Common Errors in Patient Education

One of the most important aspects of the nurse’s role is to educate patients. To do that effectively, there are a couple of points that nurses (as well as other health care professionals) should be aware of.

One is that health care illiteracy affects over one half of all Americans. Regardless of their ability to read and write, or their level of education, Americans don’t understand the health care system and how it works. They don’t even understand enough most of the time to know that they don’t understand.

The other point is that as a result of this problem, the Institute for Health Care Advancement (IHA)points out that costs are continuing to rise to the point of, “as much as $236 billion in unnecessary health care expenses annually due to the inability of patients to understand what medical providers are communicating to them.”

The IHA has complied a guide for health care professionals and consumers to help eliminate some of these problems. This list is composed of the 10 Most Common Errors Medical Professionals Make When Communicating with Their Patients.

Some of the points in this document include:

• Prescription drug instructions are often written at a 10th or 11th grade reading level. Most of the population reads at a 5th grade level.
• Communicating with patients using medical or other technical jargon such as “otitis media” or “myocardial infarction” instead of using laypersons’ terms such as “ear ache” or heart attack.”
• Telling patients to go read about their condition, treatments or medications on the Internet when this information might be too complex, might disagree with the physician’s course of treatment, or the patient may not have access or know how to search the Internet.
• Handing out reading material which is printed in too small a font to be easily read, especially by seniors who represent the largest portion of the population.
• Not using simple graphics or other visual aids to enhance the patient’s understanding.
• Not recognizing that the patient is nodding or saying “yes” as more of a means to be polite and not necessarily because s/he understands what is being said.

Providers should always ask patients to repeat back to them in their own words what they interpret to be the information or instructions given to them. Tis is the best way for the provider to be sure the patient understands correctly and then to make clarifications as needed.

Not demonstrating cultural awareness and how cultural differences may affect the patient’s ability to comply and to succeed with a treatment or other regimen.

• Speaking too quickly and not allowing the patient time to formulate or ask questions.
• Not providing the information and instructions in the patient’s first language.
• Not taking time to adequately explain the meaning of terms on prescription drug labels. For example, “Take With Food,” is written at a 1st or 2nd grade level, but what does it really mean? Studies have shown that some patients have interpreted this as meaning stuffing the pill into a piece of solid food and swallowing it without taking any liquid. This could have varying degrees of problems depending upon the drug and even the size of the pill.

Other problems patients typically have difficulty with include how and when to make follow up appointments, where to go for tests, and even which medications should be refilled and continued versus a course of antibiotics.

Even the most highly educated patients may not understand medical information. Nurses, as the primary health educators, need to understand how to educate patients as well as how to evaluate the patient’s understanding before they leave.

Resources:
IHA (http://iha4health.org)
Helen Osborne M.Ed.,OTR/L, Health Literacy Consulting (http://healthliteracy.com)
By Kathy Quan RN BSN. Kathy is the author of The Everything New Nurse Book and the author/owner of TheNursingSite.com

Issues in health information

Improving the use of information for health care decision-making: what is needed
World Health Organization / World Health Organization (WHO) (2005)

This paper, published by the World Health Organization, describes how health information systems work and considers how countries can reform them. It argues that some types of data are oversupplied whilst in other areas there are large unmet needs of information. Although many countries now have relatively good data on levels of (and trends in) child mortality, health services coverage, and health determinants, information on adult mortality and cause of death is not generally available. Other areas where better information is needed include: morbidity; coverage and costs of interventions; and equity. The use of information to inform decision- making is also weak at all levels of the healthcare system.
The paper calls for investment in sustainable national and sub-national health information systems and argues that countries will benefit greatly if such systems are based upon a national plan with a policy framework; core indicators; and data-collection, analysis and dissemination strategies. It also calls for national bodies to guide and oversee the implementation of the plan,
with full participation of stakeholders, users, and technical experts. International investors in health information should buy in to and support the country strategies. Collaborative efforts at the international level, such as the recently launched Health Metrics Network, are also important.

Available online at: http://www.who.int/healthmetrics/library/issue_1_05apr.doc

Why Health Care Information Systems Succeed or Fail

Heeks, R.; Mundy, D.; Salazar, A. / Institute for Development Policy and Management (IDPM), Manchester (1999)
This document offers an understanding and model of why health care information systems succeed or fail, and with general guidance on how to avoid HCIS failure.

Some health care information systems (HCIS) do succeed, but the majority are likely to fail in some way. To explain why this happens, and how failure rates may be reduced, this paper describes the 'ITPOSMO' model of conception-reality gaps. This argues that the greater the change gap between current realities and the design conceptions (i.e. requirements and assumptions) of a new health care information system, the greater the risk of failure. Three archetypal large design-reality gaps affect the HCIS domain and are associated with an increased risk of failure:
• Rationality-reality gaps: that arise from the formal, rational way in which many HCIS are conceived, which mismatches the behavioural realities of some health care organisations

• Private-public sector gaps: that arise from application in public sector contexts of HCIS developed for the private sector.
• Country gaps: that arise from application in one country of HCIS developed in a different country.
Some generic conclusions can be drawn about successful approaches to HCIS development. Examples include the need for more reality-oriented techniques and applications, and greater use of participative approaches to HCIS. More specifically, techniques can be identified for each of the seven ITPOSMO dimensions that will help close the gap between conception and reality. This can include the freezing of one or more dimensions of change. Such techniques will help improve the contribution that information systems can make in health care organisations. [author]

Available online at: http://www.sed.manchester.ac.uk/idpmpublications/wp/igov/igov_wp09.shtml

Using a simple health care information system for health sector reform and health system management

A guide to using the InHCC health management information system

Shankle, C.G.; Shiroma, M.G.; Gonzalez, J.G. / International Health Care Consultants (InHCC) (2002)

This paper, published by International Health Care Consultants (InHCC), presents a simple health management information system (HMIS) for collecting data to be used in the management of health sector reform policy. The system is intended to be easy to use and inexpensive. It focuses on the collection of information that measures six key dimensions of health system performance: access, effectiveness, efficiency, equity, quality, and sustainability. The paper argues that the information collected can be used not only to guide national policies, but also to direct the day-to-day management of the individual clinic or health centre and provide quality of care to the client.
The paper’s chapters cover: the purpose, definitions and framework for the InHCC system; a description of the system itself; dealing with client, household, and medical system information; and programming the system’s software. The system proposed involves rural clients using a low-cost computer system connected to the internet, and storing data in a centralised "data warehouse". Specialised computer applications for data processing can then be used to provide useful information for decision makers from the local level up to national and international level without the need for further processing.

Available online at: http://www.shetu.com/InHCc-Documentation.pdf

Virtual Private Networks

Background

Virtual private networks (VPNs) are a fairly quixotic subject; there is no single defining product, nor even much of a consensus among VPN vendors as to what comprises a VPN. Consequently, everyone knows what a VPN is, but establishing a single definition can be remarkably difficult. Some definitions are sufficiently broad as to enable one to claim that Frame Relay qualifies as a VPN when, in fact, it is an overlay network. Although an overlay network secures transmissions through a public network, it does so passively via logical separation of the data streams.

VPNs provide a more active form of security by either encrypting or encapsulating data for transmission through an unsecured network. These two types of security—encryption and encapsulation—form the foundation of virtual private networking. However, both encryption and encapsulation are generic terms that describe a function that can be performed by a myriad of specific technologies. To add to the confusion, these two sets of technologies can be combined in different implementation topologies. Thus, VPNs can vary widely from vendor to vendor.

This chapter provides an overview of building VPNs using the Layer 2 Tunneling Protocol (L2TP), and it explores the possible implementation topologies.

Layer 2 Tunneling Protocol

The Internet Engineering Task Force (IETF) was faced with competing proposals from Microsoft and Cisco Systems for a protocol specification that would secure the transmission of IP datagrams through uncontrolled and untrusted network domains. Microsoft's proposal was an attempt to standardize the Point-to-Point Tunneling Protocol (PPTP), which it had championed. Cisco, too, had a protocol designed to perform a similar function. The IETF combined the best elements of each proposal and specified the open standard L2TP.

The simplest description of L2TP's functionality is that it carries the Point-to-Point Protocol (PPP) through networks that aren't point-to-point. PPP has become the most popular communications protocol for remote access using circuit-switched transmission facilities such as POTS lines or ISDN to create a temporary point-to-point connection between the calling device and its destination.

L2TP simulates a point-to-point connection by encapsulating PPP datagrams for transportation through routed networks or internetworks. Upon arrival at their intended destination, the encapsulation is removed, and the PPP datagrams are restored to their original format. Thus, a point-to-point communications session can be supported through disparate networks. This technique is known as tunneling.

Operational Mechanics

In a traditional remote access scenario, a remote user (or client) accesses a network by directly connecting a network access server (NAS). Generally, the NAS provides several distinct functions: It terminates the point-to-point communications session of the remote user, validates the identity of that user, and then serves that user with access to the network. Although most remote access technologies bundle these functions into a single device, L2TP separates them into two physically separate devices: the L2TP Access Server (LAS) and the L2TP Network Server (LNS).

As its names imply, the L2TP Access Server supports authentication, and ingress. Upon successful authentication, the remote user's session is forwarded to the LNS, which lets that user into the network. Their separation enables greater flexibility for implementation than other remote access technologies.

Implementation Topologies

L2TP can be implemented in two distinct topologies:

•Client-aware tunneling

•Client-transparent tunneling

The distinction between these two topologies is whether the client machine that is using L2TP to access a remote network is aware that its connection is being tunneled.

Client-Aware Tunneling

The first implementation topology is known as client-aware tunneling. This name is derived from the remote client initiating (hence, being "aware" of) the tunnel. In this scenario, the client establishes a logical connection within a physical connection to the LAS. The client remains aware of the tunneled connection all the way through to the LNS, and it can even determine which of its traffic goes through the tunnel.

Client-Transparent Tunneling

Client-transparent tunneling features L2TP access concentrators (LACs) distributed geographically close to the remote users. Such geographic dispersion is intended to reduce the long-distance telephone charges that would otherwise be incurred by remote users dialing into a centrally located LAC.

The remote users need not support L2TP directly; they merely establish a point-to-point communication session with the LAC using PPP. Ostensibly, the user will be encapsulating IP datagrams in PPP frames. The LAC exchanges PPP messages with the remote user and establishes an L2TP tunnel with the LNS through which the remote user's PPP messages are passed.

The LNS is the remote user's gateway to its home network. It is the terminus of the tunnel; it strips off all L2TP encapsulation and serves up network access for the remote user.

Adding More Security

As useful as L2TP is, it is important to recognize that it is not a panacea. It enables flexibility in delivering remote access, but it does not afford a high degree of security for data in transit. This is due in large part to the relatively nonsecure nature of PPP. In fairness, PPP was designed explicitly for point-to-point communications, so securing the connection should not have been a high priority.

An additional cause for concern stems from the fact that L2TP's tunnels are not cryptographic. Their data payloads are transmitted in the clear, wrapped only by L2TP and PPP framing. However, additional security may be afforded by implementing the IPSec protocols in conjunction with L2TP. The IPSec protocols support strong authentication technologies as well as encryption.

Summary

VPNs offer a compelling vision of connectivity through foreign networks at greatly reduced operating costs. However, the reduced costs are accompanied by increased risk. L2TP offers an open standard approach for supporting a remote access VPN. When augmented by IPSec protocols, L2TP enables the realization of the promise of a VPN: an open standard technology for securing remote access in a virtually private network.

Review Questions

Q—What is a VPN?

A—A VPN is a generic term that describes any combination of technologies that can be used to secure a connection through an otherwise unsecured or untrusted network.

Q—Explain the difference between L2TP's LAC and LSN.

A—The LAC provides authentication and access concentration for remote users. After a remote user is authenticated, that user's communications session is then forwarded to the LSN, which provides access to that user's home network.

Q—What additional functionality does IPSec offer an L2TP implementation?

A—L2TP's native security mechanisms build on the assumption that the nature of a
point-to-point connection satisfies most of a remote user's security requirements. IPSec complements L2TP by offering a more robust set of technologies for authenticating remote users and for securing data in transit through foreign networks by encrypting data.

Q—What is a tunnel?

A—A tunnel is a logical structure that encapsulates the frame and data of one protocol inside the Payload or Data field of another protocol. Thus, the encapsulated data frame may transit through networks that it would otherwise not be capable of traversing.