Module 1 IT in the ER

The ER uses standard paper documentation. For our nursing documentation sheet, there is an area for triage, pre-hospital treatment, and the nursing assessment on the front side. On the back we are able to list given medications, ER interventions, IV starts, and free text everything else. The powerpoint on “coding and classification of clinical data” describe nursing documentation to be symbolic representation of concepts. There is a standard blank picture of a body, front a back, also of a head, that symbolically represents each patient. We use numbers and circles to identify pain, lacerations, abrasion, etc. This kind of structured documentation can help people find information faster. Everyone who is seen at the hospital is given a Medical Record Number (MRN) as an identifier and means to store hospital visit information. There has been a problem with standard identifiers when people have multiple MRNs, making it difficult to retrieve past medical interventions and medication regimes. The coding system used by physicians in the ED is recorded on discharge summaries. If other specialists and providers are in the same network, information is easily accessed; however, as in the quality of diagnostic coding study in New Zealand showed, transfer of information may be delayed suggesting inefficient coding practices. Structured/coded clinical data is useful in promoting quality patient care if correct terminologies and coding are used since it will help increase communication and management of patient data. A push towards information technology and proficiency with standard documentation and coding will promote quality of care so we can spend more time with our patients and understand their health history from the beginning of their visit.

Module 6 Course Reflection

What did you like or dislike about taking an online course?

I liked that the online course was self-paced so I could work on the modules when I had free time from my other course work. It introduced me to new topics. I actually learned something!

I disliked the lack of feedback for assignments. In a traditional classroom setting, mistakes I made on papers were applied to the following assignments. In this case, I was already starting on module 5 by the time we received feedback about Module 1.

What topic did you learn the most about and what was your favorite topic?

I learned the most from Module 2: Information Retrieval. I challenged myself by learning a new database, micromedex. I actually ended up learning PubMed as well because Micromedex does not contain citations to download to the reference manager I was using.

My favorite topic was taking the multiple intelligences and learning style test. It helped me see that I am about equal in all learning styles and it further confirmed to me the need for variety in teaching as well as learning. The You Tube videos made by students was very enlightening because I could relate to their hidden statements. I realized that I probably am not alone when I feel the pressures of school.

If you were the instructor, and this being the first course for all DNP and Master students, what would you do the same or different?

I thought the module order was very appropriate. I appreciate that the quizzes were open book, I think I learned more by finding the answers to the quizzes rather than if I had just memorized them. The GoogleDocs assignment was a great learning experience for me. I think we have a long way to go before submitting the article for publishing; however, I can see the potential it has. I would try to give more feedback to students so blog posting and assignments can improve with each module. Timely feedback is extremely important to me as a student.

Module 5: Agency for Healthcare Research and Quality

The U.S. Department of Health & Human Services Agency for Healthcare Research and Quality website provides links to various grant projects currently in progress, under review, and completed. I spent most of my time looking over the reports under the “Health IT” menu. There were four recent reports I browsed over: barcode medication administration, chronic disease management, computerized provider order entry, and telehealth. I also read the abstract of Mixed Patient Use of Electronic Messaging to Communicate with Doctors.

Is there any relationship between the information available on this webpage and regulatory, accreditation, and reimbursement issues and health care information system use and design?

All the methods provide insightful information on how implementation can improve the quality, safety, efficiency, and effectiveness of health care. Some considerations to keep in mind are the regulation of such IT systems, how staff will be reimbursed for their time, and if their design will truly be the most effective.

Barcode Administration was launched a few months before I left IHC to move to Salt Lake. The training was straight forward, and because the system was new, we had opportunities to participate in improving the “bugs.” I found that there were always ways to override barcode scans, whether it was because the barcode did not work or because the “do not give reason” was incorrect. The intent was good, all overrides were compiled and reviewed by the pharmacy department, and I’m positive there were less med errors after implementation of the barcode system. With the option to override, there is abuse potential. Our manager publically posted how many “overrides” were performed by each nurse each month and also stated a goal in which the department would not exceed. I don’t think we ever reached that goal.

Chronic Disease Management is always tough because there are so many factors to consider. The website states 4 technologies that may better support and manage chronic disease: clinical decision support systems, health information exchange, telehealth, and hospital information systems. All of these systems are great tools to provide information about patients and manage the course of their disease. Many labs, meds, and results can be easily accessible. The article also emphasized the need for various team members to facilitate the success of the program including nurse educators, nurse case managers, case managers, and nonclinical assistants. The problem with the various systems is that there are multiple to choose from. The one decision support system I researched, DiagnosisPro, was updated by physicians and a devoted team; however, can we stop IT programs from information overload? This may be a growing problem, as others want to contribute to the body of knowledge without having any research background.

Computerized provider order entry has been talked about since I was in nursing school. It is still being discussed today because of illegible handwriting. We double chart all the time in first net, our written charting, and through the other departments we work with. If we could all get under one system, reimbursement would not be a big issue since providers can make orders and initiate referrals. Things do not have to be put in the system more than once.

Telehealth connects people and providers from a distance and although convenience is an advantage, there is question on losing the patient-provider interaction. Body language, tone of voice, and overall presence is lacking when telehealth is the only source of communication. Three other challenges presented on the website include security, image resolution, and technical support.

In a NEJM Reader’s Forum from October 30, 2003, the author states, “In the end, medicine will always be about one patient and one physician together in one room connecting through the most basic of communication systems: touch.” For me, this is the most important ethical consideration when looking at implementation of IT in healthcare.

Module 4 Response

I agree with Michelle’s statement that there exists a huge gap between evidence and practice and the CDSS is a means to start bridging what the literature says. Not only are CDSSs a representation of the decision of human experts, they parallel a good systematic system review instead of one expert opinion which is a problem with research in general. Last semester in my evidenced based practice research class, we analyzed many articles in which the authors claimed their conclusions would increase quality of nursing, but they had no other research reports to “back them up.” Their introductions state there is lack of evidence to drive their research and claim their conclusion is the best practice. I also liked Michelle’s statement on interdisciplinary communication because we need to utilize all disciplines with the multiple complications and factors of patients.

Module 4 Part 2 Nursing Data Quality

Nursing data quality is related to decision support because without complete, accurate, and up to date information, the data is not a useful form of knowledge. In my clinical setting of the ER, we triage using firstnet, a computer system that stores initial vital signs, chief complaints, medical history, and drug history. It has been helpful to retrieve old documents from previous hospital visits because patients oftentimes do not want to repeat their medical history, medications, or other data, we as health care providers, find essential to their plan of care. The electronic medical record (EMR) is also used to list potential diagnoses after initial evaluation by a physician. This helps direct what things need to be done in order to choose one diagnosis and then develop a specific plan.
An important point made in the Hebda reading indicates the need to educate personnel since “staff who are proficient in the use of the input device and less likely to make data collection and entry errors.” I have often found incomplete or wrong information on a first net document. It has been useful when patients lie, have trouble recalling, or are unable to share information to have correct and thorough information. One cannot make an informed decision if the information given is incorrect, so we need to rely on each other to store that data in the right place and have it readily accessible when we need it. This will increase quality or patient care, as well as stay competitive as health care is becoming a business.

Module 4 Part 1 Clinical Decision Making

Anderson and Willson (2008) state, “The use of computers to aid in nurses’ decision making is a new and exciting area for the nurse theorist and one that is just beginning to be explored. Additional theoretical models for the development and testing of CDSSs in nursing are needed. More research is necessary to determine whether CDSSs offer an effective strategy for translating evidence from research into nursing practice.” Their data showed that CDSSs were more accurate than staff decisions. While it is a positive thing that decision support systems are unbiased, they can’t take place of specific cases and the individuality of each person seeking care. I found that my nursing experiences do play a role in determining diagnoses, even though technically I do not diagnosis as a Registered Nurse.
The Thompson paper states three common heuristics and biases: overconfidence, hindsight, and base rate neglect, and I have been bias in all three ways, especially with hindsight bias. Three more that are mentioned in the Kahneman and Tversky (1974) paper are representativeness, availability, and adjustment from anchors. I see this as I ask certain questions, anticipating what their answer is going to be, or based on past experience, I deem which patient will be more emergent to see than others, downplaying patients who do not seem to have typical symptoms of pain or discomfort. One way we can reconcile the value or nursing experience with known heuristics and biases used in human decision making is to simply recognize that we do enter the nurse practitioner field with biases. Just as Kahneman and Tversky (1974) state at the end of their paper, if we have a better understanding that these biases occur, our judgments will improve.

Module 3 Multiple Intelligences Test

Ranked from lowest to highest, my multiple intelligences test showed that I equally prefer linguistic and musical, next locigal-mathematical, then special-visual, interpersonal, bodily-kinesthetic, and lastly intrapersonal. My scores ranged from 27 to 37 showing me that I have multiple learning styles and can benefit from pretty much any range of activity as long as they vary from to time to time. Based on the results of the Multiple Intelligences Test, some technologies I might incorporate to augment my personal learning from each intelligence type are listed below:

Linguistic: Spoken lectures through the windows media streaming. I can pause if the lecturer is speaking too fast and take breaks when I feel necessary. I can also watch the videos at my own convenience.

Logical-mathematical: Inputting numbers into a device, for instance, the alaris pumps for IV infusions. Use of pumps while in lab can help me logically figure out where the tubing goes and what numbers to input so I have correct rates and dosages.

Musical: Although I would not prefer to have music while in a classroom setting, I have had music in the background while studying at home, or even walking to class. This gives me a break from thinking and in a way allows my mind to tune in to something completely different while still using the higher levels of my brain to interpret the notes being played. I also think it would be beneficial to hear adventitious sounds as we learn about them in a classroom setting. Often times, certain sounds are described in text, but it would be beneficial to hear them.

Bodily-Kinesthetic: Stimulation labs have a lot of potential to augment my style for physical experience. It is helpful to show pictures, but also, to be able to physically touch and perform assessments would be helpful.

Spatial-Visual: The use of computers and PDAs can be helpful here as I will be able to find answers at the touch of a button, or access information quickly. This method is incorporated in every technology I’ve been exposed to. If I can see it, I have learned that much more than just hearing someone say it.

Interpersonal: Blogs, discussion boards, and the use of email allow for communication outside of the classroom and with those whom I probably would not have communicated with in the past.

Intrapersonal: Blogs and journal entries, whether published or unpublished help solidify my thoughts on particular matters. Writing down personal impressions, or note taking can help me remember and reflect the things I am learning.

Module 2 Response

In response to Susan's Blog found at susanvanbeuge.blogspot.com for Question 1.

I’ve been present for many presentations in which these terms she mentioned in her blog are used. I find it interesting that they have been around for awhile, at least since I started college in 2001, but I just forget to use them when I’m doing my searches. What has helped me is also going through the tutorials and learning what kind of things you can do to enhance your research. I thought it was VERY interesting she found more articles when PTSD was written out fully than using PTSD. I say this because the authors of the articles we read probably understand that no one wants to read an 8o page paper. Scholars and researchers are busy, so I feel it’s important to get the results and discussion across in a concise manner and I would think using acronyms would help decrease the length. I like that you keep a list of research items in a notebook to take home. Often times while researching one topic another one is sparked, but we don’t want to get too off topic, but it may be a subject that is well worth researching at a future time. It shows me the connection that everything has.

Module 2 Part 3 Retrieval-Compare & Contrast

The electronic index I used was PubMed. The Guideline index was the National Guideline Clearinghouse (NGC), and the web search engine of google. As mentioned in my previous blog, PubMed‘s database facilitated my ability to construct an efficient search because of the nature of the database itself. This is a good place to conduct a search and find articles to do an extensive literature review. The NGC index is useful for very specific search inquiries since options for type of disease, category, year, type of research/literature review, target population, etc. may be chosen. Since it is a database for guidelines, it was not extremely helpful with my search on prescription drug abuse, but I can see the potential if I wanted to find out specific guidelines for prescribing medications. For me, this was more of a “what nurses should be doing, the gold standard for care,” document. Google had a vast array of links, it was overwhelming to decide which website would contain the most correct and helpful information. I don’t discount google just because it’s not peer reviewed, but there is a lot of information in the world and the internet is one way lay people can access it. Clearly, in an academic setting, PubMed and other electronic indices stand superior to google. The problem with google is that every website seems to validate what is published on their website. I think the key is knowing which ones are sponsored by legit governmental groups, like the NIH or the CDC.

Alternative strategies for retrieving relevant information are text books and clinical resources similar to MICROMEDEX. The University of Utah has access to Mosby’s Nursing Skills, a tool very similar to the NGC guidelines. These aren’t from peer reviewed journals, but provide very accurate information relevant for nursing practice. The important difference between electronic indices and textbooks and clinical resources is the assumption that textbooks and clinical resources make use of evidence based practice. Hopefully the information is from research and literature, but as we all know, knowing something and actually doing it are two different things.

Module 2 Part 2 End Note

End Note is a great reference management software that I am just learning how to use. Retrieved articles are sorted by all references, trash, custom groups, smart groups, online searches, and endnote web. I started to sort the articles I thought may be useful and relevant into particular groups because there are different factors that may affect abuse potential. These factors include and are not limited to age, location, social economic status, previous experience with non-narcotics, and narcotics. What I found most useful about End Note is the actual management of bibliographies themselves. All the information is stored in one library and is accessible. One can also add figures and charts. When I attended the End Note session with Jeanne Le Ber, she did mention some down sides to End Note, including the fact that access to full link articles can sometimes be missed on End Note’s online search when in fact there are links available and the searcher must manually go through each article to see if there is a link. It’s always nice to have that availability, and really with the advancement in electronic technology, most would like to have immediate access rather than search for a paper copy in the archives of the library. Over all, End Note has helped me better organize and share information more efficiently than I had in the past.

Module 2 Part 1 Electronic Index

The clinical problem I was researching was prescription drug abuse in the state of Utah. I used PubMed as my electronic index. Although a great database to retrieve information about prescription drug abuse, I was unable to find information specifically for the state of Utah. I don’t think this is because there is not any published information, but rather none submitted to this particular database. In general, I was able to find numerous articles on this topic and by limiting my search to specific age groups and recently published articles, the list became more manageable to sort through. The database facilitated my ability to construct an efficient search because of the nature of the database itself. It contains peer reviewed articles and synthesis of studies following the problem of prescription drug abuse. Other research questions were also generated as I sorted through and read abstracts helping to narrow and focus the search if I was performing a literature review for a paper. The search was very time consuming as there were many articles to sort and read through. The most time consuming part would be the actual reading of abstracts to make sure I wanted to invest my time to read the rest of the article. A barrier to using the index in daily practice is that one can probably do a very extensive literature review, which would give grounds to conduct a study specifically for the state of Utah, but most articles I read included information about drug abuse itself, not so much the evaluative piece after implementing strategies to reduce abuse rates. Over all, PubMed is a great place to begin a literature review.

Module 1 Intro and IT

My name is Sirithepphavanh Vongsikeo but I go by Sue. I graduated in April 06, worked on a Medical/Oncology floor from then until June 08 when I left the “BYU bubble” and upgraded to SLC. I am a full-time student in the BS to AC-DNP program and now working part time at the University ER. I LOVE the autonomy there and I love being part of a teaching facility. Graduate level nurses need to know about information management because every day we deal with data and we need to utilize tools to help manage this information.

The ER uses the program first net to document visits. Interestingly we then chart everything else by hand instead of using power chart. Since I was trained to do that, it hasn’t been a burden, sometimes, for time sake, it’s the easiest thing to do, but there are times when I am overwhelmed by the amount of paper we use in our ER. With the hospital’s efforts to “be green,” paper documentation seems contradictory. This is one of many reasons why developing easy to use, but thorough computer based charting is necessary. My manager constantly sends us emails about what to include in our documentation, and often we are triple documenting to make sure those who are coding for us find ways to reimburse us correctly, although in the end, auditing shows our ER is still losing money and wasting resources. Hopefully, a push towards information technology will promote quality of care so we spend more time with our patients rather than worrying about triple documentation.

Testing..

I am testing this blog for a nursing course I am taking.