NR706 Week 1 Nursing Informatics and Health Information Technology SystemsNR706: Health Informatics

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NR706 Week 1 Nursing Informatics and Health Information Technology Systems

NR706: Health Informatics & Information Systems

Week 1: Nursing Informatics & Health Information Technology Systems

Week 1 References

American Nurses Association. (2015).?Nursing informatics: Scope and standards of practice (2nd ed.). Nursebooks.org.

Quality and Safety Education for Nurses. (2020). Graduate QSEN competencies. https://qsen.org/competencies/graduate-ksas/

Zadvinskis, I. M., Smith, J. G., & Yen, P. Y. (2018). Nurses’ experience with health information technology: Longitudinal qualitative study. JMIR Medical Informatics, 6(2), e38. https://doi.org/10.2196/medinform.8734

Week 1 Introductions

Discussion

Welcome! For this discussion, write a few sentences introducing yourself to your colleagues and the course faculty. Tell us a little about your nursing background, why you chose to become a DNP-prepared nurse, your aspirations in seeking this degree, and anything else you would like to share! Then, video record your introduction. Click on the following link for a step-by-step guide on recording your video introduction. Please note that there may be a short delay before the video appears in your post.

• Link (website): Kaltura TutorialsLinks to an external site.

Week 1Informatics Competencies and Advanced Nursing Practice

Discussion

Purpose

The purpose of this discussion is for you to reflect on your current level of competency in informatics and readiness to practice as a DNP-prepared nurse.

Nurses are knowledge seekers and use the informatics framework data, information, knowledge, and wisdom daily. Technologies can be used in various settings to meet the needs of a diverse healthcare population. By enhancing efficient communication, informatics and healthcare technologies are assisting nurses to engage patients to improve their health and manage their health conditions. Interprofessional and interdisciplinary barriers are easing as technologies are facilitating collaboration. This partnership approach to patient care delivery is supported by information and communication technologies and informatics processes.

Instructions

Review the article by Studwick et al. (2019) in the readings, The Essentials of Doctoral Education for Advanced Nursing Practice, and the QSEN Competencies. Reflect on your own technology experience to address the following:

1. Analyze the information and communication technologies you use in your practice setting to improve quality of care, efficiency of communication, and interprofessional collaboration to provide a safe patient environment.
2. Assess your competency in informatics and readiness to practice as a DNP-prepared nurse.

Please click on the following link to review the DNP Discussion Guidelines on the Student Resource Center program page:

• Link (webpage): Graduate Discussion Grading Guidelines and RubricLinks to an external site.

Program Competencies

This discussion enables the student to meet the following program competencies:

2. Applies organizational and system leadership skills to affect systemic changes in corporate culture and to promote continuous improvement in clinical outcomes. (PO 6)
3. Appraises current information systems and technologies to improve health care. (POs 6, 7)

Course Outcomes

This discussion enables the student to meet the following course outcomes:

1. Assess the impact of informatics and information technology on organizational systems, change, and improvement. (PCs 2, 4; PO 6)
2. Evaluate the types of healthcare information systems, knowledge-based systems, and patient care technology and the impact on patient safety, quality of care, and outcome measurement. (PC 4; PO 7)

Due Dates

• Initial Post: By 11:59 p.m. MT on Wednesday
• Follow-Up Posts: By 11:59 p.m. MT on Sunday

Week 1: Student Attestation of the DNP Project Application (Required, Not Graded)

• Due May 14 at 11:59pm

 

• Points 0

 

• Questions 2

 

• Time Limit 30 Minutes

 

• Allowed Attempts Unlimited

Instructions

This non-graded assignment is to be completed by end of Week 1 of NR706.

Please complete two questions in this Attestation Quiz stating that your DNP Project Application is complete and submitted through the student portal.

Week 2: Information Technology: A Foundation for Healthcare Transformation

Week 2 References

Baysari, M. T., Hardie, R. A., Lake, R., Richardson, L., McCullagh, C., Gardo, A., & Westbrook, J. (2018). Longitudinal study of user experiences of a CPOE system in a pediatric hospital. International Journal of Medical Informatics, 109, 5-14. https://doi.org/10.1016/j.ijmedinf.2017.10.018

Joshi, K., & Lee, K. (2019). Making impact in the healthcare sector with outsourced information technology services: An interview with Day Veerlapati, president and CEO, Seven Seas Technologies Inc, Chesterfield, USA. Journal of Global Information Technology Management, 22(1), 71-74. https://www.tandfonline.com/doi/abs/10.1080/1097198X.2019.1567666

Pearson, E., & Frakt, A. (2018). Administrative costs and health information technology. JAMA, 320(6), 537-538. https://doi.org/10.1001/jama.2018.10819

The Office of the National Coordinator for Health Information Technology. (2020). Health IT dashboard: Electronic health record adoption. https://dashboard.healthit.gov/apps/health-information-technology-data-summaries.php?state=National&cat9=all+data&cat1=ehr+adoption

Zaroukian, M. H., & Basch, P. (2018). Quality time in healthcare: Meaningful use of health information technology and the journey to paying for value. In S.D. Kudyba (Ed.), Healthcare informatics: Improving efficiency through technology, analytics, and management (1st ed., pp. 43-78). Auerbach Publications. https://www.taylorfrancis.com/chapters/quality-time-healthcare-michael-zaroukian-peter-basch/e/10.1201/b21424-3

Week 2 Clinical Information Systems

Discussion

Purpose

The purpose of this discussion is for you to analyze different clinical information systems’ features and functionality and determine the most beneficial system for your healthcare setting.

Instructions

Conduct an online search for two different electronic health record (EHR) software solutions you view as beneficial to your healthcare setting. Examples may include, but are not limited to, the following: eClinicalWorks, McKesson, Cerner, Allscripts, Athena Health, GE Healthcare, Epic, Care360, Practice Fusion, OptumInsight, and NEXTGEN.

Then, address the following:

1. Identify two selected EHR software solutions and describe three features of each software solution.
2. Compare and contrast the benefits of the two selected EHR software solutions.
3. Select an EHR software solution that is best suited for your workplace environment and provide the rationale for your selection.

Please click on the following link to review the DNP Discussion Guidelines on the Student Resource Center program page:

• Link (webpage): Graduate Discussion Grading Guidelines and RubricLinks to an external site.

Program Competencies

This discussion enables the student to meet the following program competencies:

2. Applies organizational and system leadership skills to affect systemic changes in corporate culture and to promote continuous improvement in clinical outcomes. (PO 6)
3. Appraises current information systems and technologies to improve health care. (POs 6, 7)

Course Outcomes

This discussion enables the student to meet the following course outcomes:

2. Use information technology to collect and analyze data to generate evidence-based nursing practice across healthcare settings. (PC 4; PO 7)
3. Evaluate the types of healthcare information systems, knowledge-based systems, and patient care technology and the impact on patient safety, quality of care, and outcome measurement. (PC 4; PO 7)
4. Resolve ethical and legal issues related to the use of information, communication networks, and information and patient care technology. (PCs 2, 4; PO 6)

Due Dates

• Initial Post: By 11:59 p.m. MT on Wednesday
• Follow-Up Posts: By 11:59 p.m. MT on Sunday

Week 3: Health Informatics Beyond the Acute Care Environment

Week 3 References

Benda, N., Veinot, T., Sieck, C., & Ancker, J. (2020). Broadband internet access is a social determinant of health! American Journal of Public Health, 110(8), 1123. https://doi.org/10.2105/AJPH.2020.305784

Brooks, R., Nieto, O., Swendeman, D., Myers, J., Lepe, R., Cabral, A., Kao, U., Donohoe, T., & Conulada, W. (2020). Qualitative evaluation of social media and mobile technology interventions designed to improve HIV health outcomes for youth and young adults living with HIV: A HRSA SPNS initiative. Health Promotion Practice 21(5), 693-704. https://doi.org/10.1177/1524839920938704

McBride, S., & Tietze, M. (2023).?Nursing informatics for the advanced practice nurse:?Patient safety, quality, outcomes, and interprofessionalism (3rd ed.). Springer Publishing Company.

Week 3 Consumer Informatics/Telehealth Case Study

Discussion

Purpose

The purpose of this discussion is for you to investigate telehealth and technology relationships to social justice principles.

Case Study Scenario

Watch the following video.

Consumer Informatics/Telehealth Case Study (1:55)

Transcript

[MUSIC] Mr. Kasich is a 77-year old who was recently taken to the emergency room after he fell when trying to get out of bed. There, he was found to have a blood glucose level of 35 milligrams per deciliter and was diagnosed with uncontrolled type 2 diabetes mellitus and hypoglycemia despite many years of well-maintained the blood glucose levels. After further assessment, Mr. Kasich was transferred to a medical room in the hospital. His background includes diagnosed with type two diabetes mellitus, advanced congestive heart failure and lung cancer. Has Medicare parts A and B. Lives with wife in a remote area that is 40 miles from the closest healthcare provider. Is proficient using his home computer. Mr. Lane is a 42-year old who was admitted for exacerbation of heart failure. His background includes has diabetes mellitus type two. Is a long-haul truck driver with a large trucking company. Is privately insured. Is single and primarily lives in his truck. Both Mr. Kasich and Mr. Lane are going home with telehealth consisting of a telemonitoring device that transmits weight, blood pressure, blood glucose levels and pulse oximetry to a remote telehealth nurse. Even though the use of telehealth does not often include hands on interaction, the goal of keeping patients out of a hospital is consistent with quality nursing practice. Telehealth applications are designed to enhance the patient experience and improve clinical outcomes while providing care for patients in their home environment rather than an institutional setting. Telehealth supports self-care by empowering patients, which is a central tenet of nursing practice.

Instructions

Review the case scenario above and address the following:

1. Examine concepts such as equity, respect, self-determinism, health literacy, cyclic disadvantage, and healthcare disparities among marginalized populations or groups and how they affect patient outcomes.
2. Compare and contrast how each patient in the video may benefit from telehealth services and the ethical considerations from the viewpoint of the nurse.
3. Propose barriers that must be removed to achieve well-being, sufficiency, and healthcare access for all.

Please click on the following link to review the DNP Discussion Guidelines on the Student Resource Center program page:

• Link (webpage): Graduate Discussion Grading Guidelines and RubricLinks to an external site.

Program Competencies

This discussion enables the student to meet the following program competencies:

2. Applies organizational and system leadership skills to affect systemic changes in corporate culture and to promote continuous improvement in clinical outcomes. (PO 6)
3. Appraises current information systems and technologies to improve health care. (POs 6, 7)

Course Outcomes

This discussion enables the student to meet the following course outcomes:

3. Design programs that monitor and evaluate outcomes of care, care systems, and quality improvement. (PC 4; PO 7)
4. Evaluate the types of healthcare information systems, knowledge-based systems, and patient care technology and the impact on patient safety, quality of care, and outcome measurement. (PC 4; PO 7)
5. Appraise consumer health information sources for accuracy, timeliness, and appropriateness. (PC 4; PO 7)
6. Resolve ethical and legal issues related to the use of information, communication networks, and information and patient care technology. (PCs 2, 4; PO 6)

Due Dates

• Initial Post: By 11:59 p.m. MT on Wednesday
• Follow-Up Posts: By 11:59 p.m. MT on Sunday

Week 4: Information Technology as the Basis for Quality Improvement

Week 4 References

Harris, C., Garrubba, M., Melder, A., Voutier, C., Waller, C., King, R., & Ramsey, W. (2018). Sustainability in healthcare by allocating resources effectively (SHARE) 8: Developing, implementing and evaluating an evidence dissemination service in a local healthcare setting. BMC Health Services Research, 18(1), 151. https://doi.org/10.1186/s12913-018-2932-1

McBride, S., & Tietze, M. (2023). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (3rd ed.). Springer Publishing Company.

Otitigbe, J. (2017). Fishbone facilitation reflection: Team-based cause-and-effect study can point the way to the real problem. ISE: Industrial & Systems Engineering at Work, 49(7), 48-51.

Reed, J. E., Howe, C., Doyle, C., & Bell, D. (2018). Simple rules for evidence translation in complex systems: A qualitative study. BMC Medicine, 16(1) 92. https://doi.org/10.1186/s12916-018-1076-9

Schaefer, J. D., & Welton, J. M. (2018). Evidence-based practice readiness: A concept analysis. Journal of Nursing Management, 26(6), 621-629. https://doi.org/10.1111/jonm.12599

Warnick, R. E., Lusk, A. R., Thaman, J. L., Levick, A. H., & Seitz, A. D. (2020). Failure mode and effect analysis (FMEA) to enhance safety and efficiency of Gamma Knife radiosurgery. Journal of Radiosurgery and SBRT, 7(2), 115-125.

Week 4 Translating Evidence Into Practice

Discussion

Purpose

The purpose of this discussion is for you to evaluate a National Practice Problem within the context of your practice problem idea and technology expansion within your healthcare setting.

Instructions

Select one leading National Practice Problem that is prevalent in your patient population or healthcare setting and address the following:

1. Describe an issue related to the National Practice Problem you selected that is impacting quality, safety, or financial outcomes at your practice setting.
2. Elaborate how technology such as the electronic medical record might assist in implementing, evaluating, or sustaining an evidence-based intervention to address the identified problem.

Please click on the following link to review the DNP Discussion Guidelines on the Student Resource Center program page:

• Link (webpage): Graduate Discussion Grading Guidelines and RubricLinks to an external site.

Program Competencies

This discussion enables the student to meet the following program competencies:

2. Applies organizational and system leadership skills to affect systemic changes in corporate culture and to promote continuous improvement in clinical outcomes. (PO 6)
3. Appraises current information systems and technologies to improve health care. (POs 6, 7)

Course Outcomes

This discussion enables the student to meet the following course outcomes:

2. Use information technology to collect and analyze data to generate evidence-based nursing practice across healthcare settings. (PC 4; PO 7)
3. Design programs that monitor and evaluate outcomes of care, care systems, and quality improvement. (PC 4; PO 7)
4. Evaluate the types of healthcare information systems, knowledge-based systems, and patient care technology and the impact on patient safety, quality of care, and outcome measurement. (PC 4; PO 7)
5. Resolve ethical and legal issues related to the use of information, communication networks, and information and patient care technology. (PCs 2, 4; PO 6)

Due Dates

• Initial Post: By 11:59 p.m. MT on Wednesday
• Follow-Up Posts: By 11:59 p.m. MT on Sunday

Week 4 Translation Science Project

Assignment

Purpose

The purpose of this assignment is to identify a practice problem idea and an evidence-based intervention to address the practice problem idea. Data management is essential to drive actions and decisions to improve healthcare outcomes. The content will support the formulation of a literature synthesis related to your practice problem idea, which supports professional formulation, communication, and dissemination skills relevant to the DNP-prepared nurse.

Instructions

In order to create flexible options, we are providing you options on this assignment. Concept maps are an effective way to express complex ideas, especially for visual learners. For this assignment, each of the following sections may be presented either as a narrative or concept map:

• Practice Problem and PICOT Question
• Evidence Synthesis of Literature
• Data Driven Decision Making

Please note you are not required to complete any or all of the sections identified as conceptual maps. If you choose to use a concept map for a section, it should be created in Microsoft Word using Smart Art and placed in that section of the paper under the associated first level heading. The concept map must meet all the requirements outlined in the assignment rubric for each section. The rubric and page length are unchanged.

Concept Map Resources

If you need additional information on concept maps and how to create a concept map in Microsoft Word, review the following resources:

• Link (article): Effects of Web-Based Concept Mapping Education on Students’ Concept Mapping and Critical Thinking Skills: A Double-Blind, Randomized, Controlled StudyLinks to an external site.

Concept Map (2:48) Information:

As a leader, how you manage, and present information may vary depending upon the project, stakeholders, and goals. One approach to present information to gain support for projects is with visual aids such as a concept map. A concept map organizes and displays knowledge in a graphical manner to show relationships between different concepts. By showing interrelationships, concept maps help engage and heighten problem solving. One way to construct a concept map is by using Word and its graphic art capabilities known as Smart Art.

– Open a blank Word document. – Go to the toolbar. – Select Insert. – Select Smart Art. Select the graphic shape you think most accurately reflects the information you want to share. Let’s say the topic is related to Maslow’s Hierarchy of Needs. You know it is usually presented as a pyramid. So you select Pyramid from the SmartArt options. Once selected, it is placed on your Word document for editing.

The Smart Art tool allows you to identify three sections of the pyramid. But Maslow’s Hierarchy has five levels, so you need to add two levels to the basic design. Place the cursor in the text box, right click, copy, and paste into position. You now should have four textboxes for the pyramid. Repeat the step to have five textboxes. Then, enter your labels inside each text box. This is one example to illustrate the ease of using Word Smart Art to create a concept map.

Again, the concept map design depends upon the concepts of interest. Let’s try one more. You want to make a concept map of the three sciences integrated into nursing informatics: computer science, information science, and nursing science. – Open the Word document. – Go to Insert. – Select Smart Art. – Select Relationships, – Select Basic Venn Diagram. Click on the text boxes and enter Nursing Science in the top circle, then Computer Science and Information Science.

Once you have identified a shape from Smart Art, in addition to adding or deleting parts of the graphic, you can change the location of parts of the graphic as well. Left click the part of the graphic you want to move and drag to a new location. You can connect with lines or arrows by going to the Toolbar and selecting, Insert and then Shapes. These are some basic examples of how to create a concept map. Follow the assignment instructions and use the rubric to guide your creation of the concept map.

Additionally, review the conceptual maps section in the current APA manual.

The assignment should include the following components. Contact course faculty for questions.

1. Introduction
   1. Develop a focused one-sentence purpose statement.
   2. Explain the selected practice problem idea in general terms (cited).
2. Practice Problem and Question (Narrative or Conceptual Map)
   1. Discuss the significance of the practice problem idea (cited).
   2. Discuss the prevalence of the practice problem idea (cited).
   3. Discuss the economic ramifications of the practice problem idea (cited).
   4. Identify an evidence-based intervention to address the selected practice problem idea (cited).
   5. Construct the practice problem PICOT in question format.
3. Evidence Synthesis of the Literature (Narrative or Conceptual Map)
   1. Discuss the scope of evidence including databases searched and keywords.
   2. Compare and contrast main points from the evidence integrated in a cohesive manner (cited).
   3. Provide objective rationale for the evidence-based intervention to address the practice problem idea. (cited).
4. Data-Driven Decision-Making (Narrative or Conceptual Map)
   1. Describe the source of the evidence (i.e., internal data to support the need for change at practicum site to improve outcomes and/or nursing practice. Example: incident reports, readmission rates, infection rates, etc.).
   2. Identify how the use of information technologies potentially influence data capture, process improvement, evaluation, and patient outcomes related to your practice problem idea.
5. Conclusion (Write one concise paragraph.)
   1. Summarize the impact of the practice problem idea.
   2. Summarize the role of the evidence-based intervention to address the practice problem idea.
6. References
   1. Identify and list four scholarly sources used in evidence synthesis on the reference pages.
   2. Identify and list other scholarly sources used in the paper on the reference pages.
   3. List scholarly sources in alphabetical order.
   4. Use correct hanging-indent format.
7. Appendix: Summary Table of the Evidence
   1. Attach the completed John Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool.
      • Link (Word doc): John Hopkins Nursing Evidence-Based Practice Individual Evidence Summary ToolLinks to an external site.
   2. Provide a minimum of four research studies.
   3. Complete all sections completely for the four sources of evidence.
   4. Identify both the quality and level of evidence for each scholarly source on the table.

Level I Headings for the Assignment

• Practice Problem and Question
• Evidence Synthesis of the Literature
• Data-Driven Decision Making
• Conclusion
• References
• Appendix: Summary Table of the Evidence

Writing Requirements (APA format)

• Length: 6-8 pages (not including title page or references page)
• 1-inch margins
• Double-spaced pages
• 12-point Times New Roman or 11-point Arial font
• Headings & subheadings
• In-text citations
• Title page
• Reference page
• Standard English usage and mechanics

Graduate Re-Purpose Policy

The late assignment policy and the reuse repurpose policy (located in the student handbook) apply to this assignment.

Program Competencies

This assignment enables the student to meet the following program competencies:

2. Applies organizational and system leadership skills to affect systemic changes in corporate culture and to promote continuous improvement in clinical outcomes. (PO 6)
3. Appraises current information systems and technologies to improve health care. (POs 6, 7)

Course Outcomes

This assignment enables the student to meet the following course outcomes:

2. Use information technology to collect and analyze data to generate evidence-based nursing practice across healthcare settings. (PC 4; PO 7)
3. Design programs that monitor and evaluate outcomes of care, care systems, and quality improvement. (PC 4; PO7)
4. Evaluate the types of healthcare information systems, knowledge-based systems, and patient care technology and the imp act on patient safety, quality of care, and outcome measurement. (PC 4; PO 7)
5. Resolve ethical and legal issues related to the use of information, communication networks, and information and patient care technology. (PCs 2, 4; PO 6)

Due Date

• By 11:59 p.m. MT on Sunday
• Late Assignment Policy applies

Rubric

W4 Assignment Grading Rubric

W4 Assignment Grading RubricCriteriaRatingsPtsThis criterion is linked to a Learning Outcome Introduction

Requirements:
1. Develop a focused one-sentence purpose statement.
2. Explain the selected practice problem idea in general terms (cited).

10 pts

Includes all requirements and provides an excellent introduction.

9 pts

Includes fewer than all requirements and/or provides a very good introduction.

8 pts

Includes fewer than all requirements and/or provides a basic introduction.

0 pts

Includes 1 or fewer requirements and/or provides a poor introduction.

10 ptsThis criterion is linked to a Learning Outcome Practice Problem and Question (Narrative or Conceptual Map)

Requirements:
1. Discuss the significance of the practice problem idea (cited).
2. Discuss the prevalence of the practice problem idea (cited).
3. Discuss the economic ramifications of the practice problem idea (cited).
4. Identify an evidence-based intervention to address the selected practice problem idea (cited).
5. Construct the practice problem PICOT in question format.

70 pts

Includes all requirements and provides an excellent description of the practice problem and question.

63 pts

Includes fewer than all requirements and/or provides a very good description of the practice problem and question.

56 pts

Includes fewer than all requirements and/or provides a basic description of the practice problem and question.

0 pts

Includes fewer than all requirements and/or provides a poor description of the practice problem and question.

70 ptsThis criterion is linked to a Learning Outcome Evidence Synthesis of the Literature (Narrative or Conceptual Map)

Requirements:
1. Discuss the scope of evidence including databases searched and keywords.
2. Compare and contrast main points from the evidence integrated in a cohesive manner (cited).
3. Provide objective rationale for the evidence-based intervention to address the practice problem.

70 pts

Includes all requirements and provides an excellent evidence synthesis of the literature.

63 pts

Includes fewer than all requirements and/or provides a very good evidence synthesis of the literature.

56 pts

Includes fewer than all requirements and/or provides a basic evidence synthesis of the literature.

0 pts

Includes fewer than all requirements and/or provides a poor evidence synthesis of the literature.

70 ptsThis criterion is linked to a Learning Outcome Data-Driven Decision-Making (Narrative or Conceptual Map)

Requirements:
1. Describe the source of the evidence (i.e., internal data to support the need for change at practicum site to improve outcomes and/or nursing practice. Example: incident reports, readmission rates, infection rates, etc.).
2. Identify how the use of information technologies potentially influence data capture, process improvement, evaluation, and patient outcomes related to your practice problem idea.

70 pts

Includes all requirements and provides an excellent summary of data-driven decision-making.

63 pts

Includes fewer than all requirements and/or provides a very good summary of data-driven decision-making.

56 pts

Includes fewer than all requirements and/or provides a basic summary of data-driven decision-making.

0 pts

Includes fewer than all requirements and/or provides a poor summary of data-driven decision-making.

70 ptsThis criterion is linked to a Learning Outcome Conclusion (1 concise paragraph)

Requirements:
1. Summarize the impact of the practice problem idea.
2. Summarize the role of the evidence-based intervention to address the practice problem idea.

10 pts

Includes all the requirements and provides an excellent conclusion.

9 pts

Includes fewer than all requirements and/or provides a very good conclusion.

8 pts

Includes fewer than all requirements and/or provides a basic conclusion.

0 pts

Includes fewer than all requirements and/or provides a poor conclusion.

10 ptsThis criterion is linked to a Learning Outcome References

Requirements
1. Identify and list four scholarly sources used in evidence synthesis on the reference pages.
2. Identify and list other scholarly sources used in the paper on the reference pages.
3. List scholarly sources in alphabetical order.
4. Use correct hanging-indent format.

20 pts

Includes all requirements and provides excellent references.

18 pts

Includes fewer than all requirements and/or provides very good references.

16 pts

Includes fewer than all requirements and/or provides basic references.

0 pts

Includes one or fewer requirements and/or

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Solution: