.

BWH has over thirteen thousand (13,000+) employees, of which over two thousand (2,000+) are staff physicians, and over twenty-eight hundred (2,800+) are registered nurses.

According to the most recent data from the American Hospital Directory, Partners member hospitals account for over sixteen percent (16%) of staffed beds, and over twenty-seven percent (27%) of gross patient revenue in Massachusetts.

BWH accounts for approximately 5 percent (5%) of the staffed beds, and approximately 8 and a half percent (8.5%) of gross patient revenue.

The foundation for information technology at BWH

This paper does not consider BWH's use of information technology prior to the formation of Partners in 1994.

Massachusetts General Hospital (MGH) has a notable history of computerization dating back over 40 years, which directly influenced the implementation and use of information teachnology at BWH. When Partners was established, the department responsible for developing and supporting information systems at MGH was reorganized as a corporate service to meet the needs the new organization's member hospitals. The core systems currently in use at BWH were developed and are maintained by this corporate services group, Partners/IT.

The systems currently in use at BWH can be appreciated in the context of the history of computerization at MGH. The impact of this history is most clearly seen in the development of the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) by Neil Pappalardo and Kurt Marble, working under under G. Octo Barnett at the MGH Laboratory of Computer Sciences.

Pappalardo and colleagues developed MUMPS in 1966 and 1967 specifically to provide a set of programming and data management tools best suited for patient care computer systems. MUMPS was developed as an alternative to the tools and systems then in use to support commercial and scientific organizations.

As Henry Heffernan noted in his presentation at the 1980 meeting of the MUMPS Users Group (MUG) in Washington, DC:
“The data management and communications needs of clinical care and health care management were quite different from the business batch processing and large scale scientific computation tasks that had dominated the software system design thinking of the previous decade. The lesson…was that software systems should be designed to fit the paradigms of information usage in medical applications, instead of medical applications being twisted and stretched to fit batch processing paradigms.”

Pappalardo later founded MEDITECH, a company that continues to sell and support a wide range of integrated applications for hospitals and other health care organizations. He still heads the company as chairman. One industry observer has noted:
"...the talent involved in the founding of MEDITECH is astronomical. These are some very, very smart and successful people who made extensive contributions...I'm in awe of the influence these pioneers have had, not only in healthcare automation, but in healthcare in general...the story of MEDITECH and its founders is, to me, the most fascinating and awe-inspiring of any firm in our industry. Someone should write a book."

I worked at MEDITECH from January to October, 1986, and though I probably won't be the one to write that book, I did gain some insights into the company, its values, and its leadership role in the industry. There were about 350 people working at MEDITECH while I was there. The current count likely exceeds 3,500, just one indication of the company's steady growth.

I personally found MEDITECH's management culture too restrictive, which prompted my decision to leave. But nothing succeeds like success.

I left MEDITECH for a sales position at Collaborative Medical Systems (CoMED), where I worked for the next 8 years selling CoPATH, the best-of-breed anatomic pathology system. My customers included MGH, the Lahey Clinic, the University of Kentucky Medical Center, the University of Tennessee Medical Center, the University of Maryland Medical System, the Cleveland Clinic Foundation, University Hospitals of Cleveland, the Toledo Hospital, Children’s Hospital of Columbus, Mercy Health System, and other leading institutions throughout the country. I also sold a copy of CoMED's clinical laboratory system, CoLAB, to MGH as a replacement for an internally developed system used by the hematology and chemistry departments there.

CoPATH and CoLAB were written in MUMPS, and three of CoMED’s four founders had worked at MEDITECH earlier in their careers. One of CoMED's founders had developed MEDITECH's first commercial clinical laboratory system, and was responsible for hiring Howard Messing, who now serves as MEDITECH's president. All four CoMED founders were graduates of the Massachusetts Institute of Technology (MIT), as were Neil Pappalardo and Kurt Marble.

Another company bought CoMED shortly after I left in 1995. That company was, in turn, later acquired by Cerner Corp. CoPATH is still in wide use, including at U.S. Military hospitals around the world. That sale of CoPath to the U.S. Department of Defense was my final contribution and the company's largest sale ever.

It was a nice way to go out.

Information technology at BWH

The patient care systems currently deployed at the Brigham and Women’s Hospital include a mix of applications developed by Partners/IT, along with applications obtained from vendors.

The core inpatient care system is called BICSBrigham Integrated Computer System. It supports key administrative and patient demographic functions to support inpatient admissions and includes a master patient index (MPI), a permanent repository of information associated all admitted inpatients and registered outpatients.

BICS is also the mechanism for provider order entry (POE), where physicians and advanced practice nurses request a range of ancillary services including clinical lab tests and medications; and through which clinical staff access findings and results. Though POE does not provide all of the elements for a fully automated patient electronic medical record (EMR), it serves as an important component of the base from which an EMR is built.

Finally, BICS supports the complex needs of the BWH clinical laboratory and pharmacy departments, including the full range of each department’s functional processing and internal control requirements.

BICS was developed and is supported by Partners/IT using a toolset called Cache, provided by InterSystems of Cambridge, Massachusetts. Like MEDITECH, InterSystems is a leading vendor still headed by its founder, and whose history can be traced directly back to the initial development of MUMPS; though InterSystems evolved into a developer and provider of programming tools for others to use when building application systems.

This illustration shows the patient care applications most frequently used by clinicians and ancillary personnel at the Brigham and Women’s Hospital, and indicates the central role played by BICS.

Partners/IT has also developed an inpatient system for nurses and house staff called eMAR – the Electronic Medication Administration Record – though its capabilities go beyond administering and recording inpatient medications. eMAR is the main system used by staff nurses with mobile notebook computers during the course of most patient care, and is the conduit for access to other systems that include word processing and email, web browsing, facility and departmental policies and procedures, and BICS.

The following illustration depicts core eMAR functions, along with the interaction between BICS and eMAR.

Inpatient medication ordering and administration at BWH is controlled by several interacting information systems
  • BICS OE subsystem for provider order entry
  • BICS Pharmacy subsystem for pharmacy staff review/approval, drug-interaction and formulary check, and other internal controls
  • eMAR for scheduling medications
  • Omnicell for medication inventory management
  • Omnicell for medication access by nursing staff
  • BICS results reporting for nursing staff to review pertinent laboratory and related patient data
  • eMAR for patient/medication reconciliation by nursing staff using handheld scanner to identify the patient and the medication
  • eMAR for quick communication between nursing and pharmacy staff
Partners/IT has also developed a system for outpatient care called LMR – the Longitudinal Medical Record – which has been deployed throughout the Partners network at outpatient clinics and in provider offices. LMR supports continuity of care with access for authorized users, incuding primary care providers, to the full range of an individual’s inpatient and outpatient data.

The combination of systems developed by Partners/IT and obtained from vendors places BWH firmly within the very small minority of institutions found by reserachers to have comprehensive systems.
“On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals.”

from Use of Electronic Health Records in U.S. Hospitals

Similarly, the widespread application of information technology to support patient care establishes the Partners network as well along towards meeting national goals.

source 2008 AnnualReport, Partners HealthCare (pdf)

Other considerations

BWH house staff independently acquire and use their preferred personal digital assistant (PDA). These devices can be synchronized with various medical department schedules, as well as provide access to the Partners email system through Microsoft Exchange Server.

Partners attending physicians and house staff use online telehealth to review radiology images at affiliated sites, an application I’m personally familiar with as a member of an accredited stroke center.

Finally, the near-term system development objectives for BWH includes replacing the current paper chart used for written inpatient progress notes and other patient care charting with a fully computerized electronic medical record.

BWH is the most fully automated patient care setting I have ever worked in. The systems here meet my professional needs and support quality patient care.