Abstract:
A method and apparatus for delivering intravenous drugs to a patient provides for remote loading and programming of IV pumps that may be shipped in a loaded and programmed configuration to a remote site for use with the patient. A special carrier may be provided for pneumatic delivery of the preloaded pump. Password enabled customizing of pump features according to specific user&#39;s need may be provided to prevent undesired changing of the pump parameters at the remote site.

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
     This application claims the benefit of U.S. Provisional Application No. 61/589,204 filed Jan. 20, 2012 and entitled System for Remote Programming and Loading of Medical Pumps; and further claims the benefit of U.S. Provisional Application No. 61/493,680 filed Jun. 6, 2011, entitled: Concepts of Customizing Infusion Pumps and further claims the benefit of hereby incorporated by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     The present invention relates to medical pumps for the delivery of medicines to patients under controlled rates and dosages and in particular to a pump adapted for remote loading and set up. 
     Medical pumps, such as syringe pumps or peristaltic infusion pumps, are known for computer-controlled delivery of medication or contrast agents (henceforth drugs) to patients over a period of time. Typically the drug is delivered in a syringe (for a syringe pump) or a flexible bag (for peristaltic infusion pump) that may be connected to an IV line attached to a needle for insertion into the patient. When a nurse or other healthcare professional ministering to the patient receives the drug, the healthcare professional reviews the drug description for correctness and enters the desired dose and rate into the pump. The syringe or IV line must then be mechanically connected to the pump mechanism and the mechanism activated to begin pumping. 
     The process of programming pumps and mechanically attaching the drug container (syringes or bags and IV lines) to the pump mechanism can be time-consuming and exacting. In a large facility, there may be multiple different pump designs and models and a given healthcare professional ministering to a patient may be called upon only occasionally to work with any given type of pump. This variation in pump types can increase the time required to properly initialize and connect the pump mechanism, and create errors in dose programming or mechanical installation that can carry with them significant risks to the patient and/or cause waste of the necessary drug. Failure to properly set up or connect the drug container to the pump can raise safety issues. 
     The difficulties of setting up and programming pumps can also be a problem when the pumps are used in a home setting. In such cases, normally a nurse will deliver and attend to the proper initialization of the pump. 
     SUMMARY OF THE INVENTION 
     The present invention provides a method and apparatus for improving the workflow of drug delivery to patients using medical pumps, in which the pump may be programmed and loaded remotely by a specialist such as a pharmacist and then shipped in connected form to the healthcare professional ministering to the patient. This healthcare professional then needs only install the pump and pre-loaded drug container on a pole or the like and ensure connection to the patient (possibly through an existing IV line) to begin pumping operation. The simplified workflow significantly mitigates the risks of improper programming of the infusion pumps or improper loading of IV set. The pump may require verification of the setup (proper drug and patient) significantly reducing any risks of such a remote loading operation. In addition, programming features may be hidden, limited and locked by the specialist. 
     One embodiment of the present invention provides a method of managing patient drug infusions in which a drug infusion order is received by a first individual, at a first work area, the order providing a drug identification and infusion parameters. The first individual loads a medical pump with a drug container as attached to an IV line per the drug identification and programs the medical pump with the infusion parameters. The loaded and programmed medical pump is then transferred to a second individual at a second work area remote from the first work area. The second individual connects the IV line to the patient and activates the medical pump according to its previous programming by the first individual and using the drug container loaded by the first individual. Depending on the practical need(s), the first individual may only program the pump or only load the pump with tubing/container. 
     It is thus a feature of at least one embodiment of the invention to allow the specialized knowledge of pump programming and loading to be centralized with an individual to better leverage the skill of that individual. It is a further feature of at least one embodiment of the invention to better manage the complexity of loading and programming of multiple different types of pumps. 
     The method may include the step of requiring validation by the second individual at the second work area of certain infusion parameters before activation of the medical pump. 
     It is thus a feature of at least one embodiment of the invention to permit remote loading and programming of medical pumps while ensuring proper validation of the setup and operation of the pumps at a remote location when the programming and drug installation has been previously performed. Requiring the second individual to validate selective parameters provides a check against transportation errors and the like. 
     The infusion parameters may include patient identification, drug identification, and drug delivery rate. 
     It is thus a feature of at least one embodiment of the invention to provide for validation both of patient and/or fundamental delivery parameters. 
     The medical pump may be an infusion pump and the drug may be contained in an IV bag attached to an IV line and the loading of the medical pump with the drug may include the steps of threading the IV line through the pump and locking the tubing into the pump. 
     It is thus a feature of at least one embodiment of the invention to centralize the installation of an IV line into multiple elements of a pump. 
     The method may include the step of loading the pump into a carrier configured to hold the pump and drug during the transportation. 
     It is thus a feature of at least one embodiment of the invention to provide a mechanism for transporting a loaded infusion pump that could otherwise be susceptible to dislodgment of the drug container and/or IV tube or damage to the same. It is thus a feature of at least one embodiment of the invention to permit the efficiencies of centralized drug dispensing and pump loading to be realized in a hospital environment. 
     The pump may provide a password locking of the programming and include the step of locking the programming of the pump. 
     It is thus a feature of at least one embodiment of the invention to provide improved accountability for pump programming in a remote loading system. 
     The pump may provide a password locking of rules describing a relationship between values of the programming and constraining a reprogramming of the pump by the second individual at the second work area. 
     It is thus a feature of at least one embodiment of the invention to permit limited ability by the remote user to change parameters within predefined relationships and ranges. 
     The password may protect a setting providing selective display of infusion parameters. 
     It is thus a feature of at least one embodiment of the invention to hide unnecessary programming options from the remote user. 
     These particular features and advantages may apply to only some embodiments falling within the claims and thus do not define the scope of the invention. 
    
    
     
       BRIEF DESCRIPTION OF THE FIGURES 
         FIG. 1  is a simplified workflow diagram showing remote loading of a pump by a pharmacist and pneumatic transport of the loaded pump to a site of use in a pneumatic capsule as is possible with the present invention; 
         FIG. 2  is a data flow diagram showing communication between a computer of a pharmacist or other drug specialist and the pump for programming the pump after it has been loaded with the necessary drug by the pharmacist or drug specialist; 
         FIG. 3  is a block diagram of the principal elements of the pump including a user interface and controller holding a pump control program as well as control parameters providing information about the patient dose/rate and drug type for on-site verification; 
         FIG. 4  is a depiction of the pump and drug installed on an IV pole for administration to the patient at a location remote from the site loading of the pump and showing a bar code reader being one method of validating the set up of the remotely loaded pump; 
         FIG. 5  is a flowchart of one embodiment of the workflow steps of the present invention implemented in part by electronic computer; 
         FIG. 6  is a block diagram of data and programming structures of the pump control program of the controller of  FIG. 3  including a user interface program controlling the entry of control parameters through the pump user interface; 
         FIG. 7  is a flowchart executed by the user interface program to lock or hide some programmable features; and 
         FIG. 8  is a fragmentary representation of a screen display on the pump user interface allowing password-protected locking and hiding of programming features. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
     Referring now to  FIG. 1 , in an example workflow  10  that may be implemented by the present invention, a medical pump  12  (such as a syringe pump or a peristaltic pump) may be pre-loaded with the desired drug  14  (for example a medicine or contrast agent). In one embodiment, the drug  14  may be, for example, contained in a flexible pouch  16  communicating through tubing  18  to a connector  20  or sterile needle for attachment to a patient. Generally, the tubing  18  may be engaged within a pumping mechanism of the pump  12 , the latter which may provide controlled flow of the drug to the patient as is understood in the art. 
     Each of the pump  12 , pouch  16 , tubing  18  and connector  20  may then be loaded into a carrier  22 , for example, being part of a pneumatic cartridge  24  or a container fitting within a standard pneumatic cartridge  24  suitable for transportation over a hospital pneumatic system  26  for inter-hospital delivery. For this purpose, the pump  12 , pouch  16 , tubing  18  and connector  20  are sized to fit within the dimensions of a standard pneumatic cartridge  24  providing less than a 10 inch internal diameter (and preferably less than six inch diameter) and to have a weight of less than 20 pounds normally required for such systems and preferably less than 12 pounds. 
     As is understood in the art, pneumatic systems  26  may use air pressure to convey the pneumatic cartridge  24  holding the pump  12 , pouch  16 , tubing  18 , and connector  20  as pre-assembled and programmed at speeds of up to 25 feet per second in the hospital or dispensing environment. Pneumatic cartridges  24  and pneumatic systems  26  suitable for this use are commercially available from Swisslog Healthcare Solutions of Buchs, Switzerland. An infusion pump suitable for this purpose and having the proper size and weight for pneumatic transport is commercially available from SIGMA International General Medical Apparatus, LLC of Medina, N.Y. (acquired by Baxter International Inc), although the present invention is not limited to this pump system. 
     Alternatively, the carrier  22  may be in the form of a suitcase for home delivery. In each case, the carrier  22  may include pads and dividers  23  for stabilizing its specialized contents against damage or disconnection. The preloading may be performed by a pharmacist  28  at a remote location  30 , for example a central pharmacy and drug repository area within the hospital, and then loaded into the pneumatic system  26  for transportation to a nurse  32  or other healthcare professional administering to a patient. 
     Referring now to  FIGS. 1, 2 and 5 , at the remote location  30 , the pharmacist  28  may receive a drug order as indicated by process block  31  from a physician with necessary authentication by that physician and indicating a patient and a drug type. This order may be received electronically over an electronic medical record system  36  ( FIG. 2 ) communicating with a terminal  34  ( FIG. 2 ) accessible by the pharmacist  28  ( FIG. 1 ). The pharmacist  28  may then determine the appropriate dose and rate (if not provided by the physician), for example, as may be based on information about the patient such as the patient&#39;s weight and other concurrently administered drugs and the like. Such information may also be obtained from a drug library. The pharmacist  28  may then enter this information into the terminal  34  for integration into the patient&#39;s record in the electronic medical record system  36  which may include review features, for example decision support tools detecting drug interactions or the like. This data entry is indicated by process block  33   
     The pharmacist  28  may then program the pump  12  to deliver the drug  14  at the correct dose and rate as indicated by process block  35  ( FIG. 5 ). This programming may further provide the name of the patient and identify the drug  14  which may also be stored in the pump  12  as will be described. This programming by the pharmacist  28  may be simplified because of the frequent experience of the pharmacist  28  with the pump programming process. As will be discussed in greater detail below, the pharmacist  28  may lock certain programming features and may hide other programming features as part of this process. 
     A variety of methods may be used by the pharmacist  28  to program the pump  12  including manual programming of the pump using its keypad (as will be described below), wireless programming received by a wireless link in the pump  12  (either radio or infrared links), programming an RFID tag that may be installed on the pump  12  or close to the pump  12  (for example in the clamp  44  described below), or direct wired connection between a terminal  34  and the pump  12 , for example a USB connection. The terminal  34  may be a standard desktop computer system providing for improved user interface capabilities, for example a full keyboard and large display. The terminal  34  may further include an interpreter allowing a standard user interface to be used with a variety of different pump types. Portable devices such as an iPhone, iPad, or other brand of tablet and mobile devices including cellphones, a desktop or laptop computer may be utilized to fulfill the function of terminal  34  by wired or wireless connection to the pump  12 . 
     As indicated by process block  37 , the pharmacist  28  may then install the drug into the pump  12 , for example, by threading the tubing  18  through a pump section  42  of the pump  12  ( FIG. 3 ), locking the tubing in place (for example by closing a door over the tubing), removing air from the tubing  18  to prime the tubing  18  and installing a clamp  44  ( FIG. 2 ) on the tubing for shipment. The clamp may also be a built-in component on the IV set. The pharmacist may input drug and patient information on the clamp, for example, by utilizing an RFID that attaches to the clamp. In this case, an alternate work-flow is that the clamp carries all necessary information. Only the drug pouch and connected IV set are necessary to be transported from the pharmacy to the care site, where the pump is already mounted on the IV pole. Once the clamp is inserted into the pump, information can be read by the pump and processed. Again, the pharmacist  28 , dealing with the pump on a regular basis, may have greater familiarity with tube loading and pump programming process than the nurse  32 . 
     At this time the pharmacist  28  may record a barcode  46  on the pouch  16  and a barcode  48  on the pump  12  for record-keeping purposes and/or to validate the proper drug has been installed. The barcode  48  enables proper monitoring of service of the pumps  12  which now move from location to location. 
     As was discussed above, the loaded and programmed pump  12  may then be installed in the carrier  22  for shipment as indicated by process block  39 . While a pneumatic system  26  has been described, it will be appreciated that this shipment may be by a variety of different methods and may transport the loaded and programmed pump  12  out of the hospital environment for home use and the like. Further, the programming and loading may take place in other non-hospital environments, such as a pharmacy; it may be performed by a skill person who is not necessarily a pharmacist. 
     Referring now to  FIG. 3 , the pump  12  may include a controller  50  (which may be a microprocessor based system) having a memory  52  for holding a stored operating program  54  including operating programs  56  controlling intrinsic operation of the pump  12 . The memory  52  may also hold infusion parameter data  58  in a data table, the infusion parameter data  58  including identification of the patient, values for a dose and rate of desired drug delivery, alarm settings and the like, and a drug name. Each of the infusion parameter data  58  is programmable according to a programming method  40  ( FIG. 2 ) as described above as well as other program modes which will be discussed in more detail below. 
     The controller  50  using the data in the memory  52  may control a pump section  42  of the pump  12  during delivery of drug  14  to the patient. The pump section  42  may, for example, include one or more pressure sensors  61  monitoring pressure in the IV tubing  18  installed in the pump section  42  or detecting blockage or other pumping irregularities. In addition, the pump section  42  may include a bubble sensor  62  for detecting bubbles in the IV tubing  18 , a pump  64 , for example, providing successive compressing elements for peristaltically moving fluid through the IV tubing  18 , and the flow sensor  66  for detecting a flow rate of liquid in the IV tubing. Each of these sensors  61 ,  62 , and  66  and the pump  64  may communicate with the controller  50  so that the pumping process may be monitored by the controller  50 . 
     The controller  50  may also communicate with a display  68  for displaying various programming and operating parameters, a keypad  70  for inputting data, for example, for programming or initiating or stopping of the pumping action, and a communication module  72 , for example, communicating wirelessly either through a long-range wireless protocol or short range wireless protocol such as Bluetooth, cellular communication, infrared, WiFi or the like or by a wired protocol such as Ethernet, USB, or other communication protocols. The controller  50  may also communicate with a local barcode scanner  74 . 
     The controller  50  may also communicate with a password memory  73 , initially blank to allow entry of a new password, and subsequently holding a password whose entry is required to change the password memory, and for other programming steps as will be described. 
     Referring now to  FIGS. 1 and 4 , the nurse  32  or other specialist may then attach the pump  12  to an IV pole  75  or the like and attach the pouch  16  holding the drug  14  to a point on the IV pole  75  above the pump  12 . The barcode  46  will be readily accessible on the pouch  16 . 
     As indicated by process block  81  of  FIG. 5 , the nurse  32  may then validate the setup by using the barcode scanner  74  to scan a wrist tag  84  on the patient  86  to match the patient identification stored in the pump  12  in the infusion parameter data  58 . The barcode scanner  74  may further scan the barcode  46  on the pouch  16  to confirm that it is the correct drug  14 . In an alternative embodiment, the function of the barcode scanner  74  may be implemented by a portable wireless device such as an iPhone or Android phone or similar smart device having a camera or similar element that may be used to read the barcode, decode the barcode, and forward the information to the pump  12 , for example, by near field communication, Bluetooth, infrared channel or the like. In addition, the barcode scanner  74  may be used to scan the pump  12  itself. In this way, these devices may also be used to positively identify the pump and the drug, as well as the patient, and to allow activation of the pump only if the patient, pump, and drug matches a predetermined link combination stored in the pump  12  or in a remotely accessible database. Clearly, the barcode scanner may be replaced with other local scanning devices including RFID tags and a reader, or the like. The barcode scanner  74  may be implemented as a wireless device and the scanning operation can be performed using a portable device such as a tablet computer, smartphone or the like. 
     The nurse  32  may then activate the pump as indicated by process block  88  free from the time-consuming loading of drug  14  into the pump  12  and programming of the pump  12  which may now be accomplished by a specialized individual having great familiarity with the systems. Alternatively, the nurse  32  may authenticate the proper setup and patient by reviewing patient biographical information displayed on the screen of the pump  12  including, for example, patient name, date of birth, and the like as stored in the parameters previously described. Confirmation of this information may be indicated by pressing of the keypad button on the pump  12 . 
     In some embodiments, the nurse  32  may program or reprogram some of the pump parameters according to selections made by the originally programming user as will be described below. For example, some pump parameters may be freely programmed by the nurse  32  according to those permissions granted by the original programming user or may be programmed only within a predetermined range established by the original programming user and which may not be changed by the nurse  32 . 
     Referring now to  FIGS. 3 and 6 , the program  54  of the controller  50  may provide generally an interface program  56   a  communicating with the display  68  and keypad  70  for sending data to the screen  68  and receiving data from the keypad  70 . The interface program  56   a  may in turn communicate with infusion parameter data  58  allowing programming of infusion parameter data  58  and to display of the infusion parameter data  58  on the display  68 . The interface program  56   a  may also communicate with pump control program  56   b  serving to provide control signals to the pump section  42 , and specifically to output control signals to the pump  64  and receive sensor signals from sensors  61 ,  62 , and  66  as is generally understood in the art. 
     The interface program  56   a  may also communicate with a rules table  55  and a lock/hide table  59  as will now be discussed. 
     Referring now to  FIGS. 5, 7 and 8 , during programming of the pump  12  by a pharmacist  28  or other specialist per process block  35  of  FIG. 5 , the interface program  56   a  may begin a data entry mode indicated by process block  90 , for example, as invoked by the pressing of data entry keys on the keypad  70  (per  FIG. 3 ) as is generally understood in the art or through the programming method  40  described above. Upon beginning the data entry mode, the interface program  56   a  may request the entry of a password by the user. This entry is optional and if no user password is entered, the options for data entry and viewing are limited as will be described below. 
     The data entry mode will generally display on the display  68  different parameters of the infusion parameter data  58  and allow the entry of data into those parameters in a conventional menu-driven data entry process. At decision block  92 , for each parameter selected for entry by the user, the interface program  56   a  checks the rule table  55  to see if the particular parameter is locked data. If so and if the user is not operating under a predetermined password as described above, the interface program  56   a  proceeds to process block  94  and the user is notified that this data entry or data change may not be performed and the change in data is rejected. The program then returns to process block  90  for the entry of possibly different data. 
     If at decision block  92 , the parameter is not locked or the user is operating under a password matching the predetermined password, interface program  56   a  proceeds to decision block  96  and the entered data is received and compared against rules held in rules table  56 . Such rules may, for example, (1) provide for predetermined ranges of acceptable data entry for the particular data parameter or (2) compare currently enter data against other previously entered data values for consistency. For example, the rules may identify the drug and based on the drug identification provide a range of possible volume flow rates. The rules or ranges may be entered by a user operating under the password by similar process as described with respect to decision block  92  and  94 . 
     If at decision block  96  a rule is violated, the interface program  56   a  proceeds to process block  98  and the user is notified of that violation and changed data is rejected. This notification may include an indication of the acceptable range or the reason for the rejection, for example, providing a recitation of the rule. 
     If at decision block  96  no rule is violated, then at process block  100  the necessary changes in the infusion parameter data  58  are made and additional data may be entered. 
     Referring now to  FIG. 8 , population of the lock/hide table  59  may be performed using steps similar to those with respect to decision block  92  and  94  when the interface program  56   a  is in a data entry mode for the lock/hide table  59 . In that mode, the screen of terminal  34  may display a list of programmable data  102  providing a series of parameter names  104  together with checkboxes that allow individual parameters to be either locked or hidden. As discussed above, the state of parameters as locked or unlocked are used at decision block  92  to determine whether the change in that data may be performed by those not operating under the entered password. Hidden data results in the parameters being hidden during the data entry process of process block  35  preventing both programming and confusion by the user. Because the data is hidden, it may not be viewed or modified by those not operating under the entered password. 
     Generally the parameter data  58  may include: (1) the patient name, (2) the patient birthdate, (3) the patient identification number, (4) the flow/dose rate of the drug to be delivered by the pump, (5) the volume of drug to be infused (VTBI), (6) a maximum allowed flow rate for this patient, (7) an alarm interval for the infusion task (e.g. every 10 milliliters), (8) whether the pump enters a standby state when the alarm is set, (9) occlusion alarm pressure setting, (10) activation state of the air-in-line alarm, and the like. Other alarm settings may include, for example, battery capacity or data from other monitoring devices such as blood pressure, pulse, oximeter value, etc. that may be incorporated into the pump  12 . 
     Generally it will be understood that a mechanism will be provided for resetting the password allowing those users operating under a predetermined password to change the password. 
     EXAMPLE 
     A pharmacist may receive a physician&#39;s order to dispense a drug to be infused for a patient. The total volume of the drug is 100 mL. The patient is at home and the infusion will be administrated by a visiting nurse, who is not familiar with the pump. According to the lab results and physician&#39;s assessment of the patient, the flow rate of the drug for this patient cannot exceed 50 mL/hour and the physician has ordered 25 mL/hour as the infusion flow rate and that the patient pulse and blood pressure should be taken every 10 mL of drug infused. 
     As part of dispensing the drug, the pharmacist can configure the pump according to the infusion task by invoking a proper programming page on the pump which allows him/her to input the password. After authentication, the pharmacist can input the following information: 
     Patient information, including name, birth date, and patient identification number; 
     Flow rate: 25 mL/hour; 
     Volume to be infused (VTBI): 100 mL; 
     Maximum allowed flow rate for this patient: 50 mL/hour; and 
     Alarm interval for this infusion task: every 10 mL of drug infused (the pump can be configured so when the alarm sets off, the pump enters stand-by state). 
     If preferred, the pharmacist can also configure the pump to hide some user selectable features, such as occlusion alarm pressure setting, air-in-line alarm setting, etc. 
     After all related information is input and all configurations are completed, the pharmacist can save this infusion task on the pump, and give the pump and the drug to the visiting nurse. 
     When the visiting nurse arrives at the patient home and turns on the pump, the patient&#39;s name is shown on the pump screen for the nurse to confirm. Birth date and patient identification number then can be confirmed. Once necessary information is confirmed as correct, the preloaded pump may be set up and connected to the patient. 
     Alternatively the pump may guide the nurse to prime the tubing and load the tubing on the pump to connect to the patient and perform other steps otherwise performed by the pharmacist. 
     Once each step has been confirmed as successfully completed, the flow rate of 25 ml/hour and VTBI of 100 mL are shown on the screen, and the user is prompted to press the “Run” key on the pump keypad to run the infusion. If the pharmacist hides the selectable features to set up occlusion alarm pressure, the nurse will not see the option on the pump. The pump will alarm at the pressure level the pharmacist programmed. After each 10 mL of drug infused, the pump alarms and pauses, prompting the nurse to take pulse and blood pressure measurements. The nurse can press “Run” key again to resume the infusion after the measurements are done. When the nurse tries to increase the flow rate to speed up the process, she cannot go beyond 50 mL/hour, the maximum limit set by the pharmacist as a rule. 
     The present invention not only simplifies the workflow in administering drugs but allows different pumps to be provided to a given patient for different purposes and allows better utilization of a limited number of pumps. It will be understood that the present invention may work with a variety of different pump types including not only peristaltic pumps but also syringe pumps and the like. 
     Certain terminology is used herein for purposes of reference only, and thus is not intended to be limiting. For example, terms such as “upper”, “lower”, “above”, and “below” refer to directions in the drawings to which reference is made. Terms such as “front”, “back”, “rear”, “bottom” and “side”, describe the orientation of portions of the component within a consistent but arbitrary frame of reference which is made clear by reference to the text and the associated drawings describing the component under discussion. Such terminology may include the words specifically mentioned above, derivatives thereof, and words of similar import. Similarly, the terms “first”, “second” and other such numerical terms referring to structures do not imply a sequence or order unless clearly indicated by the context. 
     When introducing elements or features of the present disclosure and the exemplary embodiments, the articles “a”, “an”, “the” and “said” are intended to mean that there are one or more of such elements or features. The terms “comprising”, “including” and “having” are intended to be inclusive and mean that there may be additional elements or features other than those specifically noted. It is further to be understood that the method steps, processes, and operations described herein are not to be construed as necessarily requiring their performance in the particular order discussed or illustrated, unless specifically identified as an order of performance. It is also to be understood that additional or alternative steps may be employed. 
     References to “a microprocessor” and “a processor” or “the microprocessor” and “the processor,” can be understood to include one or more microprocessors that can communicate in a stand-alone and/or a distributed environment(s), and can thus be configured to communicate via wired or wireless communications with other processors, where such one or more processor can be configured to operate on one or more processor-controlled devices that can be similar or different devices. Furthermore, references to memory, unless otherwise specified, can include one or more processor-readable and accessible memory elements and/or components that can be internal to the processor-controlled device, external to the processor-controlled device, and can be accessed via a wired or wireless network. 
     As used herein programming or data entry refers not only to adding data but modifying or deleting data in electronic memory. 
     It is specifically intended that the present invention not be limited to the embodiments and illustrations contained herein and the claims should be understood to include modified forms of those embodiments including portions of the embodiments and combinations of elements of different embodiments as come within the scope of the following claims. All of the publications described herein, including patents and non-patent publications are hereby incorporated herein by reference in their entireties.