INTRODUCTIONInnovations in health care are continuously introduced.

Health care
providers apply best practices from latest researches and use appropriate tools to
enhance the quality of health care delivered.Patients appear to become more engaged
in their care, through information available on the Internet, radio, and
television. Communication problems between patients and health care providers,
brought about by geographical disparity, are easily solved by mobile phones.
Computers are used to store, retrieve, and process important health data for better
decision making. Information and Communications Technologies (ICT) ares becoming
indispensable tools in addressing some challenges in health care.ICTs are defined
as, “diverse set of technological tools and resources used to communicate, and to
create, disseminate, store, and manage information." These technologies include
computers, the Internet, broadcasting technologies (radio and television), and
services, health surveillance, health literature, telephony. This chapter explores
the actual and potential applications of ICTs geared toward improving people's
access and utilization of health care in the Philippine community health setting.
What is eHealth? eHealth is the use of ICT for health. On May 25, 2005, during the
Fifty-Eighth World Health Assembly (WHA), a resolution was adopted by the World
Health Organization (WHO) member states recognizing eHealth as the cost-effective
way of using ICT in health care services, health surveillance, health literature,
health education, and research. Given the extensive capabilities of ICT, eHealth
can be considered in any of, but not limited to, the following:
• Communicating with a patient through a teleconference, electronic mail
(e-mail), short message service (SMS).
• Recording, retrieving, and mining data in an electronic medical record
(EMR).
• Providing patient teachings with the aid of electronic tools such as
radio, television, computers, smartphones, and tablets.
eHealth, often confused with telehealth or telemedicine, is the overall, umbrella
term. According to the WHO, eHealth encompasses three main areas:

1 The delivery of health information, for health professionals and health

consumers, through the Internet and telecommunications.
2 Using the power of information technology (IT) and e-commerce to
improve public health services, for example, through the education and training of
health workers.
3 The use of e-commerce and e-business practices in health systems
management.

The power of data and information

Nurses are knowledge managers. They constantly process raw patient data into
valuable information to deliver evidence-based and individualized interventions. It
is imperative for every eHealth practitioner to know the importance and difference
between the two.

Data are the fundamental elements of cognition and are defined as unanalyzed raw
facts that do not imply meaning. When meaning is attributed to data and when data
are processed and analyzed, then data become information.

Consider, for instance, the number 39. It can be an age, house number, jersey
number, etc. This is data. The school nurse noted that it was written on the
respiratory rate field of the record of Grade 5 student Rosemarie. Number 39 now
has a meaning to the nurse and has become information. Based on the nurse's
knowledge that Rosemarie's respiratory rate is above normal and considering other
findings, the nurse concludes that she is hyperventilating. The nurse gave
Rosemarie a brown paper bag to breathe into.

The health care system builds heavily on accurate recording of obtained data.
Paper-based methods may bring inconvenience especially when it comes to
interoperability of health services, information backup, and instant data access. A
number of bigger problems may also emerge:

1 Continuity and interoperability of care stops in the unlikely event

that a record gets misplaced. If the patient suffers from a chronic condition,
previous findings supporting this diagnosis, drug allergies, preexisting
conditions, or even past accounts of the patient's previous visits may no longer be
accessed unless the health providers have made several copies of the same record.
The patient may also need to recount his/her condition for every transfer of care.
2 Illegible handwriting poses misinterpretation of data. A direct
observational study of medication administration found opportunities for errors
associated with incomplete or illegible prescriptions.
3 Patient privacy is compromised. Traditional, paper-based patient
records are vulnerable to unauthorized viewing since there is no audit trail of the
usage of the chart. The disclosure of highly private information arising from such
an incident can lead to loss of trust in the health facility or even legal risks.
4 Data are difficult to aggregate. Manual data recording and tallying
significantly delays implementation of interventions and targeted health programs.
Health care monitoring is compromised as information is not readily available and
up-to-date on a daily basis.
5 Actual time for patient care gets limited. Time spent by the community
health worker searching for a paper-based record is time lost for actual care.
Likewise, for both clinical and community settings, the overall impact of the
problems related to manual/traditional data-gathering is articulated as follows:

Internal and external changes affecting health care informatics:

1 The ability to manipulate large amounts of data

2 The ability to relate data to cohorts of people who share similar
health problems
3 The ability to link to genomic data

In contrast, having a well-managed patient information system can have the

following benefits:

1 Data are readily mapped, enabling more targeted interventions and

feedback.
• Through a system that delivers real-time and accurate patient and
community information, health care providers are able to deliver patient-centered
care and targeted disease prevention and management programs. The facility and
staff are also provided feedback on their performance through computer alerts,
enabling them to continually comply with standard guidelines and monitor monthly,
quarterly, or yearly health targets. From the societal public health perspective,
adhering to these guidelines keeps individuals healthy and lowers the risk of
disease outbreaks in communities.
• Health professionals can also track the frequency and locale of
diseases in real time through an EMR and Geographic Information System (GIS) like
the Philippine Health Atlas of the Department of Health. GIS technology enables
detailed maps to be generated with relative speed and ease. In turn, this provides
public health practitioners with the ability to provide quick responses to
questions or concerns raised in a community meeting. GIS is not the complete
solution to understanding the distribution of disease and the problems of public
health, but at is an important way in which to better illuminate how humans
interact with their environment to create or deter health.
2
3 Data can be easily retrieved and recovered.
• In the event of force majeure, retrieval of patient information is not
a problem since data are automatically backed-up periodically in a secure server.
 4
5 Redundancy of data is minimized.
• Patient data that are frequently required in various health forms such
as unique identifying information (e.g. name, birthday, age, gender) need to be
recorded only once. These can be linked and organized automatically into related
record types through a database, allowing a better record management and ease-of-
use.
6
7 Data for clinical research becomes more available.
• The potential impact of health research in the country is often
hindered by the lack of quality data. Whenever data is gathered, it is often not
communicated to the rest of the research community. Having quality data stored in
databases provides faster and more reliable research outputs that may eventually be
translated to health care innovations and actual interventions.
8
9 Resources are used efficiently.
• By making patient information more readily available, EMRs reduce costs
related to chart pulls as well as supplies needed to maintain paper charts. Studies
have also shown that having an EMR as opposed to a paper file can result in reduced
transcription costs through point-of-care documentation and other structured
documentation procedures. In developing countries, health care information systems
have been driven mainly by the need to report aggregate statistics for government
or funding agencies. Improvements in drug supply management using medication data
from EMR systems can offer the most measurable cost benefits at present; a well-
managed drug supply also improves availability and quality of patient care.
10

Good data qualities

The nursing process begins with obtaining data through assessing the patient's
signs and symptoms. These data are interpreted by the health care professional into
useful information and a diagnosis. This is then followed by necessary
interventions and again ends with gathering new data from evaluating the results.
Without data, it will be difficult for a health professional to assist the patient.

Human error, viruses, bugs, and hardware issues pose a great threat to the
integrity of data. ICT can help decrease these errors by putting safeguards in
place, such as backing up files on a routine basis and error detection. In order
for information to be valuable, data must have the following characteristics:

EHEALTH SITUATION IN THE PHILIPPINESThe developing world suffers from inadequate

health care and medical services. Lack of health care professionals and
infrastructure contributes to this problem, making it more difficult to deliver
health care to people in rural and remote communities of the developing world.The
ubiquity of mobile technologies and availability of Internet services in the
Philippines create a promising ground for eHealth access. In 2001, roughly 2.5% of
the country's population had Internet access. In the span of 10 years, this rate
steadily increased to 29%. The Philippines has also a mobile phone penetration rate
of 80%, with 73 million subscribers as of 2009. In addition, the country is ranked
first in terms of short messaging service (SMS) usage in the entire world.ICT has
changed how Filipinos access information and how the government has utilized this
to inform its citizenry. Examples of these include regular updates of traffic
conditions, current events, and critical weather reports through various social
media.The health sector has also begun utilizing ICT to improve its services. The
DOH has introduced a number of health information systems that aim to improve the
access of health data, such as the Electronic Field Health Service Information
System, Online National Electronic Injury Surveillance System, the Philippine
Health Atlas, and the Unified Health Management Information System. Factors
affecting eHealth in the countryAs mentioned earlier, numerous limitations impede
the development of eHealth in the country, especially in the community setting.
However, various innovations have allowed eHealth implementations to gain ground.
Both limiting and advancing factors are discussed in this section.Limited health
budgetAs mentioned previously, the budget allocation for health care is relatively
small. This is one of the many reasons advancements in eHealth are postponed. ICT
projects usually require a huge budget, take a long period to implement, and are
occasionally seen as risky endeavors.An example of a "failed" eHealth project was
the United Kingdom's National Health Service (NHS) National Program for IT (NPfiT),
which was launched in 2002 with a budget of £11.4 billion. The objective of the
program was to "ensure every NHS patient had an individual electronic care record
which could be rapidly transmitted between different parts of the NHS". However,
after 9 years in development and after spending almost £7 billion, the UK
government decided to revise NPfiT as it was regarded as incapable of meeting its
target objective, given the limited available remaining resources.The emergence of
free and open source softwareIn eHealth, the cost of software procurement or
development often takes up a huge portion of the budget. In addition, using ready-
made proprietary software can be limiting at times, especially when users want to
modify the software to fit their workflow better.To modify the software, its source
code needs to be changed. The source code is like the ingredients of a recipe. If
one wants to modify the recipe, one will need to adjust some of the ingredients.
Like some recipes, some source codes are kept secret too, which may cause the buyer
of the proprietary software to remain locked in to the seller's support and
maintenance. Since the sellers own the source code of the program, they are the
only ones who can modify the program. This may entail additional and unplanned
costs, adding to the problem of health budgetary limitations.An emerging trend all
over the world is the development and increasing popularity of Free and Open Source
Software (FOSS). In a nutshell, FOSS makes the source code of a program freely
available for everyone, hence the name "open source." Using the same recipe
analogy, information on the ingredients is made accessible to the public, allowing
anyone to "cook something up." This allows anyone with the knowledge of programming
to contribute to the source code, improving the program and sharing the improvement
with everyone. To some extent, FOSS can theoretically cut costs in developing the
software.A perfect example of a successful FOSS for health in the Philippines is
the Community Health Information Tracking System (CHITS), currently managed by the
University of the Philippines Manila-National Telehealth Center (UPM-NTHC).
Interested software developers and students from UP Manila, taking into
consideration recommendations of community health professionals, are able to
contribute to the development and improvement of CHITS because its source code is
made openly available. Decentralized governmentUnder R.A. 7160 or the Local
Government Code of 1991, local government units (LGUs) are autonomous, and
therefore in control of their own basic health services, including the budget.
Because of this, it is typical to see diverse and unrelated eHealth projects
developing all over the country such as the Wireless Access for Health (WAH) in
Tarlac, the Secured Health Information and Network Exchange (SHINE) in Iloilo, and
the numerous CHITS installations in municipalities all over the Philippines. LGUs
may develop their own systems. These efforts have accelerated the development of
eHealth in community health. However, to maximize advantages derived from these
systems and to produce a nationwide impact, the different health information
systems will eventually need to connect with each other. Having one EMR system for
all health centers will make consulting in different facilities easier. But
unifying and harmonizing the different existing systems for this future benefit,
though not impossible, will expectedly be difficult. Target users are unfamiliar
with the technologyeHealth is not only about technology. Along with software
development and hardware procurement, staff training and maintenance of the system
are key factors in determining its effectiveness. Recognition of the cultural
aspects of community life is important in starting them off into a new direction
such as computerization and automation.One possible pitfall of eHealth
implementations is focusing on software development before accomplishing an
assessment of the needs of health professionals in the field. Most health center
personnel are not familiar with the use of computers. Implementing an eHealth
system requires training of health personnel on basic computer skills, use of
software, and maintenance of the equipment. No matter how technologically advanced
the tools are, the success of an eHealth implementation will eventually depend on
the end-user's willingness to learn and accept the technology.The benefits of
eHealth and telemedicine occur to communities when the technology presents itself:
1 As an enhancement to existing human relationships that have been
established through conventional routes
2 As a solution to a long-felt community need.
To illustrate, in 2004, the National Telehealth Center initiated the BuddyWorks
project, which was funded under the eGov Fund from the Commission on Information
and Communications Technology (CICT). Its aim was to provide medical specialist
support through a structured telereferral system for physicians situated in
geographically isolated communities. Initially the project utilized a web-based
system. However, the lack of a reliable Internet connection in remote areas made
the system unreliable. The physicians were also unfamiliar with the use of the
system. Thus, in a 2-year period, the project was only able to process eight
referrals.

Based on lessons learned from the early BuddyWorks experience, the project switched
to the use of technology that is more appropriate to Filipinos—mobile phones.

The switch made BuddyWorks more accessible as it utilized preexisting communication

systems such as SMS offered by mobile phone service providers. After the
transition, the number of referrals drastically increased to 1,939 in a period of
17 months.

Surplus of "digital native" registered nurses

"Not too long ago we had nothing to think about except the board exams. And before
that, we had to make sure we were qualified to take the exams by completing the
requirements, along with many other adversities. Sure, passing the exams was a
reason to celebrate, but I was celebrating yesterday, not tomorrow.

I knew darker days lay ahead. The United States was in the midst of trying to
reform their health care system (again). US President Barack Obama wanted to solve
their nursing shortage from within instead of importing foreign nurses. Other
countries were not accepting new graduates and required a minimum of one year's
experience. This created a domino effect no one wanted. With the foreign-bound
staff nurses choosing to keep their local jobs, the 30,000 new registered nurses of
Batch 2009 were basically left with just their Professional Regulation Commission
licenses to be proud of.“ From the article "Cleaning Up." Published by the
Philippine Daily Inquirer, September 6, 2011.

Because of logistic limitations, government hospitals and health centers are mostly
understaffed despite the estimated 200,000 underemployed or unemployed nurses in
the country.

One of the measures of the DOH to address the accumulation of unemployed

professional nurses is the Registered Nurses for Health Enhancement and Local
Services (RN Heals) Project. It aims to provide nurses with one-year employment in
underserved and remote areas in the country as well as to provide underserved areas
with additional professional health workers. A term coined by educator and writer
Marc Prensky, digital native describes a person who grew up and is familiar with
digital technologies, and who uses them in daily living. The entry of digital
native nurses into the profession and their nationwide deployment to communities
may potentially aid the implementation of various ICT projects in health care.
Overall, the Philippines is progressing in its use of eHealth for the benefit of
its citizens. How eHealth specifically affects community health will be taken up in
greater detail in the next section.
Graphic. USING EHEALTH IN THE COMMUNITY. Universal Health Care and ICT. Electronic
medical records. Telemedicine. eLearning. End of Graphic.
USING EHEALTH IN THE COMMUNITYAs mentioned earlier, the major goal of community
health nursing is to preserve the health of the community. This is best achieved by
focusing on health promotion and health maintenance of individuals, families, and
groups within the community. This section gives details as to how eHealth enables
the community health nurse in contributing towards the achievement of this goal.
Universal Health Care and ICTIn the Philippines, making health care accessible to
all remains a great challenge. Lack of financial health care coverage leads to high
out-of-pocket expenses. The marked mass migration of health professionals leaves
the remote and rural areas of the country with limited access to specialized health
care. The archipelagic distribution of the country—with 7,107 islands—makes health
care delivery even more challenging.A series of health reforms have been
implemented. The DOH, through Administrative Order No. 2010-0036, outlined the
policy directions of Universal Health Care.Also known as Kalusugan Pangkalahatan
(KP), this reform agenda has three priority health directions:
1 Financial risk protection through expansion in National Health
Insurance Program enrolment and benefit delivery
2 Improved access to quality hospitals and health care facilities
3 Attainment of the health-related Millennium Development Goals (MDGs)

One of the aims of KP is to attain efficiency by using IT in all aspects of health

care.

One of the key instruments it underlines is the use of Health Information to

establish a modern information system that shall provide evidence for policy and
program development and support for immediate and efficient provision of health
care and management of province-wide health systems.

The DOH also recognizes the valuable purpose of ICT for health and has drafted its
National eHealth Strategic Framework for 2010-2016, with the vision of ICT
supporting UHC to improve health care access, quality, efficiency, and patient's
safety and satisfaction, for reducing cost and enabling policy makers, providers,
individuals, and communities to make the best possible health decisions.

Electronic medical records

EMRs are basically comprehensive patient records that are stored and accessed from
a computer or server. Community health centers have the capacity to rapidly adapt
EMRs because they utilize a standard process nationwide. For example, the workflow
with a patient at a health center in Quezon City is basically the same as that of a
health center at Batanes.

In contrast, EMRs are more difficult to implement in hospitals because each

hospital has its own set of protocols coupled with its own system of documentation.
Even government-owned hospitals do not have a standard system of health service
provision and of maintaining patient records. This difficulty in implementing
information systems in the health sector highlights the importance of creating
standards.

Another reason EMRs are vital to community health centers is that each patient
record is usually used more frequently. For instance, a patient undergoing
treatment for tuberculosis needs to make regular visits to the health center for
TB-DOTS (Tuberculosis Directly-Observed Treatment Shortcourse). A young child is
brought to the health center regularly for child care health services, such as
immunizations, deworming, and micronutrient supplementation. Community health
centers make health care services available to families, enabling the community
health worker to observe familial predispositions to certain diseases and provide
appropriate health promotion and prevention measures.

Ideally, a person can utilize health center services from womb to tomb. This ideal
scenario is made more likely if each patient encounter is properly documented and
the patient recording system is set up with accuracy and efficiency in mind.

As stated earlier, community health nurses should be aware of health patterns and
health indicators within their catchment area. Vital statistical indicators such as
mortality and morbidity rates must come from reliable data, which can be derived
from accurate and thorough EMRs. EMR systems also allow computerized processing of
indicators, making it easier for nurses to focus on other important aspects of
health care.

One of the most widely used community-based EMR in the country is CHITS, which
began in 2004 and was funded by the International Development Research Centre
(IDRC). It was created by Dr. Herman Tolentino of the University of the
Philippines-Medical Informatics Unit (UP-MIU) and is currently being implemented at
health centers in Pasay, Navotas, Quezon City, and several other municipalities
nationwide. Training on how to optimize the EMR for community use and on-site
follow-ups of the health workers were done. This resulted in EMR features that are
customized to the needs of the health center and the community. More importantly,
involving the target end users in the development process of the EMR gave them a
sense of ownership of the program, allowing easy acceptance and utilization of
CHITS.

Telemedicine

One of the five strategic goals of the DOH National eHealth Strategic Framework for
2010-2016 is to capitalize on ICT. This in order to reach and provide better health
services to geographically isolated and disadvantaged areas (GIDAs), to support MDG
attainment, and to disseminate information to citizens and providers through
telemedicine and mobile health (mHealth) services.

The WHO defines telemedicine as, "the delivery of health care services, where
distance is a critical factor, by all health care professionals using information
and communications technologies for the exchange of valid information for
diagnosis, treatment and prevention of disease and injuries, research and
evaluation, and for the continuing education of health care providers, all in the
interests of advancing the health of individuals and their communities".

WHO further underscores four elements that are specific to telemedicine:

1 Its purpose is to provide clinical support.

2 It is intended to overcome geographical barriers, connecting users who
are not in the same physical location.
3 It involves the use of various types of ICT.
4 Its goal is to improve health outcomes.
In the Philippines, the UPM-NTHC has been using telemedicine to provide health
services to remote and underserved areas of the country since 2004. It is a partner
of the DOH in the Doctors to the Barrios program. It enabled Municipal Health
Officers to teleconsult difficult cases with trained telehealth medical specialists
via SMS or e-mail. The teleconsults, which are received by a server, are then
triaged by the NTHC telehealth nurses to appropriate medical specialists.

In collaboration with the Philippine Council for Health Research and Development of
the Department of Science and Technology (DOST-PCHRD), the BuddyWorks project of
UPM-NTHC was continued from 2007 to 2010 as the National Telehealth Service Program
(NTSP).

A specific example of how telemedicine was applied in the community was the
discovery of a rare skin disease called tinea imbricata in a tribe from Kiamba,
Saranggani in Mindanao. The Municipal Health Office of Kiamba, Saranggani referred
multiple cases of strange, ring-like formations on a patient's skin. Images were
sent to the UPM-NTHC telehealth nurse and were referred to a dermatology specialist
at the Philippine General Hospital, who gave the initial diagnosis of tinea
imbricata—which has only been reported in the Philippines three times since 1789.
The recommended treatment was effective. This eventually led to a medical mission
by the dermatology specialist and her fellow dermatologists in cooperation with the
local government of Kiamba to help the patients affected by the disease.

As can be seen from the example, telemedicine has the capacity to bridge the gaps
in the health referral system. It is understandable that this is not a universal
solution and may be applicable only in specific scenarios. The goal of a patient
receiving the best care as soon as possible despite an unfavorable location or
other adverse circumstances may be reached through telemedicine.

eLearning

Health education, which is essential in health promotion and maintenance, can be

facilitated by ICT.

eLearning is basically the use of electronic tools to aid in teaching. It can be

done synchronously, asynchronously, or in a combination of both. This can be in the
form of simple instructional videos and information textblasts to social network
help groups and interactive simulations. eLearning can be especially useful in
correcting misconceptions about health and health care. It permits access to
reliable information about health. For example, control of communicable diseases
frequently requires community participation. With the use of eLearning technology,
community health nurses can elicit community interest by showing instructional
videos on measures to control a particular disease.

eLearning can also be used to educate fellow health professionals. With eLearning,
continuing education sessions can be frequently availed of, with less time, effort
and expense involved in the process. Continuing professional education of nurses
can be undertaken by attending online and virtual seminars through teleconferences
and multiuser virtual environments.

Examples of eHealth projects in the community

Graphics below are the summary of eHealth projects, past and present, that target
community health. Note that some projects are a combination of EMRs, telemedicine,
eLearning, and other ways by which ICTs impact health.

The similarities among the projects and their implementations are noteworthy. Also,
they are scattered in different parts of the country. The working of these projects
usually does not interfere with each other, creating potential problems as
previously explained.
ROLES OF COMMUNITY HEALTH NURSES IN EHEALTHCommunity health nurses' roles are
significantly diversified by eHealth. With the advent of eHealth, nurses are made
available to several clients at a single time, making health care delivery more
efficient. Advances in IT may also help the nurse in optimizing efforts towards
maintaining an open line of communication with clients, paving the way for
establishing and maintaining rapport. IT literally at the fingertips of the nurse
provides greater opportunity to learn more about clients and their conditions;
eHealth, however, cannot be a replacement for actual patient care. It is best
viewed as a powerful tool for nurses—bridging gaps and improving access especially
in a resource-constrained country like the Philippines.The following are the major
roles of an eHealth nurse in the Philippine community setting: Data and records
managerAs data and records managers, community health nurses monitor the trends of
diseases through the EMR, allowing for targeted interventions for health promotion,
disease prevention, curative services, or rehabilitation. Nurses also maintain the
quality of data inputs in the EMRs, making sure that information is accurate,
complete, consistent, correct, and current. Nurses also participate in regular data
audits. Change agentNurses act as change agents by working closely with the
community and implementing eHealth with them and not for them. Change agents do not
force technology on the community, but inform and guide the community in selecting
and applying appropriate ICT tools.Change agents also collaborate with health
leaders, policy makers, stakeholders, and other community health professionals to
determine their knowledge and awareness on eHealth and appropriate ICT tools.
Nurses then build on the baseline eHealth knowledge and help develop appropriate
eHealth tools for the community. EducatorNurses provide health education to
individuals and families through ICT tools (e.g. teleconference, SMS, e-mail, and
virtual/ simulated environment). They may also participate in making eLearning
videos on specific diseases (e.g. diabetes mellitus, tuberculosis), which the
patients can watch during their waiting time at health centers. Such videos may
also be installed in the clients' personal phones (if supported) and watched at a
time convenient to them.Nurses may also use scheduled text messages to patients
among the catchment population to send important health information, reminders,
etc. TelepresenterIn the event that a patient needs to be referred to a remote
medical specialist through telemedicine, nurses may function as a telepresenter.
This means that the nurse may need to present the patient's case to a remote
medical specialist, noting salient points for case assessment, evaluation, and
treatment. This usually occurs via a teleconference. Client advocateAs client
advocates, community health nurses must safeguard patient records, ensuring that
security, confidentiality, and privacy of all patient information are being upheld.
This becomes more challenging especially because with technology, transfer of
information can happen instantly.The client must also be well informed about the
benefits and challenges of EMRs, telemedicine, and other eHealth tools. Nurses must
ensure that personal and health information handling through eHealth (i.e.,
collection, storage, and transmission) is well explained. Clients must sign an
informed consent, if necessary.Nurses must also guarantee that all eHealth
interventions are performed in a safe and ethical manner, making sure that
personnel involved in eHealth are competent and have received eHealth
training/certification. ResearcherUsing eHealth tools (e.g. EMRs), patient records
can easily be retrieved and analyzed retrospectively by community eHealth nurses.
They are responsible for identifying possible points for research and developing a
framework, based on data aggregated by the system.An eHealth nurse researcher also
pursues continuing nursing informatics education, with the goal of developing a
research framework which will be beneficial to the community.