Module 6: One new thing

This module taught me about the barriers to creating meaningful electronic health records (EHR). Obviously the technology's there, but there are so many pragmatic hurdles to making EHR useful, i.e., usable. Of course, many of those hurdles are the natural byproduct of a clunky, fragmented health care delivery system. If we were to change the health care delivery system to a single-payor model it would be much easier to reap the promised benefits of EHR. The health care systems that currently use EHR successfully are closed systems that can follow their patient populations over time: the VA, Kaiser's HMOs, or even the big hospitals like the U where we see the same patients over and over for care provided by physicians working within our institution. But when a patient enters our system from another system, that patient typically will be accompanied by a sheaf of copies of paper records and we start our data collection at the beginning with an admission interview that, no doubt, misses a lot because the patient doesn't remember or understand the details of previous conditions and care. Prior to this week's module I didn't really appreciate just how big the challenge is--I mean, I'm on board with the benefit that medical informatics brings to the table, and just like everyone else I look forward to a future where we can leverage information technology to improve health care, but I didn't understand why it's such a currently impossible dream. Mainly, it seems to me that it will never happen unless it's forced on providers with no opt-out provision, and the chances that that will happen in the current political climate are zilch. What we will see is creation of larger small networks--like the one we have at the University Hospital--and the benefit is that we can work out the kinks on these small scales so when the time comes for real change we'll have the nuts and bolts of a better system ready to go.

Module 5: Clinical Decision Making

Among the readings this week, the one that most influenced my perceptions of my clinical decision-making was the Bokel article because it discussed the importance of our electronic health records system. Prior to taking this class I often chose to use the "Narrative Notes" option in my charting system to describe particular patient interactions/interventions. Why? Because it is such an easy option and I perceived it to be a "better," i.e., more fluid and comprehensive, way to explain why I was making particular choices with respect to patient care. I still use "Narrative Notes" to enrich my charting, but I now I am more consciencious about supporting those narratives with entries into the appropriate data entry boxes contained in our electronic medical records. I have come to appreciate how consistent and accruate entries into those boxes not only serves to improve patient care by making the information I enter more broadly accessible to the entire care provider team, but also how important it is for the future of nursing to be recognized for the care we provide and outcomes of our nursing interventions. By taking the time to master the "vocabulary" of the EHR and entering data into its proper place in our computerized systems I am helping our staff to quantify and qualify Nursing's enormous and unsung role in the care delivery process. When, as was my prior habit, I "opt out" of making this effort I'm shortchanging my unit and, prospectively, our profession by making it more difficult to quantify and qualify how I have helped my patient to recover from surgery, to cope with her and/or her infant's illness, and to explain the important role of nurses as educators and care givers who counter a sometimes dehumanizing experience as a hospital inpatient. I view this as especially crucial in my clinical setting where we often have patients who stay with us for weeks, and sometimes months. If I don't make this effort to memorialize my work, it might appear from the computer records that I have done nothing more than perform perfunctory rounds from time to time during the shift. Do I think this reflects my real work? Of course not. This is especially important to me, personally, where a lot of my care-giving philosophy concerns providing care that is minimally invasive of my patients' privacy and my committment to including family and friends in the care delivery process. When I make "Narrative Notes" as a shortcut to explaining the "heuristics" underlying my nursing care it is unlikely to be captured by the automated data collection systems that are meaningful in quantifying and qualifying those services. However, when I take the time to learn our systems better, and to use our computer entry system to record my best efforts, they are better relected in the Hospital's evaluations of our care and assist nursing to be better recognized . . . and maybe better compensated!!

Module 4 Posting

Responding to the question "is there any health care provider role that does not involve teaching in some manner?" may I just say "Surgeon"?!! Ok, so I'm just joking, or am I? In any event, we as health care providers should all be teaching all the time because, obviously, we need to obtain informed consent from the patient or his/her representative before we do anything at all or it's (technically) a battery. We should be explaining everything we do, and the reasons we're doing it, before, during, and after we do it. While that might sound onerous on its face, I've actually found that it's a great tool for filling in the conversational gaps that might otherwise become awkward during patient care, for staying focused, and for involving the patient and his/her family members in the care delivery process. For example, when I'm giving ANYTHING intraveneously, I show it to the patient, tell them what I'm giving them and why, wait to see if they have any questions at all before I proceed, and make sure that whatever family is in the room also has the opportunity to look at the medication and ask questions. Why do I do this? Because during my first year on the floor I noticed that whenever I made a mistake, it was because I had failed to listen to what my patient and/or a family member was saying. I mean . . . every . . . single . . . time. I am lucky that I didn't make any big mistakes, and I'm also lucky that I learned from those experiences to be very inclusive in my care delivery style. Now, instead of using my left brain to keep up a pitter-patter/chitter-chatter that smoothes the social airways while the right side of my brain keeps an eye on whatever the heck business I'm actually trying to conduct, I focus the activities of both hemispheres on the single task of getting all of us in the room--patient, family, health care providers--on the same page to provide high quality patient care. Honestly, I don't care what Aunt Martha did last year at the family reunion, and I'm pretty sure the patient and his/her family don't care that I know, or even less my opinion about it . . . but what we all share as a mutual interest is what I'm doing to promote my patient's health and safety and how it affects the big picture Plan Of Care--so I keep the focus there and I think it's a pretty good way to incorporate teaching into patient care on a routine basis.

P.S. To all my patients who actually occupy two places in my heart (patient and FRIEND) please know that I'm not talking here about our cherished friendships, but what I do to make sure I'm delivering SAFE patient care!!

Module 3 Information Retrieval

Reponding to the question "How do you anticipate that this [information retrieval] assignment will help you in your graduate coursework?" I'd say that it's invaluable. Even though I'm on a clinical--not a research--track, my ability to sift through research for information relevant to my practice and, more specifically, my DNP project is crucial to its success. If I am to persuade key stakeholders of the merit of my project, I need to be able to point to solid evidence that shows how their participation is likely to produce a good return on their investment of time and resources. Obviously, the best vehicle for that showing will be other previous demonstrations of similar outcomes. To move from abstraction to a concrete illustration, I want to persuade our local senior centers to implement the Strong Women Stay Young program here in Utah. To do that, I'd start with Miriam Nelson's excellent books explaining the program and its underpinnings, but I wouldn't want to stop there; I'd want to go further to find other examples where her theories and methods are demonstated to be in lockstep with current evidence based practice. In other words, I would seek verification linking her version of what might be best for seniors to other researchers' works. To do that, I'll rely on electronic information retrieval to find the best scholarly sources for critical review of Dr. Nelson's work, and I'll also benefit from an information management system so as not to become overwhelmed or disorganized in my collection and synthesis of that mountain of information.

Module 2 Post

In response to the question, "what is one way you could become involved in designing, selecting, evaluating, or implementing an information system in your workplace?" I was surprised to realize that I am, in fact, already involved in this at work. I didn't really even realize it until I was asked to draft this post. The University Hospital switched over from paper orders to CPOE about 2 years ago and ever since we've been working through the kinks to edit our computer charting to more transparently reflect the care process. Through various unit based teams feedback filters up through the Nursing Practice Council and then to the IT support people who make changes designed to make charting go more smoothly. I'm on my unit's Unit Based Council and in that capacity I routinely review proposed changes to provide feedback about if and how those changes might be received in my particular unit. So, for example, we were recently asked to review some changes to the pain scores in response to a visit by the Joint Commission. The changes are hoped to record more clearly how information about patients' experience of pain is collected, what measures are taken to alleviate pain, whether those measures are timely, and whether they are effective. As one of our unit based reps I'm charged with responsibility for gathering opinions from my coworkers that I take back to our monthly Unit meeting, and our leader will distill our reports into a summary that she presents at the Nursing Practice Council meeting. So, unbeknownst to me, I actually have been involved with evaluating and implementing an information system in your workplace!! Who knew?! I'll also add that I help to implement the information system in a second, informal way: I talk it up at the workplace. To the extent that people are resistant to computer charting, I think they're just whistling Dixie. We need to embrace the new systems, engage in the process of making them "friendly" enough that they don't make us want to pull out our hair, and recognize that they will ultimately improve health care delivery and are, in fact, a good thing.

Module 1--Getting Started

Hi, all! My name is Ellen and if you're reading this you know that one of the things I'm up to this summer is taking an informatics class--like all of you! I'm in my third semester of the Adult/Geriatric DNP program. As a graduate level nurse, I recognize that we're all going to have to get much better at information management if we hope to fully participate in and enjoy the 21st Century workplace. I work at the University Hospital where currently we're trying to incorporate CPOE (Computerized Physician Order Entry) into our daily grind. It's a struggle, beginning with persuading participants that it's a skill worth learning . . . I don't know that it would have happened without some stern nudges from the "powers that be." As with change generally, everyone is very leery of the new system and irritated with learning how to navigate within it. Here's hoping that we have a great class experience, and also a great summer despite the heavy class load!! Till later, e