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!!