AACN Advanced Critical Care Volume 26, Number 3, pp. 194-196 © 2015 AACN
Technology Today
Linda Harrington, RN-BC, PhD, DNP, CNS, CPHQ, CENP, CPHIMS Department Editor
Can Health Care Survive Current Electronic Health Record Usability? Linda Harrington, RN-BC, PhD, DNP, CNS, CPHQ, CENP, CPHIMS
U
sability of electronic health records (EHRs) is defined as how useful, usable, and satisfying the EHR is for end users in accomplishing the goals of their work.1 Usable refers to how easy the EHR is to learn and use. Useful refers to how well the EHR supports end users in accomplishing their work. An EHR is satisfying when end users find it pleasing to use and look forward to using it. With this definition in mind, stop and ask yourself: How easy is the EHR to learn and use? Is it easy to find what you need, when you need it and where you need it, or is it difficult to access, and are there too many clicks? How often do you find yourself wading through things in the EHR that have no relevance to your practice? More importantly, how useful is the EHR to your practice? Does it provide important guidance in delivering the appropriate patient care, and does the EHR prevent you from making errors? If the EHR is easy to use and appreciably useful to your practice, it is reasonable to assume that the EHR is satisfying as a clinical practice tool. On September 16, 2014, the American Medical Association issued a press release calling for design overhaul of “EHR systems that have neglected usability as a necessary feature.”2 Their concerns were based on a landmark study with the RAND Corporation highlighting the significant toll EHRs are exacting on clinicians,3 findings echoed in numerous usability studies, blogs, and other types of reports. In the previous Technology Today column, we focused on clinical workflow, one of the most problematic aspects of EHR usability. This column focuses on some of the most significant consequences resulting from current usability in EHRs throughout health care. Costs Costs incurred from poor usability come from multiple sources.4 For example, vendor organizations have costs for development, including documentation, support, and maintenance. It is reasonable to assume that unnecessary extra costs are passed on to EHR buyers. A classic case illustrating significant cost reductions in vendor organizations from improved software usability is from McAfee, an antivirus software developer.5 When McAfee introduced its brand-new ProtectionPlus software, the company had 20 000 downloads during an initial 10-week period with 170 support calls, a third of which dealt with presales and not support issues. This number of calls was approximately one-tenth of the number they historically had seen with new Linda Harrington is Vice President and Chief Nursing Informatics Officer, Catholic Health Initiatives, 198 Inverness Dr West, Englewood, CO 80112 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000081
194 Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-15-00008.indd 194
08/07/15 8:56 PM
VOLUME 26 • NUMBER 3 • JULY-SEPTEMBER 2015
software releases, and the decrease was no accident. McAfee strategically planned to make the user interface a priority, thereby improving usability and dramatically reducing user support needs and associated costs. When it comes to EHRs, ask yourself what other software requires so much support just to use it, including instructional designers, train-the-trainers, superusers, end-user training, one-on-one training, at-the-elbow support, sandboxes and playgrounds, weekly updates, tip sheets and pocket guides, clinical help desks and remote support, user groups and list servs, adoption programs, scribes, and more? All of these are associated with costs to EHR buyers. How much of the costs could be eliminated with better EHR usability established with early planning and design, thereby eliminating costs caused by rework? The biggest and most preventable cost incurred by both EHR vendors and EHR buyers stem from the cost of change as identified by Boehm6 almost 40 years ago. According to Boehm, the cost of changing software increases exponentially over time. Using Boehm’s cost of change curve, it is easy to appreciate that incorporating good usability early in the planning and design of EHRs is significantly cheaper than building, testing, training, and implementing EHRs and then going back to improve usability that then requires further building, testing, training, and implementing. Unfortunately, this high cost of the EHR change model is in play across the country today. Although many refer to these changes as customization, they are too often usability issues that could have and should have been dealt with earlier in the EHR lifecycle. Another cost worth mentioning involves the impact of current EHR usability on clinician productivity. Although the ability to improve productivity through improved EHR usability has been empirically demonstrated,7 common sense indicates that issues such as wading through EHR content that is never used, unnecessary clicks, scrolling and sliding, difficulty finding what is needed, seeing a clear picture of the patient, and coordinating care in the EHR affect productivity and therefore cost. Safety One of the most well-known recent safety issues regarding EHR usability occurred with the first case of Ebola in the United States. In December 2014, the physician overseeing the
Technology Today
patient’s initial emergency department (ED) visit where he was sent home reported in The Dallas Morning News that he had not seen the travel to Africa documentation in the patient’s EHR.8 The physician went on to say that the hospital’s EHR contained so much information that it, like patients, “must also be triaged” and that the “travel information was not easily visible in my standard workflow.” The physician’s statements in this first Ebola case should not be overlooked or readily dismissed by anyone involved with EHRs—not end users, not informaticists, not IT professionals, not health care leaders, and not EHR vendors. Whereas health care safety is often being compared with aviation strategies, a very important lesson drawn from aviation is applicable to this case. It surrounds what aviation refers to as “clutter” of the pilot’s flight display and what the ED physician aptly described as “travel information was not easily visible in my standard workflow” in the Ebola case. Display clutter occurs when there is “too much data on too small an area of the display diminishing the potential usefulness of the visualization, especially when the user is exploring the data rather than posing specific questions.”9(p1216) It is a key concern in the design of complex displays, given the potential negative impacts of data overload on performance, particularly in safety-critical domains such as aviation10 or in health care. Display clutter can obscure important information11 as reported in the Ebola case. With all the clutter in EHRs, where does the clinician begin searching for pertinent data and how does the clinician know where to end the search? Electronic health records today are, in large part, an electronic form of the paper record in that it remains largely siloed. It is worse than the paper record as a result of a significant increase in clutter in those siloes when all reasonable clinician documentation responses that can be anticipated have been designed and built into EHRs. Whereas all of the additional content is assumed to benefit manual data entry by providing clinicians every potential option for documentation, it actually creates clutter and interferes with the clinician’s ability to locate and remember relevant data from multiple siloed areas in the EHR to synthesize the data, which is analogous to the flight display clutter once experienced by airplane pilots. It impedes the ability to cognitively create a current and accurate picture of a patient or a flight situation
195 Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-15-00008.indd 195
08/07/15 8:56 PM
Technology Today
WWW.AACNADVANCEDCRITICALCARE.COM
from which to make important decisions, thereby creating safety risks. Loss of Transformation Electronic health records are fundamentally a database. The key driver mandating the implementation of EHRs across the United States was the highly desired benefit of using electronic data to transform health care. There has been a delay in this transformation and a realization that there is a growing amount of bad data in EHRs. Poor EHR usability is cited as a significant part of the problem and improved usability an important part of the solution.12,13 Many usability issues lead to loss of data integrity in EHRs.14 Usability problems include confusing user interfaces, workflow incompatibilities, and redundancy in content. These can lead to incomplete, diluted, or duplicative capture of data. Redundant content is worsened when the redundancy involves synonyms such as red, redness, reddened, reddish, ruddy, and rosy. When aggregating data for analytics, one would need to know all of the synonyms that were used and where they are located in the EHR, and yet that will not suffice. Nurses have confessed to documenting the same thing multiple times in each place they are aware of in the EHR, creating multiple instances of the same data, which would distort any subsequent analysis. Other EHR functionality, intended to improve usability, such as templates, standard phrases, copy forward, and automated documentation, can actually lead to inaccurate data entry. Allowing free text is also problematic. It can be overused, especially when clinicians cannot locate the structured text. Clinicians may also use words or terms in free text that do not match those in the structured text, making capture and possible merge of that free text data difficult. These different types of usability issues, including others not mentioned here, serve to undermine the integrity of the data being captured in EHRs that will ultimately result in loss or delay of clinical transformation. It is the ageold “garbage in, garbage out” notion. Analytics being applied to EHR data with low integrity will yield clinical decisions with low integrity.
Conclusion Can health care survive current EHR usability? The answer is maybe, but it will be at significant, largely unnecessary, costs, safety issues, and loss or delay in clinical transformation. The time to correct our EHR course is now. Clinicians, patients, health care leaders, and researchers should insist on significant improvements in usability from EHR vendors, health care system information technology departments, and policy makers. REFERENCES 1. Zhang J, Walji M. TURF: toward a unified framework of EHR usability. J Biomed Inform. 2011;44:1056–1067. 2. American Medical Association. AMA calls for design overhaul of electronic health records to improve usability. http://www.ama-assn.org/ama/pub/news/news/2014/ 2014-09-16-solutions-to-ehr-systems.page. Accessed January 15, 2015. 3. Freidberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. RAND Corp. http://www.rand.org/content/dam/ rand/pubs/research_reports/RR400/RR439/RAND_RR439. pdf. Published October 2013. Accessed January 15, 2015. 4. Harrington L, Harrington C. Usability Handbook for Electronic Health Records. Chicago, IL: Healthcare Information and Management Systems; 2014. 5. Hadley B. Clean, cutting-edge UI design cuts McAfee support calls by 90%. SoftwareCEO. July 6, 2004. http://goo .gl/1WbhfT. Accessed January 15, 2015. 6. Boehm B. Software engineering. IEEE Transact. 1976; 100(25):1226–1241. 7. Saitwal H, Feng X, Walji M, Patel V, Zhang J. Assessing performance of an electronic health record (EHR) using cognitive task analysis. Int J Med Inform. 2010;79(7):501– 506. 8. Lathrop D, Moffeit M. ER doctor discusses role in Ebola patient’s initial misdiagnosis. Dallas Morning News. December 6, 2014. http://www.dallasnews.com/ebola/ headlines/20141206-er-doctor-discusses-role-in-ebolapatients-initial-misdiagnosis.ece. Accessed January 15, 2015. 9. Ellis G, Dix A. A taxonomy of clutter reduction for information visualization. IEEE Trans Vis Comput Graph. 2007;13(6):1216–1223. 10. Alexander AL, Kaber DB, Sang-Hwan K, et al. Measurement and modeling of display clutter in advanced flight display technologies. Int J Aviat Psychol. 2012;22(4):299– 318. 11. Lohrenz MC, Trafton JG, Beck MR, Gendron ML. A model of clutter for complex, multivariate geospatial displays. Hum Factors. 2009;51(1):90–101. 12. Armijo D, McDonnell C, Werner K. Electronic Health Record Usability: Interface Design Considerations. AHRQ Publication No. 09(10)-0091-2-EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2009. 13. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff. 2013;32(1):63–68. 14. Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag. 2013;10:1–19.
196 Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-15-00008.indd 196
08/07/15 8:56 PM
Can Health Care Survive Current Electronic Health Record Usability? Linda Harrington AACN Adv Crit Care 2015;26 194-196 10.1097/NCI.0000000000000081 ©2015 American Association of Critical-Care Nurses Published online http://acc.aacnjournals.org/ Personal use only. For copyright permission information: http://acc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Subscription Information http://acc.aacnjournals.org/subscriptions/ Information for authors http://acc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/nci/default.aspx Email alerts http://acc.aacnjournals.org/subscriptions/etoc.xhtml
AACN Advanced Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published quarterly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright ©2016 by AACN. All rights reserved
Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
Technology Today
Linda Harrington, RN-BC, PhD, DNP, CNS, CPHQ, CENP, CPHIMS Department Editor
Can Health Care Survive Current Electronic Health Record Usability? Linda Harrington, RN-BC, PhD, DNP, CNS, CPHQ, CENP, CPHIMS
U
sability of electronic health records (EHRs) is defined as how useful, usable, and satisfying the EHR is for end users in accomplishing the goals of their work.1 Usable refers to how easy the EHR is to learn and use. Useful refers to how well the EHR supports end users in accomplishing their work. An EHR is satisfying when end users find it pleasing to use and look forward to using it. With this definition in mind, stop and ask yourself: How easy is the EHR to learn and use? Is it easy to find what you need, when you need it and where you need it, or is it difficult to access, and are there too many clicks? How often do you find yourself wading through things in the EHR that have no relevance to your practice? More importantly, how useful is the EHR to your practice? Does it provide important guidance in delivering the appropriate patient care, and does the EHR prevent you from making errors? If the EHR is easy to use and appreciably useful to your practice, it is reasonable to assume that the EHR is satisfying as a clinical practice tool. On September 16, 2014, the American Medical Association issued a press release calling for design overhaul of “EHR systems that have neglected usability as a necessary feature.”2 Their concerns were based on a landmark study with the RAND Corporation highlighting the significant toll EHRs are exacting on clinicians,3 findings echoed in numerous usability studies, blogs, and other types of reports. In the previous Technology Today column, we focused on clinical workflow, one of the most problematic aspects of EHR usability. This column focuses on some of the most significant consequences resulting from current usability in EHRs throughout health care. Costs Costs incurred from poor usability come from multiple sources.4 For example, vendor organizations have costs for development, including documentation, support, and maintenance. It is reasonable to assume that unnecessary extra costs are passed on to EHR buyers. A classic case illustrating significant cost reductions in vendor organizations from improved software usability is from McAfee, an antivirus software developer.5 When McAfee introduced its brand-new ProtectionPlus software, the company had 20 000 downloads during an initial 10-week period with 170 support calls, a third of which dealt with presales and not support issues. This number of calls was approximately one-tenth of the number they historically had seen with new Linda Harrington is Vice President and Chief Nursing Informatics Officer, Catholic Health Initiatives, 198 Inverness Dr West, Englewood, CO 80112 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000081
194 Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-15-00008.indd 194
08/07/15 8:56 PM
VOLUME 26 • NUMBER 3 • JULY-SEPTEMBER 2015
software releases, and the decrease was no accident. McAfee strategically planned to make the user interface a priority, thereby improving usability and dramatically reducing user support needs and associated costs. When it comes to EHRs, ask yourself what other software requires so much support just to use it, including instructional designers, train-the-trainers, superusers, end-user training, one-on-one training, at-the-elbow support, sandboxes and playgrounds, weekly updates, tip sheets and pocket guides, clinical help desks and remote support, user groups and list servs, adoption programs, scribes, and more? All of these are associated with costs to EHR buyers. How much of the costs could be eliminated with better EHR usability established with early planning and design, thereby eliminating costs caused by rework? The biggest and most preventable cost incurred by both EHR vendors and EHR buyers stem from the cost of change as identified by Boehm6 almost 40 years ago. According to Boehm, the cost of changing software increases exponentially over time. Using Boehm’s cost of change curve, it is easy to appreciate that incorporating good usability early in the planning and design of EHRs is significantly cheaper than building, testing, training, and implementing EHRs and then going back to improve usability that then requires further building, testing, training, and implementing. Unfortunately, this high cost of the EHR change model is in play across the country today. Although many refer to these changes as customization, they are too often usability issues that could have and should have been dealt with earlier in the EHR lifecycle. Another cost worth mentioning involves the impact of current EHR usability on clinician productivity. Although the ability to improve productivity through improved EHR usability has been empirically demonstrated,7 common sense indicates that issues such as wading through EHR content that is never used, unnecessary clicks, scrolling and sliding, difficulty finding what is needed, seeing a clear picture of the patient, and coordinating care in the EHR affect productivity and therefore cost. Safety One of the most well-known recent safety issues regarding EHR usability occurred with the first case of Ebola in the United States. In December 2014, the physician overseeing the
Technology Today
patient’s initial emergency department (ED) visit where he was sent home reported in The Dallas Morning News that he had not seen the travel to Africa documentation in the patient’s EHR.8 The physician went on to say that the hospital’s EHR contained so much information that it, like patients, “must also be triaged” and that the “travel information was not easily visible in my standard workflow.” The physician’s statements in this first Ebola case should not be overlooked or readily dismissed by anyone involved with EHRs—not end users, not informaticists, not IT professionals, not health care leaders, and not EHR vendors. Whereas health care safety is often being compared with aviation strategies, a very important lesson drawn from aviation is applicable to this case. It surrounds what aviation refers to as “clutter” of the pilot’s flight display and what the ED physician aptly described as “travel information was not easily visible in my standard workflow” in the Ebola case. Display clutter occurs when there is “too much data on too small an area of the display diminishing the potential usefulness of the visualization, especially when the user is exploring the data rather than posing specific questions.”9(p1216) It is a key concern in the design of complex displays, given the potential negative impacts of data overload on performance, particularly in safety-critical domains such as aviation10 or in health care. Display clutter can obscure important information11 as reported in the Ebola case. With all the clutter in EHRs, where does the clinician begin searching for pertinent data and how does the clinician know where to end the search? Electronic health records today are, in large part, an electronic form of the paper record in that it remains largely siloed. It is worse than the paper record as a result of a significant increase in clutter in those siloes when all reasonable clinician documentation responses that can be anticipated have been designed and built into EHRs. Whereas all of the additional content is assumed to benefit manual data entry by providing clinicians every potential option for documentation, it actually creates clutter and interferes with the clinician’s ability to locate and remember relevant data from multiple siloed areas in the EHR to synthesize the data, which is analogous to the flight display clutter once experienced by airplane pilots. It impedes the ability to cognitively create a current and accurate picture of a patient or a flight situation
195 Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-15-00008.indd 195
08/07/15 8:56 PM
Technology Today
WWW.AACNADVANCEDCRITICALCARE.COM
from which to make important decisions, thereby creating safety risks. Loss of Transformation Electronic health records are fundamentally a database. The key driver mandating the implementation of EHRs across the United States was the highly desired benefit of using electronic data to transform health care. There has been a delay in this transformation and a realization that there is a growing amount of bad data in EHRs. Poor EHR usability is cited as a significant part of the problem and improved usability an important part of the solution.12,13 Many usability issues lead to loss of data integrity in EHRs.14 Usability problems include confusing user interfaces, workflow incompatibilities, and redundancy in content. These can lead to incomplete, diluted, or duplicative capture of data. Redundant content is worsened when the redundancy involves synonyms such as red, redness, reddened, reddish, ruddy, and rosy. When aggregating data for analytics, one would need to know all of the synonyms that were used and where they are located in the EHR, and yet that will not suffice. Nurses have confessed to documenting the same thing multiple times in each place they are aware of in the EHR, creating multiple instances of the same data, which would distort any subsequent analysis. Other EHR functionality, intended to improve usability, such as templates, standard phrases, copy forward, and automated documentation, can actually lead to inaccurate data entry. Allowing free text is also problematic. It can be overused, especially when clinicians cannot locate the structured text. Clinicians may also use words or terms in free text that do not match those in the structured text, making capture and possible merge of that free text data difficult. These different types of usability issues, including others not mentioned here, serve to undermine the integrity of the data being captured in EHRs that will ultimately result in loss or delay of clinical transformation. It is the ageold “garbage in, garbage out” notion. Analytics being applied to EHR data with low integrity will yield clinical decisions with low integrity.
Conclusion Can health care survive current EHR usability? The answer is maybe, but it will be at significant, largely unnecessary, costs, safety issues, and loss or delay in clinical transformation. The time to correct our EHR course is now. Clinicians, patients, health care leaders, and researchers should insist on significant improvements in usability from EHR vendors, health care system information technology departments, and policy makers. REFERENCES 1. Zhang J, Walji M. TURF: toward a unified framework of EHR usability. J Biomed Inform. 2011;44:1056–1067. 2. American Medical Association. AMA calls for design overhaul of electronic health records to improve usability. http://www.ama-assn.org/ama/pub/news/news/2014/ 2014-09-16-solutions-to-ehr-systems.page. Accessed January 15, 2015. 3. Freidberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. RAND Corp. http://www.rand.org/content/dam/ rand/pubs/research_reports/RR400/RR439/RAND_RR439. pdf. Published October 2013. Accessed January 15, 2015. 4. Harrington L, Harrington C. Usability Handbook for Electronic Health Records. Chicago, IL: Healthcare Information and Management Systems; 2014. 5. Hadley B. Clean, cutting-edge UI design cuts McAfee support calls by 90%. SoftwareCEO. July 6, 2004. http://goo .gl/1WbhfT. Accessed January 15, 2015. 6. Boehm B. Software engineering. IEEE Transact. 1976; 100(25):1226–1241. 7. Saitwal H, Feng X, Walji M, Patel V, Zhang J. Assessing performance of an electronic health record (EHR) using cognitive task analysis. Int J Med Inform. 2010;79(7):501– 506. 8. Lathrop D, Moffeit M. ER doctor discusses role in Ebola patient’s initial misdiagnosis. Dallas Morning News. December 6, 2014. http://www.dallasnews.com/ebola/ headlines/20141206-er-doctor-discusses-role-in-ebolapatients-initial-misdiagnosis.ece. Accessed January 15, 2015. 9. Ellis G, Dix A. A taxonomy of clutter reduction for information visualization. IEEE Trans Vis Comput Graph. 2007;13(6):1216–1223. 10. Alexander AL, Kaber DB, Sang-Hwan K, et al. Measurement and modeling of display clutter in advanced flight display technologies. Int J Aviat Psychol. 2012;22(4):299– 318. 11. Lohrenz MC, Trafton JG, Beck MR, Gendron ML. A model of clutter for complex, multivariate geospatial displays. Hum Factors. 2009;51(1):90–101. 12. Armijo D, McDonnell C, Werner K. Electronic Health Record Usability: Interface Design Considerations. AHRQ Publication No. 09(10)-0091-2-EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2009. 13. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff. 2013;32(1):63–68. 14. Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag. 2013;10:1–19.
196 Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-15-00008.indd 196
08/07/15 8:56 PM
Can Health Care Survive Current Electronic Health Record Usability? Linda Harrington AACN Adv Crit Care 2015;26 194-196 10.1097/NCI.0000000000000081 ©2015 American Association of Critical-Care Nurses Published online http://acc.aacnjournals.org/ Personal use only. For copyright permission information: http://acc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Subscription Information http://acc.aacnjournals.org/subscriptions/ Information for authors http://acc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/nci/default.aspx Email alerts http://acc.aacnjournals.org/subscriptions/etoc.xhtml
AACN Advanced Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published quarterly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright ©2016 by AACN. All rights reserved
Downloaded from http://acc.aacnjournals.org/ by AACN on September 5, 2017
