What I liked most about this course has been that it took me deeper into websites than I would have gone on my own initiative. I enjoyed critiquing websites and especially valued the HON assignment that reviewed the quality and reliability of websites for healthcare on the Internet. While the journey has been good for me and one that has taught me much, I am equally certain that online education has limitations and is still in the growth and development stages.
For me the greatest challenge was opening all of the windows to see if the assignments were placed everywhere they belonged. The semantics of learning made it hard to enjoy the content at times. My own lack of exposure to online courses limited me, and I did not know what questions to ask or who could answer them. Younger classmates or those with children old enough to help were able to unblock content that I did not know I had not even viewed!
I do use technology and plan to continue learning new programs, but I have been surprised at how much has been new for me this semester. This is a definite first course in the DNP curriculum, and I am thankful to have it early in the program. It seems well placed and parallels other things that we have to do in other courses.
My main suggestion is for more communication between faculty and students. It is always helpful to know if papers are received and properly cited or placed. For example, the Leadership course faculty always sends a brief, "Received your paper" note in email, and that relieves anxiety about getting things turned in properly and timely. Also the numbering of modules was fairly confusing to me. One through six is linear and easy enough, but they were not always numbered that way, matching dates are also nice to have for each semester. The reading was helpful and informative, though it seemed quite a large volume. The stack that I have printed and read for this class is far more than in other classes. I even think it would be great to know how long the podcast would last just for planning time to sit down and listen since some I viewed were very short and others were a full hour each. The time could be added to the module READ section.
In conclusion, I have learned so much that I smile when I think about how fast we have traveled through creation of a blog, literature searches, End Notes, Ref Works, Websites, PDA downloads, HON critiques, using Pod Casts, downloading videos, unblocking syllabi's, and logging onto wireless sites (in Little Rock, AR, Dallas Fort Worth, and Salt Lake City both on campus and in the hotel). The class has stretched me, and I am glad for it. Thank you! Now I get to share what I have learned with others. For example a faculty colleague just asked me how to set up a blog, and I had the knowledge to help her. One of my assignments for the BSN students who I teach was for them to locate materials online that have the HON seal. So this class has been like a stone tossed into the water, and now the ripples have begun to reach others.
Thursday, November 12, 2009
Saturday, November 7, 2009
Policy-Ethics-Informatics
The U. S. Department of Health & Human Services Agency for Healthcare Research and Quality is a complex site full of articles, comparisons, tables of recommendations, and links to reputable organizations in healthcare. As I surveyed the site, I was surprised at what a high level the materials seemed to be as compared with other consumer sites previously visited. Because it is a government operated site, there is data related to grant money available and detailed cost analysis of health procedures that only providers could possibly understand (Agency for Healthcare Research and Quality, 2009). The research portion of this website contained articles that providers might be interested in reading, but I wonder how many actually go to the site to read the results. After listening to Deane Rehm's Public Radio Broadcasting panel discussion where she stated that only about 20% of physicians use the Internet sources for healthcare (Hanberg, 2009), it would seem reasonable to assume that the majority of physicians do not frequent this site.
Viewing this website as a consumer, there appeared to be two main elements of value, health promotion and hospital comparison. In order to promote health, there were charts detailing what tests are recommended, but how often the tests ought to be obtained was unclear. There were links to other entities such as the CDC (Center for Disease Control) which could prove helpful; for example, this link to the CDC better explained when to get certain immunizations. The second item of value to consumers was the ability to compare hospital services with one to another in selected counties or states. Most likely hospitals review these statistics to make sure they hold a secure ranking and reputation (Agency for Healthcare Research & Quality, 2009). These posted statistical comparisons could pose a threat to hospitals that do not perform well.
Authenticity is of concern because hospitals submit their own data which raises questions about accuracy. In Leah Curtin's article, she explained Moor's two stages of computer technology with the first being "introduction" and the second being "permeation" where we are clearly just beginning as healthcare providers. Moor is quoted describing computer ethics as "policy vacuums" (Curtin, 2005), which agreed with what Deane Rehm's panelist Eric Corbetts said, "We are in the early days of medical use...with reimbursement issues and privacy issues" (Hanberg, 2009). During this same podcast interview, Don Depner seemed pleased that consumers are being "empowered" and he related systems that provide privacy such as the use of Health Vault for storing private information. He echoed the need for public policy development (Hanberg, 2009). Ethics and the utilization of the Internet pose many questions yet to be resolved for healthcare provision. Though resources are abundant, authenticity and privacy are vital considerations.
During the same podcast, Jonathan Winer talked about how expensive systems are for providers to establish but that informatics systems would increase the ability to flag problems where patient follow up is imperative. Later in the podcast one of the three panelist mentioned that doctors are not accustomed to active patients and state that systems are only as smart as the people who build them (Hanberg, 2009). There seemed to be a resistance in providers trusting materials found on the Internet and clearly there must be a shift in the expectation that physicians' knowledge could be shared or in any way equaled. Physician reimbursement is an issue when using Internet and email type involvement with patients (Hanberg, 2009).
In summary, my concerns are that electronic patient information needs to be secure and shared only by permission with new providers. Providers in turn must be educated on obtaining accurate medical information from clinical decision support tools and location and access of authentic consumer health information electronically. Finally, policy needs to be written that keeps up with the changing modalities of healthcare delivery so that we can provide the best quality, efficiently, and at a reasonable cost.
Agency for Healthcare Research and Quality, (2009). Retrieved November 7, 2009 from: www.ahrq.gov/
Curtin, L.L. (2005). Ethics in informatics: the intersection of nursing, ethics, and information technology. Nursing Administration Quarterly, 29(4), 349-352.
Hangerg, A. (2009). Ethics & informatics, Allen Hanberg's Album Podcast, "E-Health" Diane Rehm retrieved November 7, 2009.
Viewing this website as a consumer, there appeared to be two main elements of value, health promotion and hospital comparison. In order to promote health, there were charts detailing what tests are recommended, but how often the tests ought to be obtained was unclear. There were links to other entities such as the CDC (Center for Disease Control) which could prove helpful; for example, this link to the CDC better explained when to get certain immunizations. The second item of value to consumers was the ability to compare hospital services with one to another in selected counties or states. Most likely hospitals review these statistics to make sure they hold a secure ranking and reputation (Agency for Healthcare Research & Quality, 2009). These posted statistical comparisons could pose a threat to hospitals that do not perform well.
Authenticity is of concern because hospitals submit their own data which raises questions about accuracy. In Leah Curtin's article, she explained Moor's two stages of computer technology with the first being "introduction" and the second being "permeation" where we are clearly just beginning as healthcare providers. Moor is quoted describing computer ethics as "policy vacuums" (Curtin, 2005), which agreed with what Deane Rehm's panelist Eric Corbetts said, "We are in the early days of medical use...with reimbursement issues and privacy issues" (Hanberg, 2009). During this same podcast interview, Don Depner seemed pleased that consumers are being "empowered" and he related systems that provide privacy such as the use of Health Vault for storing private information. He echoed the need for public policy development (Hanberg, 2009). Ethics and the utilization of the Internet pose many questions yet to be resolved for healthcare provision. Though resources are abundant, authenticity and privacy are vital considerations.
During the same podcast, Jonathan Winer talked about how expensive systems are for providers to establish but that informatics systems would increase the ability to flag problems where patient follow up is imperative. Later in the podcast one of the three panelist mentioned that doctors are not accustomed to active patients and state that systems are only as smart as the people who build them (Hanberg, 2009). There seemed to be a resistance in providers trusting materials found on the Internet and clearly there must be a shift in the expectation that physicians' knowledge could be shared or in any way equaled. Physician reimbursement is an issue when using Internet and email type involvement with patients (Hanberg, 2009).
In summary, my concerns are that electronic patient information needs to be secure and shared only by permission with new providers. Providers in turn must be educated on obtaining accurate medical information from clinical decision support tools and location and access of authentic consumer health information electronically. Finally, policy needs to be written that keeps up with the changing modalities of healthcare delivery so that we can provide the best quality, efficiently, and at a reasonable cost.
Agency for Healthcare Research and Quality, (2009). Retrieved November 7, 2009 from: www.ahrq.gov/
Curtin, L.L. (2005). Ethics in informatics: the intersection of nursing, ethics, and information technology. Nursing Administration Quarterly, 29(4), 349-352.
Hangerg, A. (2009). Ethics & informatics, Allen Hanberg's Album Podcast, "E-Health" Diane Rehm retrieved November 7, 2009.
Saturday, October 17, 2009
Nursing Data Quality
There are infinite ways that nursing data quality relates to decision support. Some of the most obvious would be evaluation of wound care management, rate of healing and appropriate selection and utilization of wound products. Nursing care is tied to quicker discharge from hospitals and educational materials are vital to the success of patients remaining healthy once home. The tools available in most decision support systems include patient education materials that are easily readable and provide support for medications and chronic disease management. Many of the printed materials have contact information for organizations that provide free support groups and comprehensive educational literature that prove helpful when patients are feeling better and more interested in their conditions.
Guidelines, algorithms, protocols, first line therapies are among the many items nurses can find in clinical decision support systems. One can tap into the evidence based plans and read definitions, epidemiology, predisposing considerations, diagnostic testing, and treatment plans using tools that didn’t exist only a few years ago. Patients can demonstrate better outcomes and become more fully partnered with the decisions of providers. For the first time in history, data from research can be obtained quickly and can guide decisions of a medical home team. Decisions then are not as prone to intuition or sequencing events.
Guidelines, algorithms, protocols, first line therapies are among the many items nurses can find in clinical decision support systems. One can tap into the evidence based plans and read definitions, epidemiology, predisposing considerations, diagnostic testing, and treatment plans using tools that didn’t exist only a few years ago. Patients can demonstrate better outcomes and become more fully partnered with the decisions of providers. For the first time in history, data from research can be obtained quickly and can guide decisions of a medical home team. Decisions then are not as prone to intuition or sequencing events.
Reconcile Nursing Heuristics
It would seem imperative to draw not only from nursing heuristics, but to continue asking for evidence with an open mind that the algorithms of today may be different from the ones deemed most effective tomorrow. Medicine and health contain many subjective parameters and one must consider the practice of medicine and experience of health is much like a living art form. One needs develop awareness of the patient’s bias, anchors, and intuitions. No different from the health care provider, both bring bias elements into the equation.
There are many judgments made based on intuitive input just as Dr. Kahneman mentioned regarding the nurse who told her father that he was going to the emergency department immediately. There he was identified with cardiac demise and she later realized that it was the color change in his face that prompted her to bring him to the emergency department. There is a time for intuitive decisions. There are also times when slower controlled reasoning and careful statistical analysis will produce a better outcome and with tools available via technological support systems, this process has rapidly improved.
There are many judgments made based on intuitive input just as Dr. Kahneman mentioned regarding the nurse who told her father that he was going to the emergency department immediately. There he was identified with cardiac demise and she later realized that it was the color change in his face that prompted her to bring him to the emergency department. There is a time for intuitive decisions. There are also times when slower controlled reasoning and careful statistical analysis will produce a better outcome and with tools available via technological support systems, this process has rapidly improved.
Readings Influence Perception of Decision Making
The readings make one introspective related to intuition and heuristics and cognitive biases. In the video lecture Dr. Kahneman illustrated how a single word evokes responses that are similar across an audience with immediate accuracy. In his article he used number sets to demonstrated that people anchor and make adjustments that are not always accurate based on intuitive estimates, much like the video drawing of a man walking into a tunnel that gave the illusion of bigger size when and all drawings of the man were identical sized.
In the video, the intuition system 1 which was quick, automatic, with slow learning, associative coherence, and effortless seemed of value. The intuitive assumptions were particularly significant when related to heat under the boots of a fireman and the need to abandon the fire immediately. It would seem that there is value in recognition of intuition and the skill acquired. Then he compared it with the reasoning system2, slow, controlled, flexible, and effortful and rule governed to draw conclusion that one cannot function well without the other. Reasoning collects data and make judgments and draws conclusions that may be quite different from those derived from intuition. In his article, one concluding comment was that statistical principles are not learned from everyday experiences. Another conclusion was that people usually do not detect the biases in their judgments.
In the video, the intuition system 1 which was quick, automatic, with slow learning, associative coherence, and effortless seemed of value. The intuitive assumptions were particularly significant when related to heat under the boots of a fireman and the need to abandon the fire immediately. It would seem that there is value in recognition of intuition and the skill acquired. Then he compared it with the reasoning system2, slow, controlled, flexible, and effortful and rule governed to draw conclusion that one cannot function well without the other. Reasoning collects data and make judgments and draws conclusions that may be quite different from those derived from intuition. In his article, one concluding comment was that statistical principles are not learned from everyday experiences. Another conclusion was that people usually do not detect the biases in their judgments.
Friday, October 9, 2009
Augment Learning
After reading the preferences, personal potential and related tasks I am inclined to turn on music while I sit and read the computer tasks. That might actually improve my tolerance or joy of the online educational journey. I wish there was another person in central Arkansas who could sit at a computer next to me as I struggle to learn in a medium that feels foreign. I will indeed plan time to phone a friend or take a walk in the neighborhood and mentally prepare for my next computer challenge.
As an educator I am aware of students need to engage in their own learning. I plan classes to incorporate a variety of senses and styles and know that if they do not engage every six minutes, they are lost and may as well take a nap. I wonder what might happen if there was low soft music in the background for classroom settings? Application games from Soft Chalk, case studies that they read and respond, quizzes, video clips, ever present PowerPoint on Blackboard, and guest speakers are some of the tools used today that I find helpful.
As an educator I am aware of students need to engage in their own learning. I plan classes to incorporate a variety of senses and styles and know that if they do not engage every six minutes, they are lost and may as well take a nap. I wonder what might happen if there was low soft music in the background for classroom settings? Application games from Soft Chalk, case studies that they read and respond, quizzes, video clips, ever present PowerPoint on Blackboard, and guest speakers are some of the tools used today that I find helpful.
Multiple Intelligence Preferences: Strengths
Having taken a number of learning style inventories, I am not surprised to see that I am an auditory learner above all other preferences. In this particular tool, musical scored highest followed closely with linguistic then interpersonal and intrapersonal. I love learning most of all by hearing and being involved with other people. I spend time next thinking about what I have learned and meditating of the value and application of learning. Not far behind the auditory and interaction with people is kinesthetic learning. I abhor sitting endlessly and find excuses to get up and move around, especially when faced with learning from a computer screen!
Wednesday, September 23, 2009
Compare Results of Retrieval Processes
The Google search engine was extremely fast and is the process I have used most over the last ten years. However, Google provided 154,000,000 results for medical home which is an incomprehensible number. As I looked at the first few citations, it was interesting how the article we read came to life. One that sounded really good by title was truly an advertising site for electronic training modules and appeared very biased once I looked at the source. the PubMed searches, though broad in the first steps, did reduce the number of credible sources in just four steps total. I did apply MeSH terms, Limits of date terms and added on operational term, "AND cost" to further reduce the search to a much more manageable as well as relevant citation listing. PubMed provided a context relevant option that seemed similar to the automatic concept mapping in NGC that matches terms against a standard table derived from the U.S. National Library of Medicine. When I applied the matching terms, my citations dropped from 25,000 to 1537 in one simple step. I did not apply the use of quotes to locate guidelines bu will need to do that this week for another class. The ability to store these citations for later retrieval is invaluable to me. Though I expect to get faster with practice, I also expect to glean more pertinent information.
RefWorks Management Software Program
RefWorks is a web based program that is available to all students and faculty at the University of Arkansas Medical Science Campus. It has the capacity to import data, convert references from other bibliographic management products, import from saved text files, or from Really Simple syndication Feeds. It allows manually entered references, attaching files to a reference, importing online catalogs. In RefWorks one can create folders, put references into folders, sort references, and globally edit references. RefWorks provides online support, email support, at support@refworks.com and webinars of complimentary training. They have technical support via phone. On our campus, we have a person who is the contact for training users, and she was a valuable support for me.
Clinical Problem and Electronic Index
The clinical problem investigated was: "What is a medical home, and what impact might a medical homes have on the management of chronic disease?" Since it is a broad medical model concept, I decided to stay within the PubMed electronic index believing it to be the most powerful for such a wide survey issues. PubMed provided 25,000 citations. An "also try" feature on the right of the screen suggested adding medical home model to filter the search and reduced the number to 1537 citations. Adding a five year limit reduced the number to 604 publications and the Boolean tool of "AND cost" dropped the number to 94 citations. I ran this search alone and with help a number of times to better grasp how to navigate and narrow the number for more relevant publications. Each time the process grew smoother, and I soon realized that it doesn't matter which steps one takes first or second which reduced my fear of the process considerably. There isn't a substitute for practice. Barriers were mainly my lack of use of the system, my fear of getting totally lost in the steps, and the tutorials along the pathway that were time consuming and a blur as they appear in so many windows. I had to create another log in for utilization of the library and free resources and need an index to keep up with all of the log ins now created over the last few months. As for barriers at work, the clinical I have been working has access to six central shared computers and a number in private side offices allowing on-line searches. No matter where one is in the world, these eresources are available to faculty and providers within our system. One must simply have the knowledge and take the time to look for them.
Sunday, September 13, 2009
Probably the most outstanding feature of quality with the usage of informatics in the Ambulatory Care Clinic at the Institute on Aging is that the intradisciplinary team has access to all appropriate and approved features allowing better continuity of care. Clients do not have to give the same informatin repeatedly, once employees are properly trained and approved for accessing the system, the client information is availble at the touch of a screen. The one element that is highly guarded is the psychological testing which has limited access due to the sensative nature of the information stored there. Confidentiality is guarded just as in other hard copy charts.
Structured Documentation Present
Each discipline accesses an electronic patient chart and then moves to review summary or previous visits, medications or labs, then opens and documents the new visit history and physical details along with prescriptions and other orders. The system has flags for follow up and can send postings to others involved on the team with care for each individual patient. There are signatures required and certain elements that must be posted prior to closing the chart and filing it away completed. The system has drop boxes and the ability to look up searches for specific persons such as doctors or elements within a given record.
IT Clinical Happenings
In the Institute on Aging ambulatory care clinic, there are doctors, advanced practice nurses, social workers, dietitians, and pharmacist who provide optimal health decisions for every person who visits the clinic. This team approach happens in an area called the "war room." Other team members are in the same building to assist with physical therapy and occupational therapy when needed. The Institute on Aging was the first on campus to integrate an elaborate informatics program that allows one to access the record and follow the client in all elements of care. The continuity of care is greatly strengthened as a result.
Information Management for Nursing
As an APN, in the University of Arkansas campus system, it is important to be trained on their information systems program in order to access, navigate, and insure confidentiality to client records. Accessing these integrated programs allows one to view lab results, medications and reports of visits to others involved in the care of each client.
I am Sandra N. Berryman, commonly called Sandy. My nursing passion is for care of the elderly. I currently am a Clinical Assistant Professor at the University of Arkansas for Medical Sciences Campus in the College of Nursing. I am the course coordinator for Older Adult Health, which is the geriatric course taught to senior nursing students in a BSN program.
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