Fool Chapter 8 Free Essays

string(248) recollections of copying pee and foul release, yet what sentiment worth the memory is without the bittersweet? At the point when I initially met her, Goneril was nevertheless seventeen, and albeit promised to Albany from the age of twelve, she had never observed him. EIGHT A WIND FROM FUCKING FRANCE Tracker was right, obviously, he wasn’t ready to take care of Lear’s train. We forced on towns en route for admission and quarter, however north of Leeds the towns had endured terrible harvests and they couldn't bear our cravings without starving themselves. I attempted to cultivate happiness among the knights, while keeping good ways from Lear †I had not excused the elderly person for abandoning my Cordelia and sending ceaselessly Drool. We will compose a custom paper test on Simpleton Chapter 8 or on the other hand any comparable theme just for you Request Now Furtively I savored the soldiers’ protests about their absence of solace, and put forth no genuine attempt to hose their rising hatred for the old lord. On the fifteenth day of our walk, outside of Lint-upon-Tweed, they ate my pony. â€Å"Rose, Rose, Rose †would a pony by some other name taste so sweet?† the knights recited. They thought themselves astute, throwing such jokes while splashing simmered bits of my mount from their oily lips. The dull consistently look to be cunning at the fool’s cost, to by one way or another compensate him for his cutting mind, however never are they smart, and frequently are they pitiless. Which is the reason I may never possess things, never care for anybody, nor show want for anything, in case some miscreant, thinking he is interesting, remove it. I have mystery wants, needs, and dreams, however. Jones is a fine foil, however I should like some time or another to claim a monkey. I would dress him in a little jester’s suit, of red silk, I think. I would call him Jeff, and he would have his own staff, that would be called Tiny Jeff. Truly, I should especially like a monkey. He would be my companion †and it is taboo to kill, expel, or eat him. Silly dreams? We were met at the entryway of Castle Albany by Goneril’s steward, consultant, and boss flunky, that most poisonous twat, Oswald. I’d had dealings with the rat confronted garbage sucker when he was nevertheless a footman at the White Tower, when Goneril was still princess at court, and I, a modest jongleur, was discovered meandering stripped in the midst of her imperial circles. In any case, that story is best left for some other time, the lowlife at the door obstructs our advancement. Spidery in appearance just as manner, Oswald sneaks in any event, when in the open, hiding being his normal condition of velocity. A fine dark fluff he wears for a facial hair, the equivalent is his responsibility, when his blue plaid hat is lowered at his heart, which it was not that day. He neither expelled his cap nor bowed as Lear drew nearer. The old lord was not satisfied. He halted the train a bolt shot from the château and waved me forward. â€Å"Pocket, go see what he wants,† said Lear. â€Å"And inquire as to why there is no flourish for my arrival.† â€Å"But nuncle,[24]† said I. â€Å"Shouldn’t the commander of the gatekeeper be the one †â€Å" â€Å"Go on, fool! A point is to be made about regard. I send a simpleton to meet this scalawag and set him in his proper place. Save no habits, remind the canine that he is a dog.† â€Å"Aye, majesty.† I feigned exacerbation at Captain Curan, who nearly snickered, at that point halted himself, seeing that the king’s outrage was genuine. I pulled Jones from my travel bag and sallied forward, my jaw set, as decided as the fore of a warship. â€Å"Hail, Castle Albany,† I called. â€Å"Hail, Albany. Hail, Goneril.† Oswald said nothing, didn't to such an extent as evacuate his cap. He looked past me to the lord, in any event, when I was standing an arm’s length from him. I stated: â€Å"King of bleeding Britain here, Oswald. I’d propose you pay appropriate respect.† â€Å"I’ll not lower myself to talk with a fool.† â€Å"Primping little whoreson wanker, innit he?† said the manikin Jones. â€Å"Aye,† said I. At that point I detected a watchman in the barbican, looking down on us. â€Å"Hail, Cap’n, appears someone’s discharged a privy on your drawbridge and the steaming heap obstructs our way.† The watchman chuckled. Oswald smoldered. â€Å"M’lady has trained me to teach you that her father’s knights are not welcome in the castle.† â€Å"That so? She’s really conversing with you, then?† â€Å"I’ll not have a trade with an impudent fool.† â€Å"He’s not impudent,† said Jones. â€Å"With appropriate motivation, the chap sports a woody as bold as a securing pin. Ask your lady.† I gestured in concurrence with the manikin, for he is generally savvy for having a mind of sawdust. â€Å"Impudent! Impudent! Not impotent!† Oswald foaming a piece now. â€Å"Oh, well, why didn’t you state so,† said Jones. â€Å"Yes, he’s that.† â€Å"To be sure,† said I. â€Å"Aye,† said Jones. â€Å"Aye,† said I. â€Å"The king’s riffraff will not be allowed in the castle.† â€Å"Aye. That along these lines, Oswald?† I came to up and tapped his cheek. â€Å"You ought to have requested trumpets and flower petals dissipated on our path.† I turned and waved the development to the train, Curan prodded his pony and the section dashed forward. â€Å"Now get off the scaffold or be stomped on, you rodent confronted little twat.† I walked past Oswald into the mansion, siphoning Jones noticeable all around as though I was driving rhythm for war drummers. I figure I ought to have been a representative. As Lear rode by he clouted Oswald on the head with his sheathed blade, thumping the unctuous steward into the canal. I felt my annoyance for the elderly person slip an indent. Kent, his camouflage currently finished by about three weeks of yearning and living in the outside, fell in behind the train as I had taught. He looked lean and rugged now, more like a more seasoned adaptation of Hunter than the old, overloaded knight he had been at the White Tower. I remained to the side of the door as the section entered and gestured to him as he passed. â€Å"I’m hungry, Pocket. All I needed to eat yesterday was an owl.† â€Å"Perfect charge for witch finding, methinks. You’re with me to Great Birnam Wood today around evening time, then?† â€Å"After supper.† â€Å"Aye. On the off chance that Goneril doesn’t poison the parcel of us.† Ok, Goneril, Goneril, Goneril †like an inaccessible love serenade is her name. Not that it doesn’t call recollections of copying pee and foul release, yet what sentiment worth the memory is without the clashing? At the point when I initially met her, Goneril was nevertheless seventeen, and albeit promised to Albany from the age of twelve, she had never observed him. An inquisitive, round-bottomed young lady, she had consumed her whole time on earth in and around the White Tower, and she’d built up an epic craving for information outwardly world, which some way or another she figured she could satisfy by flame broiling an unassuming numb-skull. It began on odd evenings, when she would call me to her chambers, and with her women in-holding up in participation, ask me all way of inquiries her mentors had wouldn't reply. â€Å"Lady,† said I, â€Å"I am nevertheless an idiot. Shouldn’t you ask somebody with position?† â€Å"Mother is dead and Father treats us like porcelain dolls. Every other person is hesitant to talk. You are my nitwit, it is your obligation to talk truth to power.† â€Å"Impeccable rationale, woman, however honestly, I’m here as nitwit to the little princess.† I was new to the château, and would not like to be considered responsible for disclosing to Goneril something that the lord didn’t wish her to know. â€Å"Well, Cordelia is having her rest, so until she wakes you are my dolt. I so order it.† The women applauded at the imperial declaration. â€Å"Again, undeniable logic,† said I to the thick however attractive princess. â€Å"Proceed.† â€Å"Pocket, you have ventured to every part of the land, let me know, what is it like to be a peasant?† â€Å"Well, milady, I’ve never been a worker, carefully, yet generally, I’m told it’s wake early, buckle down, endure hunger, get the plague, and pass on. At that point get up the following morning and do everything again.† â€Å"Every day?† â€Å"Well, if you’re a Christian †on Sunday you rise early, go to chapel, endure hunger until you have a major dinner of grain and gulp, at that point get the plague and die.† â€Å"Hunger? Is that why they appear to be so pitiable and unhappy?† â€Å"That would be one reason. Be that as it may, there’s a lot to be said for difficult work, ailment, regular misery, and the odd witch consuming or virgin penance, contingent upon your faith.† â€Å"If they are eager, why don’t they simply eat something?† â€Å"That is a great thought, milady. Somebody ought to recommend that.† â€Å"Oh, I will make a most incredible duchess, I think. The individuals will adulate me for my wisdom.† â€Å"Most unquestionably, milady,† said I. â€Å"Your father wedded his sister, at that point, did he, love?† â€Å"Heavens no, mother was a Belgian princess, for what reason do you ask?† â€Å"Heraldry is my side interest, go on.† When we were inside the principle blind wall[25] of Castle Albany, plainly we would go no farther. The fundamental keep of the mansion remained behind one more window ornament divider and had its own drawbridge, over a dry discard instead of a channel. The extension was bringing down even as the lord drew nearer. Goneril left the drawbridge unaccompanied, wearing an outfit of green velvet, bound a piece too firmly. On the off chance that the expectation was to reduce the ascent of her chest it bombed hopelessly, and brought wheezes and laughs from a few of the knights until Curan lifted his hand for quietness. â€Å"Father, welcome to Albany,† said Goneril. â

4) Discuss the differences in Religious Jurisprudence between of Essay

4) Discuss the distinctions in Religious Jurisprudence between of Sunnites and Shiites - Essay Example This has caused in some cases battles among the huge populace of Muslims in the Islamic nations. According to the records accessible, Prophet Muhammad kicked the bucket in the year 632 A.D. His demise left a hole for the political authority of the Muslim people group, as to progression of the prophet. The discussion over the determination of the replacement left predominantly two decisions with the Muslim masses. While one decision was to locate a devout individual who might follow the percepts of Islam and principals spread out by the prophet, other view point was to discover the replacement from the bloodline of the prophet itself. The principal Caliph named as Abu Bakr, who was a nearby partner of the prophet was reported after this discussion. In any case, a portion of the Muslims didn't bolster this choice, despite the fact that larger part was in support of its. Prophet Muhammad had a little girl named Fatima whose spouse, Ali ibn Abi Talib was extremely dynamic during the lifetime of the prophet. In any case, he didn't have the necessary position to supplant the prophet after his demise. Regardless, a specific group of the Muslims opined that this child in-law of the prophet ought to succeed him. Indeed, even among the adherents of Ali, a few voices bolstered the name of Abu Bakr as replacement. From that point, two Caliphs, Umar and Uthman, who were viewed as real progressive Caliphs by most of the Muslims, succeeded Abu Bakr. Be that as it may, the dissident voices supporting Ali had not faded away totally and a portion of the Ali’s supporters murdered the third Caliph, Uthman in the year 652 A.D.. This brought about the declaration of Ali as the new Caliph......(1) As the contention included previously taken roots inside the Muslim human progress, Ali was likewise executed in the year 661 A.D. He had two children Hassan and Hussein who likewise kicked the bucket a few years after the fact in the fight against Sunnis. This turned into the reason for the division of the Islamic religion in two groups. The rate supporting Ali as the Caliph was called Shias and the other lion's share supporting the prior Caliphs were

The Alienating Lack of Disability Representation in Literature

The Alienating Lack of Disability Representation in Literature As a kid, I read and wrote constantly. I was born with cerebral palsy, which affects my balance and mobility. When I wasnt at physical therapy, I had a lot of extra time to read while my non-disabled classmates were playing sports. I always wanted to write to convey my unique experiences of growing up disabled. However, I almost never saw disabled characters represented in literature. Like most people in my age group, I loved the Harry Potter series. In 1997, when the first book was published in the US, I was eight. I identified with Hermiones perfectionismâ€"even her know-it-all attitude!â€"and her loyalty to her friends. I fantasized about going to Hogwarts and imagined that my school was the Great Hall. Yet I noticed that, apparently, none of Harry s classmates were disabled. Madame Pomfrey cured temporary injuries in the infirmary, making injury almost a non-issue in the Wizarding world. But what about people like me, with lifelong or genetic disabilities? I wondered. Would they also be cured? Many disabled writers, myself included, consider the magical cure tropeâ€"when a character suddenly stops being disabledâ€"offensive. It implies that were inferior and denies an important part of our identities. Or, because Wizarding ability is at least partly hereditary, would no witches or wizards be born with disabilities? The first fictional, disability representation that I ever encountered was Robin, the young protagonist of The Door in the Wall by Marguerite de Angeli. In medieval Europe, Robin loses the use of his legs, and a monk carries him around, like Hodor does for Bran in Game of Thrones. The book seemed like a revelation to me. For the first time, I didnt have to speculate on how disabled people might be treated in the story. The Door in the Wall won the Newbery Medal in 1950, and I noticed that the author had been born in 1889â€"100 years before I was. Although I was reading it almost 50 years after its publication, disabled representation hadnt improved much. Of course, people enjoy reading fiction for countless reasons, not just to see themselves reflected. Other reasons include envisioning fictional worlds and empathizing with characters who are different from ourselves. The problem is that not all children have the privilege of seeing characters who resemble them. Children of all races, disabilities, religions, and genders grow up reading about white, Christian, non-disabled, cisgender boys, but the reverse is rarely true. In high school and college, I encountered countless examples of ableism in classic literature. These books often used disability as a symbol, rather than a part of human diversity. At one extreme, characters like Tiny Tim are objects of pity, whose disabilities make them seem saintlike. At the opposite extreme, Shakespeares Richard IIIs genetic condition can either symbolize or justify his evil acts. When The Hunger Games series came out, I was already an adult in my early twenties. I imagined that any physically disabled teenagers probably would have been easy fodder in the Games, among the first killed despite any other skills. The Avoxes, people who are mute because the government has cut out their tongues for dissent, are omitted from the Hunger Games movies. Catching Fire, my favorite book in the series, touches on mental illness and neurodivergence. Mags, Finnicks mentor, has limited mobility due to her age. Most of the former victorsâ€"such as Katniss, Peeta, Annie, Johanna, and Haymitchâ€"struggle with their mental health as a result of multiple traumas. Beetee and Wiress, who outwit the Games in a unique way, seem possibly neurodivergent. It might seem ironic for me to mention examples in which disabled people are not included, but our exclusion is significant. My elementary school had mentally and physically disabled students of many different ethnicities, but   books didnt reflect that diversity. Some readers call the lack of representation erasure, which sounds deliberate. It might not be deliberate on individual authors parts, but this elaborate word-building at least fails to take us into account. The  lack of nuanced disability representation helped motivate me to write. Although we still need more, Im relieved that authors are creating more multifaceted disabled characters. One of my favorite recent examples is Leigh Bardugos YA fantasy series, Six of Crows. Two of the five main characters are physically disabled and mentally ill. Kaz Brekker, a thief and the ringleader of a heist, uses a cane. He subverts stereotypes of helpless or self-pitying disabled young people by taking agency over his own life. He considers his cane a point of pride: It became a declaration. There was no part of him that was not broken, that had not healed wrong, and there was no part of him that was not stronger for having been broken (428). I hope that the next generation of kids grows up with more diverse, accurate disability representation than I had, particularly by disabled writers. Our lived experience is the best counter to negative assumptions, marginalization, and clichés.  In this 2016 BR guest post, Kayla Whaley discusses the future of disability representation in childrens and YA literature. Like many readers, including me, this BR contributor found Me Before You problematic. Alaina Leary on ableism in literature (at The Establishment) In this essay for Catapult, Keah Brown discusses not seeing herself represented in pop culture as a black, disabled woman.  Browns debut essay collection, The Pretty One, will be published in 2019. Sign up to Unusual Suspects to receive news and recommendations for mystery/thriller readers.

an analysis of the qualifications of an Epic Hero - 887 Words

An epic hero is someone who goes down in history as being brave, courageous, and obviously heroic. They don’t have to be asked to save the day, and often times, they aren’t even saving their own people. There are several epic poems that come to mind when thinking about European culture and where it came from. These stories are held as sacred to many different people, and will always be studied whenever the topic of government or culture comes up. In these poems, or stories, there is always a hero that the story is centered around, often times even named for. These heroes include Achilles, Odysseus, Aeneas, Socrates, Gilgamesh, Beowulf, and Arthur; there are certain things about these men that make them heroes. Achilles is the ideal hero,†¦show more content†¦439) Unlike Achilles, Odysseus is a king. He rules his country with a firm hand, but cares for his subjects. During the Trojan War, he is one of king Agamemnon’s highest ranking officers, and is a man who is constantly sought after for advice. One thing that makes him a hero unlike others is that he is willing to ask for help and is humble enough to take advice. â€Å"Odysseus is one of the first Greek mythic heroes renowned for his brain as well as his muscle.† (Education Foundation) This makes him all the more powerful as a ruler. Aeneas is one who few think of when naming epic heroes, but his story is much like that of Odysseus. â€Å"While the figures of Homers work might have been praised by the Greek tangibility Publius Vergilius Maro, a statesman and poet during the Pax Romana under Augustus would come to harshly criticize the Greek epic ideal and redefined what it meant to be a man with his hero Aeneas.† (Krause) He goes through struggle after struggle, and is constantly tested. His bravery is what defines him as a hero. He can seemingly endure anything. He must take a journey to the underworld, similar to that of Odysseus. When one thinks of an epic hero, they thing strong, brave, and handsome; Socrates is not the man who comes to mind. When it really comes down to it though, Socrates is more of a hero than the others previously mentioned. HeShow MoreRelatedFundamentals of Hrm263904 Words   |  1056 PagesHRM 28 PART 2 Chapter 3 Chapter 4 THE LEGAL AND ETHICAL CONTEXT OF HRM Equal Employment Opportunity 56 Employee Rights and Discipline 84 PART 3 Chapter 5 Chapter 6 Chapter 7 STAFFING THE ORGANIZATION Human Resource Planning and Job Analysis 110 Recruiting 132 Foundations of Selection 154 PART 4 Chapter 8 Chapter 9 TRAINING AND DEVELOPMENT Socializing, Orienting, and Developing Employees 182 Managing Careers 208 PART 5 Chapter 10 Chapter 11 Chapter 12 Chapter 13 MAINTAININGRead MoreMarketing Management130471 Words   |  522 Pagesmixer of ingredients. The ingredients in Borden s marketing mix included product planning, pricing, branding, distribution channels, personal selling, advertising, promotions, packaging, display, servicing, physical handling, and fact finding and analysis. E. Jerome McCarthy later grouped these ingredients into the four categories that today are known as the 4 P s of marketing, depicted below: Marketing decisions generally fall into the following four controllable categories: †¢ Product †¢ †¢ †¢ Read MoreOne Significant Change That Has Occurred in the World Between 1900 and 2005. Explain the Impact This Change Has Made on Our Lives and Why It Is an Important Change.163893 Words   |  656 Pageslamentable. Taken together, the key themes and processes that have been selected as the focus for each of the eight essays provide a way to conceptualize the twentieth century as a coherent unit for teaching, as well as for written narrative and analysis. Though they do not exhaust the crucial strands of historical development that tie the century together—one could add, for example, nationalism and decolonization—they cover in depth the defining phenomena of that epoch, which, as the essays demonstrate

Cultural Values And Social Values - 1439 Words

Culture plays a key role in individual motivation. Culture is defined as, â€Å"†¦values, attitudes, meanings (attributed to language), beliefs, and ways of acting and interacting that are learned and shared by a group of people over a period of history and are often taken for granted as reality by those within the ‘said’ culture† (Glazer, 2002, p. 146). If culture defines our values and beliefs, then culture influences our cognitive representations of needs, in turn affecting how individuals perceive his/her own needs. Different perceptions of needs alter individuals’ goals and how they are achieved. The way we act and interact comes from our culture’s desire to express core cultural values. Looking into cultural values provides context for understanding what might motivate individuals. Hofstede (1980) and Schwartz (1999) have each developed a cultural values framework. Cultural value frameworks Hofstede’s dimensions of culture were postulated from access to an IBM employee survey database obtained from over 50 countries (Hofstede, 1983). Initial factor analysis matrices of 32 values questions developed four dimensions of culture: individualism versus collectivism, power distance, uncertainty avoidance, and masculinity versus femininity (Hofstede, 1980). Later, a fifth and sixth dimension were added: long-term vs. short-term orientation and indulgence vs. restraint (Hofstede et al., 2010). These dimensions relate to Schwartz (1999) purposed three dimensions of sevenShow MoreRelatedSocial And Cultural Values On Economic Development1764 Words   |  8 PagesSocial and cultural values directly affect economic development through the attitudes toward progress and changes in perspective. Dynamics of economic development in different countries vary as those countries recognize the different values and views on the economy. Some societies that are valuing achievement and personal gain experience a greater and faster level of economic development than the societies that discourage personal achievement and collection of wealth. â€Å"Changes in social structuresRead MoreModernization And Western Cultural Values On The Social Status1666 Words   |  7 PagesFriday March 4 at 5:00pm.   A.  Ã‚  Ã‚  Ã‚   In at least 5 sentences (with clear and distinct points) explain the impact of â€Å"modernization† and western cultural values on the (1) social status and (2) economic status of â€Å"Third World† women during the colonial period. (400-500 words) 5 points 1. The results of modernization and western cultural values on the social status and economic status in â€Å"Third World† women can be greatly attributed and resulted from colonialism, industrialization, and economic andRead MoreValues and Ethics in Social Work, Cultural Competency Essay1076 Words   |  5 PagesIn the National Association for Social Workers (NASW) Code of Ethics, there are many standards a social worker should uphold in order to promote a healthy and helpful relationship with the client. One such aptitude is Cultural Competence and Social Diversity, which is in section 1.05 of the NASW code of ethics (National Association of Social Workers, 2008). There are three sections associated with this competency â€Å"Social workers should understand culture and its function in human behavior and societyRead MoreSocial Cultural Factors : The Basic Beliefs And Values Of Consumers Essay1667 Words   |  7 PagesSocial-cultural factors outlines the basic beliefs an d values of consumers. It is the forces that influences an individual’s way of thinking, lifestyles and behaviors. Marketers must take into consideration the various characteristics of the consumers it is going to sell or target as this is vital in the development of marketing strategies, therefore, making the product or services appealing to customers. One important development is the changing and growth in racial and ethnicity, affecting theRead MoreBrainwashed By Advertising : A Cultural Force, Social Values And The Quality Of Life1410 Words   |  6 Pagescan be found almost anywhere from small town flyers to multi-million dollar Super Bowl TV spots. Advertising affects almost all facets of society, and although initially imagined as an economic tool, advertising is now, â€Å"a socio-cultural force, influencing social values and the quality of life,† (Bondrea and Stefanescu-Mihailia 341). 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More specifically, cross-cultural psychology examines the â€Å"†¦similarities and differences in psychological functioning in various cultural and ethnocultural groups†¦Ã¢â‚¬  (p

What is an Interest Group Free Essays

An interest group (also referred to as advocacy groups) is an organization organized by a special set of people with specific skills to lobby for or against a specific interest to benefit their cause. They usually lobby for one or more shared concerns to manipulate public policy and opinion especially in the U. S. We will write a custom essay sample on What is an Interest Group? or any similar topic only for you Order Now Congress to benefit their cause, supporters, or one segment of society. They include a vast array of organizations such as: charitable organizations, civil right groups, corporations, professional and trade organizations, etc. Their main goal is to publicly or discreetly promoting and creating an advantage for its cause. Different types of Interest Groups There are a variety of interest groups such as business/trade organization, agricultural groups, professional groups, labor groups, promote causes groups, promote the welfare groups, religious groups and last but definitely not leads public interest groups. A business/trade organization is created by merchants, business personal’s or owner’s and commercial organizations to represent both small and large business groups. An ideal example of these groups are the U. S. Chamber of Commerce, American Bankers Association, National Association of Manufacturers or N. A. M. (www. srvhs. org. Aug 26th, 2012). The sole objective of an agricultural group is to sort and look after the interest of farmers and farming policy. They represent a variety of farmers in the agricultural sector in the work force who specialize in diary, grain, fruit, livestock etc. Anything pertaining to farming and their specialized products. Arguable the most known agricu ltural groups are the National Farmers Union, The National Grange, and the National Farmers Bureau. Professional groups are classified as occupations that require extensive training through a certificate or higher education such as education, medicine and law. They are created to promote and protect their member’s occupational interests and safety. Examples include The American Medical Association or AMA, The American Bar Associate (ABA) , and The National Education Association (NEA). One of the well known interest groups is labor unions. It is an organization of workers who share the same type of jobs or work in the same industry. (www. srvhs. org. Aug 26th, 2012). They press the government to formulate policies that will be beneficial to their members. The largest and most well known labor union is the AFL-CIO (The American Federation of Labor Congress of Industrial Organizations). Organized labor unions usually advocate with one voice on issues ranging from welfare to Social Security, employment and wages, etc. Promote causes groups are a large number of groups that either promote or advocate against a specific their members demand to be voiced upon. Examples include and not excluding the American Civil Liberties Union (ACLU), The National Right-to-Life Committee, the National Wildlife Federation (NWF), Planned Parent and the National Rifle Association (NRA). Promote the welfare groups are defined as interest groups seeking promote interest of a certain segment of the population and its welfare like minority groups. They include the American Legion, Vetarens of Foreign Wars, American Association of Retired Persons (AARP), National Association for the Advancement of Colored People (NAACP). Religious groups are interest that try to persuade policy in the favor of religious matters. Examples include the National Council of Churches, the Christian Coalition, the National Catholic Welfare Council, the American Jewish Congress, and the Anti-Defamation League. How to cite What is an Interest Group?, Papers

Liquidity and Profitability Business Management †MyAssignmenthelp.com

Question: Discuss about the Liquidity and Profitability Business Management. Answer: Introduction In the given case, there is a sole proprietorship business at Kota Kinabalu area. The business is dealing in the groceries item. As an owner, different business requirements and the source of business is required. The bried description of the business, its products/services, location/address has been given. Besides that, the manpower it employs and the detailed source and types of documentation that is required in cost of goods sold, sales, payment and receipts have been shown. A detailed report of these have been given below(Alexander, 2016). The name of the grocery store will be A Z Grocery Store and the main reason for selecting such a name for the business is that all the types of the grocery material would be available at the store be it food material or fruits or vegetables. It also consists of frozen food, stationery, bakery items, health and beauty products, beer, wine and liquor, baby care products, dried food items, cosmetics, diet foods, etc(Goldmann, 2016). The business is located in Kota Kinabalu area of Malaysia. It is the capital of Sabah state which is the northern part of Borneo Island. The shop is situated in the middle of the market which is assessible to the people residing all around the city. The shop is open 6 days a week from Thursday to Tuesday and half a day on Wednesday. Full address of the shop is mentioned below: Payment to workers: Documentation There are 2 workers who are being employed in the shop. They are being paid RM 1200 per month towards the end of every month. The main documentation which is required at the point of time of payment of salaries is the Salary slip, the format of which is mentioned below. Besides this, all the details pertaining to a particular employee is already being maintained in the master file as to the no. of days of attendance, the salary package, the family details, the identity card, etc. The payment is done through cash or bank as per the convenience. There are various types of transactions which happen during the course of the business. Some of these are cash or credit prurchases, return outwards and inwards, carriage inwards and outwards, insurance, cash and credit sales, payment to creditors and other 3rd party vendors, receipts from the debtors and revenue recognition. There are numerous other transactions which cannot be limited to a fixed number. The documentation required for the following mainly include the invoices for sale to customers, credit and debit notes, bills for all the types of expenses, payment voucher for vendors, bill of entry in the of imports and exports, etc. Some of these are shown below. The month which has been considered here for the purpose of the documentation is March. References Alexander, F. (2016). The Changing Face of Accountability. The Journal of Higher Education, 71(4), 411-431. Goldmann, K. (2016). Financial Liquidity and Profitability Management in Practice of Polish Business. Financial Environment and Business Development, 4, 103-112. Retrieved from https://doi.org/10.1007/978-3-319-39919-5_9

Dunkirk was a great deliverance and a great disaster Essay Example

Dunkirk was a great deliverance and a great disaster Essay Source d is a first hand painting of the evacuation of Dunkirk it shows the ships being bombarded with shells, bombs and torpedoes form planes, It shows hundreds of men on the beach rushing towards the boats in big swarms, proving the fact that they were very nervous and desperate to get on board and off the beaches, thee is a lot of smoke coming from the destroyed ships, in which thousands of solders and crews would have been killed in each boat! Source e is a photograph of troops waiting on the beaches, this photo shows the troops quite in order and disciplined, there is also no attacks from the Germans at this point so this must mean that the attacks werent on going and there were breaks. There are hundreds of solders in this single photograph so this means that there were thousands and thousands being evacuated. Source f is a different matter this is a point were the solders are being attacked on the beach, as they are firing at planes above, there is a very low possibility that they would hit the planes, although it could scare them off! This also gives you evidence that thee was bravery along the beaches as the English and French were fighting back. Source g isnt a primary account as this person was not on the beaches but he was the English minister of war of the time, so this evidence could be counted as first hand, he describes how the army is not destroyed but is there fighting as veterans as they have now have gained in experience of warfare and self-confidence. He is also saying that the British army has got Great Spirit and those they refuse to accept defeat, which is the guarantee of victory. This source is saying that the evacuation of Dunkirk was a great success but also a great disaster. We will write a custom essay sample on Dunkirk was a great deliverance and a great disaster specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Dunkirk was a great deliverance and a great disaster specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Dunkirk was a great deliverance and a great disaster specifically for you FOR ONLY $16.38 $13.9/page Hire Writer Source H is two extracts from the daily express a English news paper that was published in may 31st, 1940 the newspaper articles see the evacuation of Dunkirk as a great success, as they point out the bravery of the ships crews daring the German guns, pointing out that tens of thousands back softly already but do not point out that thousands dead and captured, calling the fleet an armada of ships-all shapes and sizes, but that was only the first article the second is more of a rundown version as it is calling the army: Tired, Dirty, Hungry but unbeatable this is not far from the truth, also saying that there was a touch of glory in the army as it was see-able on the solders faces. Source I is an extract from a book from 1965 written by an British Historian so this is a secondary piece of evidence, he gives a lot of information on the evacuation but we cant be sure that it is reliable as he was not there, he believes that operation dynamo succeed beyond all expectation, He gives evidence of boats such as destroyers and says that there was a wide verity of boats helping, he proves that on the 3rd June the last men were evacuated, in all 339, 226 men evacuated but only 139,997 were French this shows that a lot of French were left behind either presumed captured or dead, it was a great deliverance as nearly all the B.E.F. were saved. All guns, tanks and other heavy equipment were lost, 6 destroyers were sunk and 19 were damaged, the R.A.F. had lost 474 planes. This extract is a great source of evidence for the question. Source J is my own information from various other sources, I found out that there was more or less no food, weapons or ammunition and this adds more info to the fact that it was a great disaster as well. All together 220 ships were destroyed these include, fire ships, travel, destroyers E.T.C. And from these destroyed ships smoke was seen in Dover. When the solders were getting on the boats they were tired, warn out, and a lot of them had gone slightly crazy from the sight of battle and death so as they were climbing aboard they were in a hurry, so they tried to scramble up the slippery sides of the boats which quite a few of people didnt make it and fell back into the smaller boats or water and had to go all the way back to the back of the line, this proves that the solders had turned undisciplined and non-organised, which caused a great delay and trouble in the evacuation. The planes used by the Germans were Ju87 dive bombers which whilst scattering bullets and bombs over the solders and beaches, these planes were designed to go very low at an vertical axis (they were able to pull up very quickly and avoided crashing), which to the solders looked like it was going suicide to hit them, this caused more despair and a loss of self-confidence. There were 2 very long wave breakers that were untouched the navy tried to bring up a large destroyer beside one and it managed to collect about 1000 solders every hour, this was a quicker way of evacuating, but it was bombed and the ship was destroyed but this proved hat it worked, on the second wave breaker they retried this and it worked again, the Germans did not destroy this one and it proved effective. In the begging when the B.E.F. was sent to Dunkirk in September they were sent with insufficient food and equipment, which pro-told the events, which would happen.

Free Essays on Colonization And The Heart Of Darkness

In Joseph Conrad’s Heart of Darkness he tells the story of a young man who gets involved in the ivory trade for the money. Marlow, the main character, recounts his experiences to a group of men he is sailing with and tells of a man named Kurtz and of the native people to Africa. He gives many visual images of the Congo, relates the impacts of colonization on the colonizers and those of the colonized. The entire novel is dark and almost depressing in a way. Marlow describes the Congo around him and almost always it is dark and seemingly scary. The first image Marlow describes is that of the first place he lands in Africa. There are slaves there, making a railroad. He says, â€Å"a rocky cliff appeared, mounds of turned-up earth by the shore, houses on a hill, others with iron roods, amongst a waste of excavations, or hanging to the declivity†¦[I] found a path leading up the hill. It turned aside for the boulders, and also for an undersized railway-truck† (Conrad 23). The image of a cliff gives the image of a dry, desert life place, which is what I would imagine Africa to be. Later he describes the area going up the river. â€Å"The great wall of vegetation, an exuberant and entangled mass of trunks, branches, leaves, boughs, festoons, motionless in the moonlight, was like a rioting invasion of soundless life, a rolling wave of plants, piled up, crested, ready to topp le over the creek, to sweep every little man of us out of his little existence† (Conrad 49). This describes a lavish rainforest, something I would picture once a rainforest was mentioned. Initially, thinking of Africa, I wouldn’t imagine rainforests but lean more towards his first description, of a dry, desert-like area. Marlow gives quite the picture of this new place he’s traveling in, giving the ready a picture perfect idea of where he is. Marlow describes the colonizers as mean and power-hungry. He focuses mainly on one man by the name of Kurtz. For most of the ... Free Essays on Colonization And The Heart Of Darkness Free Essays on Colonization And The Heart Of Darkness In Joseph Conrad’s Heart of Darkness he tells the story of a young man who gets involved in the ivory trade for the money. Marlow, the main character, recounts his experiences to a group of men he is sailing with and tells of a man named Kurtz and of the native people to Africa. He gives many visual images of the Congo, relates the impacts of colonization on the colonizers and those of the colonized. The entire novel is dark and almost depressing in a way. Marlow describes the Congo around him and almost always it is dark and seemingly scary. The first image Marlow describes is that of the first place he lands in Africa. There are slaves there, making a railroad. He says, â€Å"a rocky cliff appeared, mounds of turned-up earth by the shore, houses on a hill, others with iron roods, amongst a waste of excavations, or hanging to the declivity†¦[I] found a path leading up the hill. It turned aside for the boulders, and also for an undersized railway-truck† (Conrad 23). The image of a cliff gives the image of a dry, desert life place, which is what I would imagine Africa to be. Later he describes the area going up the river. â€Å"The great wall of vegetation, an exuberant and entangled mass of trunks, branches, leaves, boughs, festoons, motionless in the moonlight, was like a rioting invasion of soundless life, a rolling wave of plants, piled up, crested, ready to topp le over the creek, to sweep every little man of us out of his little existence† (Conrad 49). This describes a lavish rainforest, something I would picture once a rainforest was mentioned. Initially, thinking of Africa, I wouldn’t imagine rainforests but lean more towards his first description, of a dry, desert-like area. Marlow gives quite the picture of this new place he’s traveling in, giving the ready a picture perfect idea of where he is. Marlow describes the colonizers as mean and power-hungry. He focuses mainly on one man by the name of Kurtz. For most of the ...

Cancer Pain in End of Life Cancer Patients Essay

Cancer Pain in End of Life Cancer Patients - Essay Example This will be considered a supplementary strategy to the existing official request process. I will also need support from my peers particularly in project review and data collection. I will also need to describe the significance of the project to my peers in order to win their support. Current Problem/ Deficit Pain treatment is a significant aspect in the end of life care. Different people develop different pain symptoms and hence the need for differentiated pain management strategies. Unfortunately, the current pain management strategies concentrate on pain symptoms rather than the source of pain. For example, a doctor will concentrate on symptoms of pain such as headache and backache, rather than the actual cause of the pain. The second issue relates to the definition and scope of pain. The mainstream pain management strategies underestimate the significance of other dimensions of pain such as social and spiritual pain. A comprehensive pain management strategy needs to incorporate t he other aspects of pain. The project proposes a standardized scale to assess pain, using four basic approaches to pain relief, which include: modify the source(s) of pain(s), alter the central perception of pain, modulate transmission of pain to the central nervous system and block transmission of pain to the central nervous system (Ferrel, Levy and Paice, 2008, p.577). Moreover the project proposes an interdisciplinary intervention integrating â€Å"physical, physiological, social and spiritual well-being of the patient so that the patient experiences comfort and dignity at the end of life. The process will involve counseling and use of pain relieving medication. Medication is primarily intended to relieve physiological pain without inflicting additional... The paper throws light on pain treatment as a significant aspect in the end of life care. Different people develop different pain symptoms and hence the need for differentiated pain management strategies. Unfortunately, the current pain management strategies concentrate on pain symptoms rather than the source of pain. For example, a doctor will concentrate on symptoms of pain such as headache and backache, rather than the actual cause of the pain. The second issue relates to the definition and scope of pain. The mainstream pain management strategies underestimate the significance of other dimensions of pain such as social and spiritual pain. A comprehensive pain management strategy needs to incorporate the other aspects of pain. The project proposes a standardized scale to assess pain, using four basic approaches to pain relief, which include: modify the source(s) of pain(s), alter the central perception of pain, modulate transmission of pain to the central nervous system and block t ransmission of pain to the central nervous system. Moreover the project proposes an interdisciplinary intervention integrating â€Å"physical, physiological, social and spiritual well-being of the patient so that the patient experiences comfort and dignity at the end of life. The process will involve counseling and use of pain relieving medication. Medication is primarily intended to relieve physiological pain without inflicting additional complications on the patient.

Attributes and Primary Keys of the ERD Coursework

Attributes and Primary Keys of the ERD - Coursework Example SoniDream is the company, forming one of the entities. Within it, there several other entities, derived from their various attributes. I, therefore, consider how each of the following has different characteristics from the other (Moreira et al. 2013, p.455). Â  The company, with the main office headquartered in London. A company as an entity must have attributes such as physical location. In this case, its physical address in London. A company must also have the people who run it. Using this knowledge, I identified members of staff who fall into different categories and play different roles. They include studio managers, sound engineers, and van drivers. Â  Recording studios distributed over different parts of London. Studios are fixed entities and must, therefore, have their physical locations. In this case of the studios are in London and the other 8 are located in different parts of the UK. Â  Equipment used in the studio is an entity and must be comprised of different pieces. In this case, they included recorder, mixing desks, studio monitors, controllers, microphones, converters, musical instruments, and other music accessories. The different entities are joined by different relationships. Â  3. I identified the main relationship types for SonicDream using a hierarchical order. A relationship type is an association between two or more entity types. Relationship types may associate an entity type with itself. In such a case the roles of the entity types in the relationship type will be listed on the edges like shown in the ERD in part 1.

Patient Healthcare Using SMS Technology Application

Patient Healthcare Using SMS Technology Application Chapter 1 Introduction to Patient Care Using SMS Application Patients travel longer distances for the opinion of consultant which is not possible either due to patient situation or due to distances. Enhancement of health care in different locations and other remote areas can be achieved using mobile phone applications [1]. 1.1 Problem Statement Development of mobile communication networks playing an important part in the enhancement of a mobile medicine. Patient Care Using SMS Application represents a feasible solution of patient care such as text messaging and booking appointments using mobile phones, which are best aspects of mobile medicine. The main idea is improve patient access to healthcare; encouraging patients to use mobile health application and supporting people with long term conditions [5]. 1.2 Objectives Incredible growth of mobile communication and recognition of new generation Wireless protocols has initiated the advance SMS based medical applications. Following that facts Patient care using SMS based application for mobile application for patient is good solution [5 6]. * To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis-à  -vis Exchange Server etc * Main aim of this application is to achieve â€Å"greater quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patients care â€Å"[5 6]. 1.3 Scope The goal of Patient Care Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between General Practitioners and consultants care have to be provided. The second is sufficient exchange of patients information have to be provided. Additionally, privacy of communication and stored information has to be guaranteed. Both ethical and technical aspects are equally important [7]. 1.4 Existing Systems The existing system of treatment consists of two different systems. They are as follows: * Traditional or manual system * Online application 1.4.1 Traditional or Manual system The present system of treatment consists of manually consulting a doctor by taking prior appointment or else registering at that instant of time, waiting to get register themselves and then consulting the doctor which is a time consuming process. 1.4.1.1 Drawbacks * Time consuming * Patient need to stand in long queues to make appointments * Patients not follow prescription directions once they leave the surgery or hospital. Research has showed that more than 50 percent of patients not follow the management advised by their doctors may be due to lack of time and interest. 1.4.2 Online System Online application is also available where the user is provided a login and password through which he can access the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. The online systems are discussed below are: * EMIS * VISION System 1.4.2.1 EMIS System EMIS ® stands for Egton Medical Information Systems Limited. EMIS provides a service that enables you access to your healthcare online [9]. After registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their practice and update personal information if practice has set up these features online [10]. This example has been explained in detailed in chapter 2. 1.5.2 Example 2: Vision System Vision [14] is the most famous system in use UK, within the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP practices which are using Vision system across the UK each day. â€Å"Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, proven and reliable. The strong product-base has allowed other features such as advanced-scanning, PDAs support and incorporated voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third party systems† [14]. In this project we are more concentrating on EMIS rather than Vision system. Key Features Messaging Incorporated External system Appointments Consultation Manager Problem Orientated Views Community Caseload Search and Reporting 7. Clinical Audit Vision and the National Applications [14] Few of the above features are explain below [14]: 1. Messaging This system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patients data from number of external sources including the NHS Spine or local CPRs to be easily accessed and used within Vision, supporting the requirements of the NHS IT-strategy. Vision also manages a range of clinical messages from third party systems to support the patient care as follows: * Choose and Book Referrals (electronic booking) * E- Discharge Summaries * Radiology reports and Encrypted pathology reports * OOH Summaries With a powerful XML event and messaging engine, Vision is designed to ensure the performance of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message types are managed. 2. Incorporated External System In the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be seamlessly from the Vision desktop. The patient is automatically recognised in the target system, when the required data is passed to the third-party application. For integration into the patient record when required, important data may also be written back to Vision 3. Patients Appointments This Vision system allows user full access to the appointment screen. â€Å"Using session templates developed by the practice† the appointment books are defined in advance. The view of appointment book can be defined by user: all significant doctors and other Healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctors room or leave the surgery, their status is recorded. Our evaluations are based on EMIS system, its features and limitation which have been explained in later chapters. 1.5 Thesis Organisation In chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages. The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained. In the chapter 4 we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter. The chapter 5 focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions. The chapter 6 is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained. Advance system and its features are discussed in this chapter 7. Waterfall Models activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations. The chapter 8 explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter. Chapter 2 Egton Medical Information Systems EMIS ® and EMIS intellectual technology are trading names of â€Å"Egton Medical Information Systems Limited†. EMIS had begun 18 years ago in a rural area dispensing practice in Egton near Whitby in North Yorkshire [11]. EMIS ® head-offices are based in Leeds, including Development and Support departments. Training for general practices is localised and headed by Provincial Operations Directors [11]. 2.1 Practice Care System Enterprise Due to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMISs Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at many levels and ease safe access 24/7 by the wider health care-community [11]. PCS Enterprise for PCTs has been designed with capability of future technological and keeping development in mind, such as sharing data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 Version 3 the patient data is transferred between dedicated health care systems directly [11]. 2.2 An overview of PCS Enterprise This edition has been designed to develop EMIS provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with shared EPRs and seamless data exchange. This system is based on three-tier architecture, while utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to scale to thousands of instantaneous user connections [11]. EMIS Primary Care System Enterprise edition is designed to meet GP needs as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system: 2.3 EMIS Primary Care System Practice edition Health information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has been designed to meet GP needs, combining functionality with simplicity of use [11]. Key features of EMIS PCS * Complete patient record management * Quick and good prescribing * Formulary managements * Incorporated consultation mode * Incorporated appointments * Mentor Library * Integrated with MS Word support * User defined templates * Drug Explorer 2.4 EMIS LV Version 5.2 In the PCS market, EMIS Live Version [11] is the main text based medical system. Approximately 5000 GPs currently using EMIS LV system (which is shown below) in the UK. The system offers GPs consultation mode option, medical record, search and reports option, prescription and booking appointments. 2.5 Population Manager This system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Population Manager [11] has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy and standardised information entry. Population manager is an incorporated part of EMIS LV system. 2.6 Version 5.2 features This is the most recent release of EMIS LV. This LV offers users the following key features [11]: 2.6.1 MS Word incorporation Patient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to create patient related letters in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS. 2.6.2 Referral template for Cancer patients If cancer is suspected GPs requires produce and fax or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks; hence these referrals are named as â€Å"two week rule referrals†. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2. 2.6.3 Electronic Insurance reports One of the most common and time taking medical information requests for GPs is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system. 2.6.4 Scanning and attachments This module enables to scan corresponding or images and attaches them directly to a patients record in consultation mode. These documents are instantly available during consultation. 2.7 EMIS Clinical Communication Modules The following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care [11]. 1 Online Referrals with Booked Admissions 2 Electronic Referrals 3 Incoming Reports including Electronic Discharges 4 Online Results Ordering With an approved list of suppliers this Clinical Communication Modules work. Using the common set of messaging standards currently being developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the further testing of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below [11]: 2.7.1 Online Referrals and booked admissions Traditionally referring patients from doctors at general practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and occasional loss. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding patient demographics and clinical information and in some cases booking an appointment. Requirements: Each EMIS practice must have: * EMIS LV 5.2 * NHS Net connectivity * Router access for EMIS * Version 2 clinical terms (5 byte Read Codes) The Secondary Care Provider will need: * An EMIS approved website 2.7.2 Electronic Referrals This module enables us to create a referral letter within EMIS LV and transmit it electronically to a secondary care consultant [11]. The way electronic referrals work You can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission: answer ‘Yes and the referral letter is placed in the Communications outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter immediately or wait until the next scheduled transmission. Upon receiving the referral letter, the secondary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen. Requirements Each EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS Support * SMTP or DTS mailbox * MS-Word Integration The secondary care provider will need: * SMTP or DTS mailbox * Suitable software capable of sending and receiving XML messages and acknowledgements * SMTP/DTS and EDI code addresses of the practices involved the trust should obtain these from the health authority or national tracking database 2.7.3 Incoming Reports including electronic discharges Use this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hours services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider [11]. How does the Incoming Reports module work? Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the incoming report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider. When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for viewing, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL function in Consultation Mode. Requirements To use Incoming Reports, an EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS * A DTS address To use Incoming Reports, a secondary care provider must have: * A DTS address. * The DTS addresses and EDIâ‚ ¬Ã‚   codes for all required practices this information is available from the health authority or from the national tracking database. * Software to create and send XML messages and receive acknowledgements 2.7.4 Online Test Ordering Requesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service. The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a secure NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results [11]. Online Test Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current patients demographic and GP details are transferred to the laboratory system when you request the required tests. After you have ordered the tests, the test information is transferred to your EMIS system and filed in the patients record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can print a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as soon as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before [11]. Requirements Each EMIS practice must have: * EMIS LV 5.2 or EMIS PCS * NHSnet connectivity * Router access for EMIS * Version 2 clinical terms (5-byte Read codes) Support issues The overall Online Test Ordering process relies on different services and software all working in conjunction with each other: the EMIS software, the laboratory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to resolve issues with the two areas; therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities. 2.8 Storage area network (SAN) Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run [11], on which EMIS stores data [Detail explanation in later chapter]. Chapter Summary The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. Chapter 3 Drawbacks of Online systems Although online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example. 3.1 Patient Record  ¨ Time required to put all relevant information onto system  ¨ Possible security issues  ¨ Doctor can focus too much on patient information onscreen which could intimidate the patient  ¨ Scanning and entry of data is more time consuming. Important information lost can when overlooking the record.  ¨ Medical record print-outs are frequently of poor quality and difficult to understand necessary information  ¨ In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable.  ¨ Often using computer and paper records together will make patient data look very difficult.  ¨ Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data[16] 3.2 Appointments  ¨ Patients have to be checked into appointment system by receptionist  ¨ Problematic if patients cant read, or unable to view sign (e.g. blind people) 3.3 Prescriptions  ¨ Relies on drug information being up to date  ¨ Aptitude of doctor in using computer effectively  ¨ Some times doctors issue hand written prescription; they may not be available on computer. The acute and repeat prescribing registers can make it more confused. Printouts of Pharmacy still required [16]. 3.4 Email  ¨ Relies on doctor checking their mail daily  ¨ Troublesome patients abusing the system  ¨ Hospital letters not emailed (would be preferred) 3.5 Security issues  ¨ Doctors have to go to bother of signing on and off EMIS  ¨ Forgetting passwords  ¨ Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be absolutely in-operable  ¨ Leaving computer on  ¨ Locum doctors  ¨ Experts are need to show computer frauds and misuse [16] 3.6 Internet connection  ¨ Continuous internet connection required  ¨ The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. 3.7 Backup  ¨ System backed up every night onto tape  ¨ Two copies:- Fireproof safe Remote location 3.8 Read codes Maintenance of enormous clinical expressions or codes is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the principle because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility [17]. The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2 The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems arise from different uses and from the different views of Healthcare professional. [17]. Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its diagonal section closely mirrors ICD9, even though this doesnt always reflect a clinicians view, and correct hierarchy placement of a concept according to ICD9 rules may appear anomalous to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map correctly to ICD9 [17]. Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated [17]. Read/SNOMED Codes Read/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. â€Å"Unlike the principal of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical activity to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners† [24]. Read codes has been explained more clearly in chapter 4. 3.9 GP2GP Record transfer The experience of the GP2GP record transfer and the clinical involvement are explained this section. 3.9.1 The underlying principle for electronic GP-GP record transfer The vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable proportion of these practices use their computer systems for recording patient record information in whole or in part [33]. This results from a variety of causes whose main headings are: * Patient records that are an unpredictable mix between paper and electronic. * The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant (but un-quantified) resource implications for practices. There is also widespread anecdotal evidence of resulting adverse effects on patient care. The rationale for the electronic transfer of records is therefore: * As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities. * To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus reduce resource implications * To reduce the risks to patients arising from the transfer of confusing records. 3.9.2 The nature of electronic GP-GP record transfer Electronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of [33]: * Record encounters; what constitutes a single transaction with the record like a doctors consultation, a letter received from hospital or outside, an examination result etc * Names for these encounters; e.g. home visit, * Headings within these encounters * Complex clinical constructs * Read code mappings; such medication codes sets * Codes and associated text * Major modifiers of clinical meaning 3.9.3 The Problems of electronic GP-GP record transfer There are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below [33]. Medication information There are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are: * The multiple coding schemes used and * Failure of previous code mapping exercises (see chapter 5 on data transfer). 3.10 The Problem Oriented Medical Record (PMOR) Electronic health records (EHR) are more used in UK General Practice despite continuing improbability about its legality and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple sequential list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) [31]. 3.10.1 Limitations of the PO Medical Record The limitations of POMR are explain below [31] * It is very easy to pick up but very difficult to maintain. * In the strict way of the word not all headings are problems. For example, the heading of Immunisation is used usually to indicate where all the entries related to a immunization history may be found. * Many different problems may be discussed within a single consultation * To check scanned documents is very difficult especially when patient record is too big * Problems are frequently linked in a fundamental way. * The PO Medical Record only gives a basic measure of the state of a problem. * Different clinicians, view the clinical record, required different information from the medical record as well as with different views. * Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again. Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress [31]. 3.11 Other Disadvantages * Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms. * Many screen need to be changes to find results and mouse activity * Information can be hidden as only the informati Patient Healthcare Using SMS Technology Application Patient Healthcare Using SMS Technology Application Chapter 1 Introduction to Patient Care Using SMS Application Patients travel longer distances for the opinion of consultant which is not possible either due to patient situation or due to distances. Enhancement of health care in different locations and other remote areas can be achieved using mobile phone applications [1]. 1.1 Problem Statement Development of mobile communication networks playing an important part in the enhancement of a mobile medicine. Patient Care Using SMS Application represents a feasible solution of patient care such as text messaging and booking appointments using mobile phones, which are best aspects of mobile medicine. The main idea is improve patient access to healthcare; encouraging patients to use mobile health application and supporting people with long term conditions [5]. 1.2 Objectives Incredible growth of mobile communication and recognition of new generation Wireless protocols has initiated the advance SMS based medical applications. Following that facts Patient care using SMS based application for mobile application for patient is good solution [5 6]. * To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis-à  -vis Exchange Server etc * Main aim of this application is to achieve â€Å"greater quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patients care â€Å"[5 6]. 1.3 Scope The goal of Patient Care Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between General Practitioners and consultants care have to be provided. The second is sufficient exchange of patients information have to be provided. Additionally, privacy of communication and stored information has to be guaranteed. Both ethical and technical aspects are equally important [7]. 1.4 Existing Systems The existing system of treatment consists of two different systems. They are as follows: * Traditional or manual system * Online application 1.4.1 Traditional or Manual system The present system of treatment consists of manually consulting a doctor by taking prior appointment or else registering at that instant of time, waiting to get register themselves and then consulting the doctor which is a time consuming process. 1.4.1.1 Drawbacks * Time consuming * Patient need to stand in long queues to make appointments * Patients not follow prescription directions once they leave the surgery or hospital. Research has showed that more than 50 percent of patients not follow the management advised by their doctors may be due to lack of time and interest. 1.4.2 Online System Online application is also available where the user is provided a login and password through which he can access the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. The online systems are discussed below are: * EMIS * VISION System 1.4.2.1 EMIS System EMIS ® stands for Egton Medical Information Systems Limited. EMIS provides a service that enables you access to your healthcare online [9]. After registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their practice and update personal information if practice has set up these features online [10]. This example has been explained in detailed in chapter 2. 1.5.2 Example 2: Vision System Vision [14] is the most famous system in use UK, within the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP practices which are using Vision system across the UK each day. â€Å"Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, proven and reliable. The strong product-base has allowed other features such as advanced-scanning, PDAs support and incorporated voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third party systems† [14]. In this project we are more concentrating on EMIS rather than Vision system. Key Features Messaging Incorporated External system Appointments Consultation Manager Problem Orientated Views Community Caseload Search and Reporting 7. Clinical Audit Vision and the National Applications [14] Few of the above features are explain below [14]: 1. Messaging This system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patients data from number of external sources including the NHS Spine or local CPRs to be easily accessed and used within Vision, supporting the requirements of the NHS IT-strategy. Vision also manages a range of clinical messages from third party systems to support the patient care as follows: * Choose and Book Referrals (electronic booking) * E- Discharge Summaries * Radiology reports and Encrypted pathology reports * OOH Summaries With a powerful XML event and messaging engine, Vision is designed to ensure the performance of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message types are managed. 2. Incorporated External System In the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be seamlessly from the Vision desktop. The patient is automatically recognised in the target system, when the required data is passed to the third-party application. For integration into the patient record when required, important data may also be written back to Vision 3. Patients Appointments This Vision system allows user full access to the appointment screen. â€Å"Using session templates developed by the practice† the appointment books are defined in advance. The view of appointment book can be defined by user: all significant doctors and other Healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctors room or leave the surgery, their status is recorded. Our evaluations are based on EMIS system, its features and limitation which have been explained in later chapters. 1.5 Thesis Organisation In chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages. The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained. In the chapter 4 we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter. The chapter 5 focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions. The chapter 6 is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained. Advance system and its features are discussed in this chapter 7. Waterfall Models activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations. The chapter 8 explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter. Chapter 2 Egton Medical Information Systems EMIS ® and EMIS intellectual technology are trading names of â€Å"Egton Medical Information Systems Limited†. EMIS had begun 18 years ago in a rural area dispensing practice in Egton near Whitby in North Yorkshire [11]. EMIS ® head-offices are based in Leeds, including Development and Support departments. Training for general practices is localised and headed by Provincial Operations Directors [11]. 2.1 Practice Care System Enterprise Due to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMISs Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at many levels and ease safe access 24/7 by the wider health care-community [11]. PCS Enterprise for PCTs has been designed with capability of future technological and keeping development in mind, such as sharing data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 Version 3 the patient data is transferred between dedicated health care systems directly [11]. 2.2 An overview of PCS Enterprise This edition has been designed to develop EMIS provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with shared EPRs and seamless data exchange. This system is based on three-tier architecture, while utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to scale to thousands of instantaneous user connections [11]. EMIS Primary Care System Enterprise edition is designed to meet GP needs as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system: 2.3 EMIS Primary Care System Practice edition Health information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has been designed to meet GP needs, combining functionality with simplicity of use [11]. Key features of EMIS PCS * Complete patient record management * Quick and good prescribing * Formulary managements * Incorporated consultation mode * Incorporated appointments * Mentor Library * Integrated with MS Word support * User defined templates * Drug Explorer 2.4 EMIS LV Version 5.2 In the PCS market, EMIS Live Version [11] is the main text based medical system. Approximately 5000 GPs currently using EMIS LV system (which is shown below) in the UK. The system offers GPs consultation mode option, medical record, search and reports option, prescription and booking appointments. 2.5 Population Manager This system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Population Manager [11] has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy and standardised information entry. Population manager is an incorporated part of EMIS LV system. 2.6 Version 5.2 features This is the most recent release of EMIS LV. This LV offers users the following key features [11]: 2.6.1 MS Word incorporation Patient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to create patient related letters in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS. 2.6.2 Referral template for Cancer patients If cancer is suspected GPs requires produce and fax or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks; hence these referrals are named as â€Å"two week rule referrals†. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2. 2.6.3 Electronic Insurance reports One of the most common and time taking medical information requests for GPs is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system. 2.6.4 Scanning and attachments This module enables to scan corresponding or images and attaches them directly to a patients record in consultation mode. These documents are instantly available during consultation. 2.7 EMIS Clinical Communication Modules The following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care [11]. 1 Online Referrals with Booked Admissions 2 Electronic Referrals 3 Incoming Reports including Electronic Discharges 4 Online Results Ordering With an approved list of suppliers this Clinical Communication Modules work. Using the common set of messaging standards currently being developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the further testing of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below [11]: 2.7.1 Online Referrals and booked admissions Traditionally referring patients from doctors at general practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and occasional loss. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding patient demographics and clinical information and in some cases booking an appointment. Requirements: Each EMIS practice must have: * EMIS LV 5.2 * NHS Net connectivity * Router access for EMIS * Version 2 clinical terms (5 byte Read Codes) The Secondary Care Provider will need: * An EMIS approved website 2.7.2 Electronic Referrals This module enables us to create a referral letter within EMIS LV and transmit it electronically to a secondary care consultant [11]. The way electronic referrals work You can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission: answer ‘Yes and the referral letter is placed in the Communications outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter immediately or wait until the next scheduled transmission. Upon receiving the referral letter, the secondary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen. Requirements Each EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS Support * SMTP or DTS mailbox * MS-Word Integration The secondary care provider will need: * SMTP or DTS mailbox * Suitable software capable of sending and receiving XML messages and acknowledgements * SMTP/DTS and EDI code addresses of the practices involved the trust should obtain these from the health authority or national tracking database 2.7.3 Incoming Reports including electronic discharges Use this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hours services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider [11]. How does the Incoming Reports module work? Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the incoming report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider. When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for viewing, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL function in Consultation Mode. Requirements To use Incoming Reports, an EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS * A DTS address To use Incoming Reports, a secondary care provider must have: * A DTS address. * The DTS addresses and EDIâ‚ ¬Ã‚   codes for all required practices this information is available from the health authority or from the national tracking database. * Software to create and send XML messages and receive acknowledgements 2.7.4 Online Test Ordering Requesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service. The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a secure NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results [11]. Online Test Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current patients demographic and GP details are transferred to the laboratory system when you request the required tests. After you have ordered the tests, the test information is transferred to your EMIS system and filed in the patients record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can print a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as soon as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before [11]. Requirements Each EMIS practice must have: * EMIS LV 5.2 or EMIS PCS * NHSnet connectivity * Router access for EMIS * Version 2 clinical terms (5-byte Read codes) Support issues The overall Online Test Ordering process relies on different services and software all working in conjunction with each other: the EMIS software, the laboratory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to resolve issues with the two areas; therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities. 2.8 Storage area network (SAN) Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run [11], on which EMIS stores data [Detail explanation in later chapter]. Chapter Summary The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. Chapter 3 Drawbacks of Online systems Although online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example. 3.1 Patient Record  ¨ Time required to put all relevant information onto system  ¨ Possible security issues  ¨ Doctor can focus too much on patient information onscreen which could intimidate the patient  ¨ Scanning and entry of data is more time consuming. Important information lost can when overlooking the record.  ¨ Medical record print-outs are frequently of poor quality and difficult to understand necessary information  ¨ In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable.  ¨ Often using computer and paper records together will make patient data look very difficult.  ¨ Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data[16] 3.2 Appointments  ¨ Patients have to be checked into appointment system by receptionist  ¨ Problematic if patients cant read, or unable to view sign (e.g. blind people) 3.3 Prescriptions  ¨ Relies on drug information being up to date  ¨ Aptitude of doctor in using computer effectively  ¨ Some times doctors issue hand written prescription; they may not be available on computer. The acute and repeat prescribing registers can make it more confused. Printouts of Pharmacy still required [16]. 3.4 Email  ¨ Relies on doctor checking their mail daily  ¨ Troublesome patients abusing the system  ¨ Hospital letters not emailed (would be preferred) 3.5 Security issues  ¨ Doctors have to go to bother of signing on and off EMIS  ¨ Forgetting passwords  ¨ Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be absolutely in-operable  ¨ Leaving computer on  ¨ Locum doctors  ¨ Experts are need to show computer frauds and misuse [16] 3.6 Internet connection  ¨ Continuous internet connection required  ¨ The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. 3.7 Backup  ¨ System backed up every night onto tape  ¨ Two copies:- Fireproof safe Remote location 3.8 Read codes Maintenance of enormous clinical expressions or codes is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the principle because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility [17]. The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2 The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems arise from different uses and from the different views of Healthcare professional. [17]. Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its diagonal section closely mirrors ICD9, even though this doesnt always reflect a clinicians view, and correct hierarchy placement of a concept according to ICD9 rules may appear anomalous to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map correctly to ICD9 [17]. Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated [17]. Read/SNOMED Codes Read/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. â€Å"Unlike the principal of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical activity to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners† [24]. Read codes has been explained more clearly in chapter 4. 3.9 GP2GP Record transfer The experience of the GP2GP record transfer and the clinical involvement are explained this section. 3.9.1 The underlying principle for electronic GP-GP record transfer The vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable proportion of these practices use their computer systems for recording patient record information in whole or in part [33]. This results from a variety of causes whose main headings are: * Patient records that are an unpredictable mix between paper and electronic. * The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant (but un-quantified) resource implications for practices. There is also widespread anecdotal evidence of resulting adverse effects on patient care. The rationale for the electronic transfer of records is therefore: * As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities. * To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus reduce resource implications * To reduce the risks to patients arising from the transfer of confusing records. 3.9.2 The nature of electronic GP-GP record transfer Electronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of [33]: * Record encounters; what constitutes a single transaction with the record like a doctors consultation, a letter received from hospital or outside, an examination result etc * Names for these encounters; e.g. home visit, * Headings within these encounters * Complex clinical constructs * Read code mappings; such medication codes sets * Codes and associated text * Major modifiers of clinical meaning 3.9.3 The Problems of electronic GP-GP record transfer There are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below [33]. Medication information There are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are: * The multiple coding schemes used and * Failure of previous code mapping exercises (see chapter 5 on data transfer). 3.10 The Problem Oriented Medical Record (PMOR) Electronic health records (EHR) are more used in UK General Practice despite continuing improbability about its legality and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple sequential list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) [31]. 3.10.1 Limitations of the PO Medical Record The limitations of POMR are explain below [31] * It is very easy to pick up but very difficult to maintain. * In the strict way of the word not all headings are problems. For example, the heading of Immunisation is used usually to indicate where all the entries related to a immunization history may be found. * Many different problems may be discussed within a single consultation * To check scanned documents is very difficult especially when patient record is too big * Problems are frequently linked in a fundamental way. * The PO Medical Record only gives a basic measure of the state of a problem. * Different clinicians, view the clinical record, required different information from the medical record as well as with different views. * Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again. Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress [31]. 3.11 Other Disadvantages * Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms. * Many screen need to be changes to find results and mouse activity * Information can be hidden as only the informati