In 1982, computers disguised as game machines were just starting to become a consumer product. Atari was popular for it's games like Donkey Kong and Pac Man. The Commodore 64 was also becoming popular. I bought an Atari but was more interested in it's word processing capabilities than I was the games. The games didn't hold my interest very long at all. I have never understood why one would think it was an accomplishment to win a game when the same energy could be applied to some real accomplishment in life.
As I was going through nursing school, I was becoming more interested in the early computers. A new company named Apple, with it's founders Steve Jobs and Steve Wozniak had released their revolutionary computer called the Apple II and IBM soon came out with their personal computer which quickly became the standard of the time. By this time, I was following computer development in the news and news magazines related to their development and getting on line with the first on line service called Compuserve. I had grown tired of the Atari's limitations and was interested in something more powerful. I remember reading in a magazine about something new that was coming out from Apple, which they called Macintosh.
The early IBM PC's were not really "user friendly" at all. Everything was done by typing in arcane commands on a command line in something called DOS which had been created by a young company called Microsoft and it's founder Bill Gates. This was fine for business users but not really much fun. The new Macintosh that was coming out was the first computer for consumers that would use a graphic user interface, (GUI), and something called a "mouse." Instead of typing in codes, one just clicked on little pictures called "icons." You could do everything on a Macintosh that you could do on a PC but in addition to the word processing and spreadsheets, you could also do something new called desktop publishing. The Macintosh had enormously more appeal for artists and other creative types as well. It was the computer for "the rest of us." It was released with the iconic George Orwellian 1984 Super Bowl commercial. Computing would never be the same.
At about this same time, in my nursing program, we wanna-be nurses were learning how to write "care plans." A care plan is a document that describes a patients problems and the goals for those problems and the interventions to reach those goals. It is a kind of roadmap of patient care for the bedside nurse. While we were studying how to write care plans in my classes, we were having a hard time keeping the same kind of documents updated at my job on 4-East at Saint Francis Hospital. Patients would get admitted and the nurse would sometimes do all the paperwork involved in the admission except for the care plan or the care plan was written quickly and often incomplete. The Joint Commission on Accredidation of Hospitals were emphasizing care plans about that same time and so the managers at my job were nagging staff to write better care plans and keep them updated.
I got tired of hearing management nagging the staff to do care plans without coming up with any realistic plan or means for getting them done and I figured out a way to write some standardized care plan templates that one could just use a copy machine to copy onto our forms. Although this technique for doing care plans was a big time saver and staff and management loved the idea, the problem with that was that the care plans were not specific to the patient and could not be easily editable. This caught my imagination and in a staff meeting one day with our medical director, Dr. Anderson, I suggested that we could "computerize" care plans.
I explained that from what I had been reading about computers and something called databases, care plans would be a great project for computerization. Dr. Anderson seemed intrigued by the idea. I let him know that the Macintosh was supposed to be something that anyone could use. He encouraged me and actually got funding for a new Macintosh computer. There was a little confusion as to ownership initially as he had also told one of the Social Workers, who had their office elsewhere that she could use the Macintosh. Once the computer had been purchased, I felt like it was my responsibility to see that it warranted the outlay of funds which came to about three thousand dollars if I remember correctly and I saw to it that it stayed on the psychiatric unit where the entire nursing staff would have access to it rather than just one Social Worker.
When the Macintosh arrived, I was excited by the graphical user interface. The screen was only about nine inches and black and white but it used something new for computers, called icons, to navigate through commands. I read everything I could find in my spare time about using the machine and searched for software that would help me do care plans. Almost every day that I could, I would clock out after my shift and then stay on the unit to work on the Macintosh.
At first, I just tried putting the same standardized care plans I had written earlier into a word processing program. The problem was that we were using pre-printed forms and it was difficult to get the text to line-up on the pre-printed forms. The only solution in my mind was to actually put the pre-printed forms onto the computer. One of the programs I experimented with early on and which worked well initially was Filemaker. The forms could be put into the database and the nurse could select a standardized care plan but they were still not able to customize it completely. Eventually I read about a new relational database program called 4th Dimension made by a company called ACIUS. I could create separate databases that would relate to one another. I could creaate a database of nursing problems that could merge with a database of patient information.
By this time, I had gone into debt to buy my own Macintosh. I had gotten a copy of the database software, 4th Dimension, which came with several thick manuals and I would sit up all night at the computer, trying to get it to work. In the beginning, 4th Dimension itself was a little buggy and it made it difficult to know when it was me that was making programming errors or if problems were being caused by the initial bugs in 4D. As the bugs got worked out in 4D and I got better in my programming skills, what I would eventually call "MacNursing" started coming together.
The database was developed initially for the needs of Western Psychiatric Center at Saint Francis hospital and eventually almost all of the written forms for the admitting process were transitioned into the computer database. The nurse would enter the patient data and then select patient problems specific to the patient and then could edit those problems and truly customize the care plan to each individual patient. The forms were put into the official medical record and passed inspection by Joint Commission. Even the California State 5150 and 5250 forms were approved and printed from the MacNursing database.
When the Western Psychiatric Center budget got tight, a new position was created around my computer program and the admitting process as it became more efficient for a nurse with typing and computer skills to admit patients using my computer program. An admitting process that had been slow, cumbersome and ineffecient, now became much faster and thorough.
Western Psychiatric Center would continue to use my program for admitting patients for the next ten years. Although Saint Francis never compensated me for the hours of work I had done on my own time to develop the program up to that time, I was okay with that since there was never any question as to who owned the rights to the MacNursing. After I had resigned and left Saint Francis, they did hire me to come back and customize a new version of the program for them and I was compensated for that work.
Meanwhile, one of the nurses and a social worker at Saint Lukes hospital across town heard about my program and contacted me and made arrangements to come and see what I had acomplished at Saint Francis. They got their own Macintosh computer and raised funds to pay me to customize a program for their use. The problem at Saint Lukes, I believe, was that they did not have a "MacNursing" evangelist there as Saint Francis had in me. In those days, nurses most often did not type and most felt intimidated by computers. There were very few hospitals that even used computers in those days and if they used them at all, they were primarily for billing purposes rather than nursing purposes. Once Saint Lukes had paid me for their own version of "MacNursing," I don't think that the staff were willing to adapt to the program. Change is always difficult and nurses that were used to writing everything out by hand found it easier to do things in the way they had always done them rather than learn a new way of doing things. The learning curve would take time and most nurses were not willing to put in that time and I don't think they were given any extra time to do so.
By this time, I was getting visits from from others in the healthcare field that heard what I was doing at Saint Francis. I received visitors from Kaiser Permanente. I was more than willing to show anyone and everyone what I was doing as I truly was an evangelist for computers in nursing, especially Macintosh computers in nursing as I believed the Macintosh was actually user friendly and so it was nurse friendly.
I rented at booth at the California Nurses Association, nursing Convention in Oakland sometime in the late eighties and showed my program there. I rented an extra Mac and an overhead projector so that people walking by could see the program on a big screen. There was some interest but it did not lead to any new consulting jobs or sales.
At one point in the 80's, Apple contacted me and invited me, to their offices at One Post Street in San Francisco for a meeting of developers that were using Macintosh computers in health care. There were probably 10 or 15 entrepreneurs at the meeting. The only company I remember, though, is A.D.A.M. which had developed an anatomy application that ran on the Mac. After this first meeting with Apple, I was invited to a small conference of Macintosh healthcare developers where we could show our work to business persons and venture capitalists that might be willing to invest. I had no business background and a terror of public speaking. I had not been informed that there was going to be an opportunity to show my product to a group and had not prepared for that. When an Apple representative came and asked if I was ready to do my "presentation," I answered that I had not prepared a presentation and did not want to try to improvise one. This is probably one of my greatest regrets in life- a missed opportunity.
Apple continued to be supportive though. When Apple moved from black and white to color monitors, they loaned me a color Mac to rewrite my program to add color to it. Milton and I drove down to the Cupertino headquarters to pick up the loaner Mac and I was able to keep it long enough to re-write MacNursing.
A year or two after I had been at the C.N.A. convention in Oakland, I signed up for a booth at the American Nurses Association's convention in Boston. That was My sister, Donna, took a train from Seattle and met me there to help with my booth that weekend. I had rented a couple of Macs and had a similar set up as in Oakland. This time, there was much more interest and I met Elaine Lloyd, MS, a nursing administrator for the spinal cord injury unit in Palo Alto. We made arrangements for a meeting after the convention.
In nursing, it was never necessary to wear a suit. With my MacNursing business, I had to buy a couple of suits to feel like I was in "business." I loathed wearing a suit or tie buy I convinced myself that I had to wear the costume to fit the part. "Business" was very stressful for me. I always felt like I was playing a "role." I had to attend various meetings at the V.A. spinal cord injury unit and others seemed to think at the time that my program might even be used at other V.A.'s across the country but I think my lack of business experience was evident and this was another missed opportunity.
While consulting with the V.A. in Palo Alto, Elaine and Linda Toth, MS, RN another nurse manager wrote an article called "Development and Testing of Computer Software for Nursing Assessment and Care Planning at a Spinal Cord Injury Center" which was published in the SCI Nursing, a publication of The American Association of Spinal Cord Injury Nurses. The three of us went to Las Vegas for a convention of Spinal Cord Injury nurses and they presented the findings of the paper, published August 1994.
By the time my consulting at the V.A. ended, they had a network of about 10 computers running my program and they had used my consulting services for about ten years. Eventually, it was mandated that the Palo Alto V.A. use a different program that was in use elsewhere. I was told by the charge nurses that the new program did not do anywhere near as much as my program did but that didn't matter to the bureaucrats at the time.
Over the years after that, I would see some of my ideas from those early years integrated into the programs of others. I don't really know if that was because the developers had seen MacNursing or if they had come up with similar ideas on their own.
Development and Testing of Computer Software for Nursing Assessment and Care Planning at a Spinal Cord Injury Center
E. Elaine Lloyd, MS, RN; Linda L.Toth, MS, RN; Sylvan Rogers, RN
This paper describes a pilot project using a Macintosh personal computer and customized software to computertize nursing admission assessment and care planning data. The project setting is a 47-bed Spinal Cord Injury Center with two inpatient units and an outpatient department serving approximately 1,000 patients with spinal cord injury at a Department of Veterans Affairs Medical Center in northern Califronia. The computer software development, implementaiona, and evaluation are described. This sofware was found to be a low cost, customized approach to computerizing spinal cord injury admission assessment data and care planning which reduces repetive writing and facilitates continuity of care. Personal computers and this sotware have provied the mechanism for establishing a spinal cord injury patient database.