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Running head: INFORMATICS PRACTICUM 1

Informatics Clinical Practicum Proposal

Mary Hefferan RN, BSN

Ferris State University

INFORMATICS PRACTICUM 2

Abstract

Developing a clinical practicum proposal guides learning and prepares master’s degree seeking

nurses for their advanced specialty role. This proposal outlines an informatics clinical practicum

that will take place during a hospital-wide transition to a new electronic health record (EHR)

system. The student will assist in providing education and support to end-users in order to

develop skills as an informatics nurse specialist (INS). Guiding this experience is a self-

assessment highlighting areas in need of improvement and a leaning plan that utilizes American

Nurses Association standards (2008) to develop learning objectives. A literature review

identifies barriers and facilitators to EHR implementation and how they correspond to the INS

role. Support from theorists Patricia Benner and Everett Rogers provides a foundation for the

role of an INS and provides a framework for the experience. The practicum will take place in a

35 bed hospital under the supervision of a master’s prepared nurse. Evaluation tools created will

serve as a measure of how well learning objectives were met; occurring at mid and end points of

the practicum.

KEY WORDS: clinical practicum; informatics nurse specialist; electronic health record; end-

user education


Informatics Clinical Practicum Proposal

The informatics nurse specialist (INS) plays a key role in integrating new

technology into the clinical environment. Advances in technology aim to increase patient safety

and improve nursing care, but without careful education and involvement of end-users, quality of

care may actually suffer (Staggers & Rodney, 2012). Gaining experience in transitioning an

organization to new technology is important to developing INS skills. A clinical practicum is

intended to help develop and prepare the advance practice nurse for their specialty role. The

purpose of this informatics clinical practicum is to participate in a hospital wide transition to a

new electronic health record (EHR) system and provide education and support to end users. The

INS ensures patient safety and quality of care is upheld while the end users optimize its use in

practice. During this transition, standards of nursing informatics (NI) practice will guide

achievement of informatics skills and learning outcomes. The purpose of this paper is to outline

a detailed learning plan to guide achievement of learning outcomes, provide literature support for

the practicum experience, and describe the setting in which the practicum will take place. A

preceptor is identified and their role defined. Finally, evaluation tools are included for mid and

end of semester evaluation to be completed by the preceptor and student.

Student Self-Assessment

The following student self-assessment provides insight regarding where the student

should seek experiences that serve to fill gaps in learning and need for improvement. The

American Nurses Association (ANA, 2008) standards for NI and the Learning Nurse (2015)

website that provides advanced self-assessment tools were utilized to provide guidance. The

Learning Nurse (2015) website lists qualities a nurse leader should demonstrate in the advanced

nurse role competencies. The student has not experienced leading a team and/or being in a


supervisor role. Previous class projects completed helped achieve competency in effective

communication, prioritization, and exchanging constructive feedback. However, when in an

advanced nursing role, more responsibility will be assumed and there will be a need to delegate

tasks and evaluate goals more independently.

Also noted from the Choi and Zucker’s (2013) article discussing self-assessment of NI

competencies, was the need for immersion in more aspects of utilizing data retrieved from

informatics tools for use in practice. During the clinical practicum, the student hopes utilize

different methods of data collection to help guide the project. Specifically, utilizing qualitative

and quantitative data will help identify where the EHR implementation can be improved during

the education of super-users and on-site training. Additionally, Sherwood and Barnsteiner

(2012) describe INS competencies of leading use of an EHR by “model[ling] behaviors that

support implementation and appropriate use of EHRs” (p. 177) and serving as a resource for

nursing documentation. Displaying these behaviors as the practicum experience progresses will

be crucial to developing skills as an INS.

Learning Plan

The learning plan describes learning objectives created for the practicum utilizing the

ANA’s (2008) standards of assessment, problem and issues identification, planning, and

education. The four standards were integrated into the learning plan outlined in Appendix A.

The ANA (2008) standard 1: Assessment, states the INS “collects data, information, and

knowledge in a systematic and ongoing process…to examine current practice workflow, and the

potential impact of an informatics solution on that workflow” (p. 67). Focus on this standard

during the clinical practicum will occur by participating in interdisciplinary meetings analyzing

impacts of informatics solutions on workflow, optimizing the implementation of an informatics


solution, and incorporating human-computer interaction (HCI) principles into the informatics

solution. Incorporating research regarding HCI and nursing informatics principles will facilitate

achievement of this goal. Standard 2: problem and issues identification, involves identifying

needs or issues that may arise when implementing an informatics solution. Identifying potential

issues or problems will be achieved by attending super user training classes and eliciting

feedback.

In addition, focus on Standards 4: Planning and 7: Education will occur during the

clinical practicum (ANA, 2008). Working closely with key stakeholders and end users to

identify shared goals and expectations of the informatics solution as well as organizational

policies influencing implementation, will assist in achieving the ANA (2008) standard 4:

Planning. Also, attending meetings discussing progress and integrating current research into

planning, will “contribute to the development and continuous improvement of organizational

systems” (ANA, 2008, p. 70). The final standard 7: Education, tasks the INS to seek experiences

to develop professional skills needed for this advanced role. To meet this standard, learning

experiences will be sought through relevant conferences and/or classes that aid in knowledge

advancement and skill development specific to nursing informatics. Goals will be

communicated with the chosen preceptor as well as gaps in learning in order to cater the

experience to the identified gaps.

Literature Review

The literature review intends to provide support and guide the practicum experience.

Theories by Patricia Benner and Everett Rogers are described to offer a foundation for the

practicum experience. Barriers and facilitators to electronic health record (EHR) implementation

are identified and their relationship to the informatics nurse specialist (INS) role is described.


The literature describes the INS role as assisting in end-user involvement, education, and

usability of new technologies incorporated into the nursing workflow (ANA, 2008). Darvish,

Bahramnezhad, Keyhanian, and Navidhamidi (2014) explain the INS’s importance in interacting

with and involving end users. They state without adequate training for nurses, integration of new

technology will be difficult and negatively affect nursing practice. The authors also explain

since nurses are required to utilize technology in their daily patient care, their successful

utilization is imperative to providing quality care. The INS is in a position to facilitate

successful implementation of new technology and help optimize its impact on nursing workflow.

Staggers and Rodney (2012) describe the INS role in terms of its importance on

evaluating usability of new technology. They found the INS often identifies issues affecting

usability of technology and provides important feedback regarding end user experience.

Through an understanding of what an organization values most, the INS assesses the impact a

new product will have and its usability. Optimal usability entails that efficiency and

effectiveness is improved and end users are satisfied. Not evaluating usability can effect

productivity and increase the risk of error.

Irizarry and Barton (2013) describe how the social aspect of an organizational

environment must be considered when implementing new technology. The authors state there is

an interdependence “between the social and technical aspects of an organization” (Irizarry &

Barton, 2013, p. 283). By recruiting end users and engaging them, the INS helps support

implementation and spread adoption. Staggers and Rodney (2012) also describe the role of the

INS as a social change agent and how they positively influence user experience by becoming

internal “champions” promoting usability. To help facilitate EHR implementation, the INS


utilizes specialized skills and knowledge identified by these authors to support and train end

users, improve nursing workflow, and optimize usability.

Support through Theory

Patricia Benner

Patricia Benner’s theory discussing nurses’ skill development through education and

experiences will guide and support learning during the practicum experience. Her theory, from

novice to expert, describes five levels of nursing skill acquisition as “novice, advanced beginner,

competent, proficient, and expert” (Blum, 2010, p. 304). This practicum will provide experience

in the INS role, as described by Benner, as being necessary to develop and build a proficient skill

base. The practicum will not serve to facilitate progression to expert role, but to the advanced

beginner who has gained meaningful experiences related to a future INS role. Also, this theory

describes the expert as one who has more than five years of experience and makes decisions

intuitively based on role proficiency. The identified preceptor for this practicum experience has

the characteristics of an expert under Benner’s theory. The expert provides leadership and

direction, serving as an appropriate guide to a novice.

Everett Rogers

In addition to Benner’s nursing theory, Roger’s Diffusion of Innovation Theory will

provide a framework for the practicum experience of implementing a new EHR into an

organization. This theory proposes an innovation or new practice, is adopted and diffused

through an organization in four stages: Dissemination, adoption, implementation, and

maintenance (Dingfelder & Mandell, 2011). Dissemination and adoption of the new EHR is

currently underway within the organization. The key stakeholders have been made aware of the

new change (dissemination) and are committed to utilizing the new EHR (adoption).


Implementation and maintenance will occur during the EHR go-live and when support is

provided and users commit to the program. Roger’s theory also discusses characteristics of the

end-users that will guide the practicum objective. There are innovators, early adopters, early

majority, late majority and laggards (Sahin, 2006). Focusing on the social system when

implementing change as Roger’s suggests, may help support and gain organizational acceptance.

EHR Implementation

Barriers

Identifying barriers to implementing an EHR will help identify potential problems and

guide preventive actions. Lluch (2011) conducted a literature review identifying key areas that

would hinder EHR adoption. The author found organizational structure and hierarchal practices

can prevent young “change agents” who tend to embrace technological change, from becoming

valuable key stakeholders during EHR implementation. Change agents can be influential in

motiving and supporting an organization through a complete practice change such as a new EHR

system. The INS can mitigate this barrier, serving as both a change agent and one to recognize

and engage change agents who will be valuable in assisting EHR adoption.

McGinn and colleagues (2011) found lacking interest and motivation to utilize the EHR

was a major barrier to implementation. Facilitating and encouraging interest may suffer when

cohesion within the organization does not exist. McAlearny, Sieck, Hefner, Robbins and Huerta

(2013) stated the gap between early adopters and the majority is difficult to unite and is a factor

in failed EHR implementation. Similarly, if an organization does not support and facilitate

teamwork throughout the varied tiers of an organization, EHR adoption will be hindered and use

fragmented (Lluch, 2011). The leadership skills of an experienced INS can help promote

teamwork and the interdisciplinary interaction needed for successful implementation.


Another barrier identified through the literature is fear related to the risk to the privacy of

information when implementing an EHR. Kruse, Regier, and Rheinboldt (2014) found security

and privacy concerns as a barrier stating the Health Information Portability and Accountability

Act (HIPAA) created “hypersensitivity for patient privacy and security of health information” (p.

8). Kumar and Aldrich (2010) stated some policymakers are insisting patients obtain legal

documentation protecting their privacy prior to EHR implementation; further promoting this fear.

Privacy issues were the second most identified barrier for healthcare professionals and patients

as reported by McGinn et al. (2011). If healthcare providers distrust or feel they could be liable

for misuse of information, EHR adoption will suffer. Maintaining confidentiality and promoting

the ethical use of protected information is at the core of ethics for nursing and the INS (ANA,

2008).

Facilitators

In order for an EHR to be successfully adopted by the staff of a healthcare organization,

it must represent an improvement in workflow efficiency, patient safety and quality of care

(Huryk, 2010). Cherry (2011) identifies a key sign of readiness for EHR implementation is that

the chosen EMR system has evidence it will improve care. EHR use is shown to improve

effectiveness, clinical decision making, and management (Ghazisaeedi, Mohammadzadeh, &

Safdari, 2014). After careful evaluation of the EHR’s quality, the INS can be influential in

representing the evidence showing EHRs improve overall nursing care (ANA, 2008). When

provided with knowledge based on research showing EHRs reduce errors from drug interactions

and medical diagnostic errors, staff will be more receptive to change (Ghazisaeedi, et al., 2014).

Another facilitator to successful EHR adoption is including analysis of clinician

workflow and how processes will be changed following the implementation. McAlearney, and


colleagues (2013a) found a redesign and analysis of workflow is critical to ensuring effective

utilization of the EHR. Documenting and discussing varied workflows within an organization

will determine changes in practice and tests where potential problems may arise (Lorenzi,

Kourobaldi, Detmer, & Bloomrosen, 2009). This should also reduce the risk of staff transferring

old habits into the new workflow (McAlearney et al., 2013a). The INS is a key stakeholder

during discussions of workflow processes as new technology is introduced. By advocating for

nursing practice and patient care, the INS assists in ensuring workflows are efficient, safe, and

support the nursing practice.

Lastly, in most all the literature reviewed, education and support during EHR

implementation was shown to be an important key to success. McAlearney et al. (2013b) stated

post implementation support must consist of individuals who had extensive knowledge regarding

the technology and clinical knowledge. Training and support must include real scenarios and

encourage communication regarding staff’s needs (Lorenzi et al., 2009; MacDonald & Riahi,

2012). Kumar and Aldrich (2010) also stress the importance of education and support that

continues post-implementation. Ongoing training is crucial for inevitable upgrades and changes

that occur with technology and for complete optimization of its full potential. The INS must

play a key role in preparing educational models and support following implementation. The

ANA (2008) states the INS participates in all phases of information technology installations and

must ensure safe, quality patient care is upheld.

Setting and Preceptor

The practicum will take place on the Spectrum Health (SH) Big Rapids Campus. This

hospital joined the SH system in 2013 and they will be transitioning to Cerner; the electronic

health record (EHR) system the SH hospitals uses. This transition to Cerner will provide


continuity of care across the SH system by increasing provider access to patient information as

they receive care at multiple SH locations. Linking all of SH to one EHR system will assist in

data sharing and supporting meaningful use objectives that aim to improve coordination and

safety of care through technology (HealthItT.gov, 2015). The Big Rapids location has a total of

35 beds including a birthing center and a four critical care beds. The informatics department the

student will be working with focuses on nursing informatics (NI) within women’s and children’s

areas of the hospital. There are two staff members that specialize in NI and a manager.

The preceptor chosen to help guide this practicum is Ms. Schmoekel (see Appendix B).

Her credentials are as listed: MSN, RNC-NIC, CPHIMS. She is a clinical informatics

coordinator for SH’s Helen DeVos Children’s Hospital (HDVCH) and has held this position for

seven years. She provides supportive informatics education and coordinates implementation of

informatics solutions for nursing staff of HDVCH and the women’s center. Ms. Schmoekel has

extensive knowledge of the Cerner system and of SH's policies. During the EHR

implementation, she will serve as an educator, nursing practice advocate, and resource. As an

expert in her practice, she will guide achievement of the goals outline in the learning plan.

Professional practice evaluation will occur throughout this practicum by receiving regular

feedback from Ms. Schmoekel and professional peers.

Evaluation Tools

This clinical practicum will be evaluated with a tool to assess the level of achievement of

the learning outcomes (see Appendix C). These measurement criteria address the foundations of

NI practice according to the ANA (2008) standards of assessment, problem and issues

identification, planning, and education. Each outcome will be evaluated by how the student met

expectations at the mid semester point and the end of the practicum experience. The mid-


semester evaluation allows the preceptor to address outcomes not yet achieved and comment on

areas to be considered for the remaining portion of the practicum. The final evaluation tool

serves as a measurement of the practicum in its entirety. The tool includes an area for

commentary serving as self-reflection for the student. Self-reflection is important in developing

leadership qualities and promoting emotional intelligence (Horton-Deutsch & Sherwood, 2008).

The use of a rating scale assists the preceptor and student in highlighting strengths, detecting

weaknesses, and documenting progression towards goal attainment (Durkin, 2010).

Conclusion

The purpose and goals of this informatics practicum are outlined through a learning plan

addressing the main focus areas for the experience. A literature review that includes information

from theory and evidence based research regarding EHR implementation will support the

experience and learning outcomes. Ms. Schmoekel has agreed assist as a preceptor on-site at the

SH Big Rapids campus where the practicum will take place. A mid and end semester evaluation

tool will measure the level of goal achievement and growth through self-assessment as perceived

by the preceptor and student. The elements described serve to facilitate growth in INS skills to

assist use of technology in supporting the nursing practice to providing safe, quality patient care.


References

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Silver Spring, MD: Nursesbooks.org

Blum, A. C. (2010). Using the Benner intuitive-humanistic decision-making model in action: A

case study. Nursing Education in Practice, 10(5), 303-307.

doi:10.1016/j.nepr.2010.01.009

Cherry, B. (2011). Assessing organizational readiness for electronic health record adoption in

long-term care facilities. Journal of Gerontological Nursing, 37(10), 14-19.

doi:10.3928/00989134-20110831-06

Choi, J., & Zucker, M. D. (2013). Self-assessment of nursing informatics competencies for

doctor of nursing practice students. Journal of Professional Nursing, 29(6), 381-387. doi:

http://dx.doi.org/10.1016/j.profnurs.2012.05.014

Darvish, A., Bahramnezhad, F., Keyhanian, S., & Navidhamidi, M. (2014). The role of nursing

informatics on promoting quality of health care and the need for appropriate education.

Global Journal of Health Science, 6(6), 11-18. doi:10.5539/gjhs.v6n6p11

Dingfelder, E. H., & Mandell, S. D. (2011). Bridging the research-to-practice gap in autism-

intervention: An application of diffusion of innovation theory. Journal of Autism and

Developmental Disorders, 41(5), 597-609. doi:10.1007/s10803-010-1081-0

Durkin, G. (2010). Development and implementation of an independence rating scale and

evaluation process for nursing orientation of new graduates. Journal for Nurses in Staff

Development, 26(2), 64-72. doi:10.1097/NND.0b013e3181d47991


Ghazisaeedi, M., Mohammadzadeh, N., & Safdari, R. (2014). Electronic health record (EHR) as

a vehicle for successful health care best practices. Medical Archives, 68(6), 419-421.

Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25648601

HealthIT.gov. (2015). Meaningful use definition and objectives. Retrieved from

http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives

Horton-Deutsch, S., & Sherwood, G. (2008). Reflection: An educational strategy to develop

emotionally-competent nurse leaders. Journal of Nursing Management, 16(8), 946-954.

doi: 10.1111/j.1365-2834.2008.00957.x

Huryk, A. L. (2010). Factors influencing nurses’ attitudes towards healthcare information

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2834.2010.01084.x

Irizarry, T., & Barton, J. A. (2013). A sociotechnical approach to successful electronic health

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Kruse, S. C., Regier, V., & Rheinboldt, T. K. (2014). Barriers over time to full implementation

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(2011). Comparison of user groups perspectives of barriers and facilitators to

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Appendix A

Clinical Practicum II Learning Plan

Mary Hefferan

ANA or NLN Standards of Practice: Specialty role

Outcome Criteria: (taken from the ANA Standards/NLNCompetencies)

Activities to Achieve Outcome.(sufficient in number, measurable, and realistic to achieve each outcome)

Resources needed to be successful

Timeline (Identify semester for now. In

NURS 792, you will add in detail and specifics

dates)

Nursing informatics standard 1: Assessment (ANA, 2008, p. 67)

Involves the patient, family, nurse, other healthcare providers, and key stakeholders, as appropriate, in holistic data collection (ANA, 2008, p. 67)

Collects data, information, and knowledge in a systematic and ongoing process, such as with a needs assessment…or with workflow analyses to

Participate in interdisciplinary meetings that discuss current practice and impact of informatics solutions on workflow; identify key stakeholders for input

Discuss current workflow and analyze to optimize integration of informatics solution, discuss and incorporate human-

Preceptor advice and direction, goals identified for informatics solutions; key stakeholders’ input in assessment data

Current practice workflow and identification of process changes; Research regarding key HCI and informatics principles that will be integrated into informatics solution.

5/19/15-8/12/15


examine current practice, workflow, and the potential impact of an informatics solution on that workflow (ANA, 2008, p. 67)

computer interaction (HCI) principles into design/implementation of informatics solution.

Resource preceptor for advice and input.

Nursing informatics standard 2: Problem and Issues Identification (ANA, 2008, p. 68)

“Derives the problems, needs, or issues based on assessment data” (ANA, 2008, p. 68)

“Documents problems, needs, or issues in a manner that facilitates the determination of the expected outcomes and plan” (ANA, 2008, p. 68)

Attend 3 super user training classes and assess needs of super user and/or issues with training. Analyze training classes through qualitative and quantitative measures

Utilize evaluation tools to identify if any gaps in training and/or issues identified from super user input. Identify how issues may affect implementation. Document and validate issues and proposed solution with key stakeholders

Measures of success identified; evaluation tool, key stakeholder and super user input

Data from evaluation tools and input, research regarding solutions to training gaps in EHR implementation, key stakeholder approval of issues and plan

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Nursing informatics standard 4: Planning (ANA, 2008, p. 70)

Develops a plan in conjunction with the patient, family, nurse, other healthcare providers, key stakeholders, and others, as appropriate (ANA, 2008, p. 70).

Identify shared goals and expectations of key stakeholders and the organizational policies that will influence implementation; meet with key stakeholders to plan

Goals/expectations; organizational policies and supportive research regarding ethical implications of informatics solution. Resource preceptor for advice and

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Contributes to the development and continuous improvement of organizational systems that support the planning process (ANA, 2008, p. 70)

how to address issues that arise during EHR go-live

Attend at least 2 meetings per month with preceptor and key stakeholders regarding prioritization of goals, support of nursing principles, and supportive education during/after implementation

input

Schedule of meetings with key stakeholders, effective communication skills, current research to guide planning/development process

Nursing informatics standard 7: Education (ANA, 2008, p. 77)

Contributes to the development and continuous improvement of organizational systems that support the planning process (ANA, 2008, p. 70)

Seeks experiences that reflect current practice in order to maintain skills and competence in informatics practice and role performance (ANA, 2008, p. 77)

Provide supportive education by participating in at least 4 on-site support days during EHR go-live.Discuss issues with implementation that could be improved from nursing and patient safety perspective

Identify areas for skill development and opportunities to further develop in nursing informatics. Find at least one education opportunity or conference to attend specific for nursing informatics specialty

Education tools for use during EHR go-live, effective communication skills, support from informatics and nursing principals

Preceptor input and resources, access to conference/class.

5/19/15-8/12/15


Appendix B


Appendix C

Evaluation: Mid-Semester

o Preceptor

o Student

Please evaluate the graduate student’s performance based on the elements listed derived from the American Nurses Association’s

(ANA, 2008) scope and standards of practice for Nursing Informatics. Each competency listed is evaluated through terms of

exceeding requirements, meets requirements, needs improvement, or unsatisfactory. For purposes of mid-semester evaluation, the

N/A column applies for goals not yet achieved. Please provide additional comments for consideration and areas for growth and

development and how to improve performance for the final weeks of the practicum.

Competency Exceeds requirements

Meets requirements

Needs improvement

Unsatisfactory N/A Comments/Considerations

The student involved key stakeholders as appropriate to collect information pertinent to the project.The student collected data to refine issue and gain


knowledge towards the impact of a solution.The student identified needs or issues based on assessment dataThe student documented needs and developed plan and expected outcomesThe student developed a plan with key stakeholder involvement and identified goalsThe student supported organizational priorities and goals during the planning processThe student sought experiences to develop skills and competency in informatics practiceThe student utilized current research to support knowledge and growth in specialty area


Summary of practicum experience (identify strengths, areas for improvement and skill development):

Preceptor name ______________________________________________________ Date________________

Preceptor signature ___________________________________________________


Preceptor Evaluation: End of Semester

o Preceptor

o Student

Please evaluate the graduate student’s performance based on the elements listed derived from the American Nurses Association’s

(ANA, 2008) scope and standards of practice for Nursing Informatics. Each competency listed is evaluated through terms of

exceeding requirements, meets requirements, needs improvement, or unsatisfactory. Please provide additional comments for

consideration and areas for growth and development and how to improve professional practice as a masters prepared nurse.

Competency Exceeds requirements

Meets requirements

Needs improvement

Unsatisfactory Comments/Considerations

The student involved key stakeholders as appropriate to collect information pertinent to the project.The student collected data to refine issue and gain knowledge towards the impact of a


solution.The student identified needs or issues based on assessment dataThe student documented needs and developed plan and expected outcomesThe student developed a plan with key stakeholder involvement and identified goalsThe student supported organizational priorities and goals during the planning processThe student sought experiences to develop skills and competency in informatics practiceThe student utilized current research and theory to support knowledge and growth in specialty area


Summary of practicum experience (identify strengths, areas for improvement and skill development):

Preceptor name ______________________________________________________ Date________________

Preceptor signature _______________________________________


Resource List

Kaminski, J. (2010). Theory applied to nursing informatics: Novice to expert. Retrieved from

http://cjni.net/journal/?p=967

Nursing Theories. (2013). From novice to expert. Retrieved from

http://currentnursing.com/nursing_theory/Patricia_Benner_From_Novice_to_Expert.html

Spectrum Health. (n.d.) About Big Rapids hospital. Retrieved from

http://www.spectrumhealth.org/new-medicalsurgical-and-critical-care-units

Wilson, L. M. (2012). Clinical informatics: Evaluation, selection, implementation, and

management of electronic health records [PowerPoint slides]. Retrieved from

http://www.aacn.nche.edu/qsen-informatics/2012-workshop/presentations/wilson/

Clinical-Informatics.pdf

http://cjni.net/journal/?p=967