What lessons are public health nurses learning lately when it comes to technology? Although the cost of computers has continued to drop, training and support remain big hurdles in an era of limited budgets.

At the recent American Public Health Association annual meeting in San Francisco, two county public health departments presented advances in collecting and analyzing data required to move health care records from pen and paper to computerized problem-identified and outcome-driven formats. Client outcome data are valuable for policy decisions surrounding health care services in the United States.

For the Marion County Health Department public health offices in Indianapolis, the goal is to move away from paper-based charting. The challenge is twofold: First, nurses must agree upon a standardized vocabulary for classifying client diagnoses, interventions and outcomes. For public health nursing, such vocabulary still is being solidified, according to several nurses who presented research at APHA.

Secondly, financially strapped public health agencies must find resources with which to implement a new client-care vocabulary, purchase supporting software and hardware, as well as train nurses in each of their uses. Health care agencies are being called upon to produce data supporting program area needs and justify their existence and merit.

Patience is a critical watchword. After careful planning and collaboration, one public health nursing information systems' project begun in 1997 just now is coming to fruition.

The MCHD was one agency highlighted at APHA's annual conference. (The incoming APHA president, Virginia Caine, MD, also happens to be the agency director for the MCHD.)

Public health departments spend more and more of their time educating the public on health concerns through home visitation, school encounters, clinic settings and other community events. In Marion County, public health nurses conduct home visits for a variety of reasons such as postpartum/newborn assessments, communicable disease follow-up, chronic disease case management and maternal child-related conditions.

"We wanted to standardize the language used in the charting process, so that it would be clear and concise," said Donna Daulton, RN, a public health nurse with the MCHD.

The MCHD hired a consultant familiar with the Omaha System, which directs and documents nursing diagnoses, interventions and client outcomes. In looking at electronic documentation, the decision was made to use a software package that based its taxonomy on the Omaha System. CareFacts, a software system based in St. Paul, Minn., was selected. Consultants came to the MCHD to provide training for all the public health nurses on the use of the Omaha System and a 19-member nurse Core Training Team to the CareFacts software.

The plan to integrate the electronic medical record into daily practice was met with many challenges that included software/hardware incompatibility, additional nursing responsibilities and nursing shortages. Nurses who had initially been trained on the Omaha System left the health department and the initial Core Training Team of nurses grew smaller.

When the decision was made to again move on the automated record project, the Core Training Team was reactivated to serve as trainers and mentors for the remaining public health nursing staff. The team held four formal four-hour training sessions for about 60 public health nurses. Training sessions allowed staff to learn via structured content presentation, small-group activities and hands-on computer client input. Robert Boehler, a district health worker, was valuable in setting up a Web-based computer tutorial for staff use, said Connie Schneider, RN.

Initially, the training sessions included the use of "pathways," more commonly known as care plans to nurses. Each pathway allowed the nurse to have a minimum set of care activities to follow for each client in a select program area. The ongoing training now is focusing on developing greater use of the Omaha System, allowing staff to document any client problem in the automated CareFacts software.

Staff resistance to the new software has continued following training. "It's the old thing, why rock the boat?" Schneider said. "Some nurses do not want to do away with paper charting. But with practice, you can increase your use of the software when you know what you are doing."

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