MODULE 6: Wrapping it up

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

Probably the greatest advantage for me in taking an asynchronous online course such as this was the ability to work on modules and assignments when the timeframe fit my schedule. I actually started some of the assignments for this course while I was with a group of my students in Taiwan….now that is long distance learning! Additionally, when limitations in health prevent completing a module assignment at a specific deadline, the timeframe can be and was adjusted.

This course lends itself to being an online course by the nature of the material being presented. After all, if one is to become more savvy and comfortable with computers, software, electronic tools, then there is no better way than to immerse the learner into the subject matter. This was a course which assisted the learner in learning by doing. Some of it was by trial and error, but still a very valuable learning experience. This course reminded me of my most favorite course of all time. It was at the University of Maryland in my graduate program. In that course, the students showed up for the first day of class. We were instructed to go forth and design an interactive program related to nursing for the internet. The faculty mentor said something to the effect of, “see you on the final class day!” Now, remember, this was back in 1996. I never even heard of HTML let alone programmed it to do something on the computer. I learned volumes above and beyond the course objectives in that class. This class held a similar appeal to me. Instead of reading about blogs, wikis, CDSS, and EHR, we actually were able to experience them and work with them.

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

Well, it is hard to find just one favorite topic. I did find it interesting that you can teach this ole’ dog new tricks. I think my kids are newly impressed that I have developed a blog, understand wikis, actually facebook and, most recently, downloaded applications on my new IPhone. But I think the topics I learned the most about, and were my favorite, were the sections related to the different tools available to help make decisions in the clinical environment. Also, the topics of CDSS and the HON were very interesting as well.

What did you like least?

Probably what I liked the least was the topic of Coding and classification of clinical data and the standardized taxonomies, vocabularies and coding systems topics. Although necessary, I found the subject matter a bit dry.

Do you have any other comments for us?

I enjoyed reading the thoughts and blogs of the other students as well as getting to know them a bit more as well. Unfortunately, I did not find the opportunity/time to respond to as many as I would have liked to. Maybe a suggestion for next time is to pair people up or place them in small groups where they need to comment back on the blogs.

MODULE 5: Ethical Considerations

Why would a patient want to create a blog?

There probably are as many reasons why a person starts a blog as there are bloggers. Blogs created by patients can be a creative way of expressing viewpoints, concerns, experiences and life stories. They can be a source of healing for many people as demonstrated by one blog I viewed where a woman lost her husband in a fishing accident in Alaska. She received many positive support comments from friends of the man she had never even met and how her husband’s life had changed theirs. Other blogs created by patients can act in a similar manner as support groups do for people undergoing physical, mental, spiritual and financial challenges related to their conditions. Everyone, including the patient, can gain a sense of support, express ideas to overcome challenges, provide insight to personal experiences and can keep up on the “latest news” about the person’s condition. The blog created by a patient can be a way of disseminating information to a larger group of people in a more efficient manner. Additionally, the comments linked to the blog tend to connect all the reviewers allowing them to share in the patient’s life story.

Why would a health care provider create a blog?

Similar to a patient’s blog, a healthcare provider may establish a blog to help people who are suffering from certain conditions/challenges. A provider may open this blog to anyone for comments or keep it private to his/her patients. Again, similar to the patient’s blog, this “support blog” could be beneficial to all who read it. This type of blog would also allow the provider to gain insight into the patient’s thoughts and concerns which they may not openly discuss during clinic visits. The provider could also correct misconceptions, expand on related treatment information, provide additional avenues of support and develop a greater appreciation for the patient’s day to day life experiences. If a provider is willing, the blog site can also be used as a way for patients to provide information related to customer satisfaction.
A provider could also use a blog site as a way of educating the viewers. In addition to narrative and pictures to represent the training, video clips or links to relevant information can be imbedded in the blog.

What are ethical considerations when blogging on a public website, such as we've used for this class?

Certainly the issue of privacy is a huge concern when posting anything into cyberspace. While there are protective strategies one can institute to minimize the ability of hackers to gain access to protected information, there will always be the potential to have the site compromised. Something we have probably all heard at one time or another is, “Only put on the internet what you would not mind having on the evening news”…because in essence, that is what could actually happen. Personal information should and must be protected as much as possible. If the website is private, establishment of some basic guidelines and rules should be agreed upon by the users. But if a site is truly public, then anything can and probably will happen.
There is no doubt that Americans are probably one of the most litigious groups of people in the world. This is a lawsuit happy society. After all, we have heard about the woman suing Google because she walked into traffic because of the directions provided by Google were “unsafe”. Blog postings, emails, website information can all be entered into courts of law as evidence in privacy violations, breeches in ethical conduct, malpractice and negligence. Before you push the send button, only type things you can justify in a court of law.

MODULE 4: Decision Support for Care Delivery

How did the readings influence my perception of my own clinical decision making?

It is amazing to me that more information has been discovered in the past five years than has ever existed in the history of humankind. How do we as simple carbon based units process this information when we are developing computers with the ability to store yottabytes of information? (Just how big is a yottabyte anyway?) Can we, or should we, as healthcare providers be expected to know it all and to keep up with one of the fastest changing professional fields? In our profession, when we don’t have all the pertinent facts and ability to synthesize information outcomes can be poor and people can die. Unfortunately, we are being held to the standards as if we were a precise, methodical, reliant computer. But we are human beings, capable of making decisions that are sometimes deemed as miracles and at other times less than humane.

This weighted responsibility impresses upon me just how dependent healthcare providers must become on today’s technology in order to provide the best possible care. However, I think Pat Benner’s five levels of nursing experience cannot be underestimated. No matter how much technology I have to support my decisions, it still will ultimately be up to me to make some decisions. Much like a compass directing us on a path, it is only a tool to be used by the wise traveler. If we are oblivious to the compass pointing us in a direction that leads to a cliff, then the technology is useless and can even become dangerous unless we apply our own wisdom in the decision making process. We must not lose ability to think on our own, for if all these wonderful tools come crashing down around us someday, we will need to be able to think on our feet. Realizing just how much I do not know about the uniqueness of each patient, the 8000+ medications, tens of thousands of disease processes, thousands of labs, radiographs, CTs MRI, et al. can be intimidating, but not knowing where to go for information, data, protocols, CPGs et al. can be outright neglectful of sound, competent patient care.

MODULE 3: TEACHING WITH TECHNOLOGY

What sort of teaching is done in your nursing role?

As an educator in a baccalaureate nursing program I have seen many styles and strategies of teaching...some good, others less than optimal. Today's learners encompass several generations with a diverse set of learning needs. Likewise, today's educator must be up to the challenge of teaching by using an equally diverse set of teaching strategies. As an educator, I have used interactive team building games, ppt presentations, reflective writing assignments, case studies, small group dialogue, internet activities, immersion experiences and assignments where I let the student design his/her own learning outcomes. It may not always be about what teaching is done.....but what learning is accomplished.


Is there any nursing role that does not involve teaching in some manner?

While I have not experienced every role in nursing I would find it rather difficult to believe that each role fulfilled by the professional nurse would not involve some aspect of teaching. While serving in the Navy Nurse Corps for 26 years I was afforded the opportunity to work in many settings from small community hospital environments, large trauma centers, ship board and in tents out in the field. In all, I have had the pleasure of working in more than 20 different nursing roles from a staff nurse on a cardiac stepdown unit to the acting CEO of a hospital. In ALL these roles I found myself an educator. Whether I was teaching corpsmen, nurses, doctors, ancillary staff or patients, I do not think a day went by without teaching someone something. In fact, when new nurses would come into the military the standing question would be, "What do you see your primary role as a Navy Nurse Corps Officer to be?" The answer would typically be, "to take care of the sailors". But in fact the more correct answer would be, " To teach corpsmen to do you job as a nurse so when they went into harm's way, they would be providing the best possible care to our sailors."

Module 2

MODULE 2: Using an electronic index, a guideline index, and a web search engine to retrieve information relevant to your clinical problem, compare and contrast your results. Which resources were useful/ not useful for your information retrieval task, and why? Identify some alternative strategies for retrieving relevant information - would context relevant information retrieval be useful?

As I once again date myself, I remember back to the time when I would sit in the library, pad and pencil in hand, combing through the hard bound volumes of MicroMedex searching for journals that matched my interest. Feverishly scribbling the information I needed I would then proceed to the “stacks” looking for the journal in print. If I was fortunate, the library would have the journal in their collection. Then, the decision…to read it all or spend money on copying the article. Now at the touch of keypad from the comfort of my own home I can access a wealth of information far exceeding what those old dusty volumes could ever hope to contain. We live in a marvelous time where the world is literally at our fingertips.

Recently, I had the pleasure of observing clinical practices in an intensive care unit in Taiwan. One noticeable difference which struck me immediately was the lack of sequential compression devices and the minimum use of low molecular weight heparin to prevent deep vein thrombosis. With a DVT rate similar, or less than incidence of DVT compared to that in the US, the question begged to be asked….what are the benefits of these two therapies in the prevention of DVT?
Three major sources of information retrieval were used to search the answer to this question. Each of the information sources comes with advantages and disadvantages. For example, when using Google or Yahoo, a general search using the search term “DVT prevention” will net the reader over 75,000 results with one click of a button. While this certainly is a wealth of information, it would take months to shift through the important pieces separating them from the irrelevant pieces of information. If the topic one searches for is not highlighted in the titles within the first few pages of the search the researcher will often abandon using this strategy. Both Google and Yahoo searches do allow for “advanced search” strategies but they are not specific as those found in PubMed. For example, the most you can limit a search strategy is by using “all of the words, the exact phrase, any of the words or none of the words”. These can be applied to any part of the page, in the title of the page or in the URL of the page. Using this strategy limited the results to still a non-manageable number of 9000. One can also distinguish between .com and .gov domains. Google also allows a “wildcard” feature which essentially tells the system to look for any unknown terms and then finds a best match when you use a * as a placeholder. Beyond these strategies the advanced search mode is not very useful. The credibility of the information obtained from Google or Yahoo must also be evaluated by the investigator, whereas electronic indexes and guideline indexes have typically undergone more rigorous peer review processes.

Electronic indexes such as PubMed and MEDLINE allow for what Poynton (2003) calls high-precision searches directed toward the minimization of irrelevant and less useful citations. Bibliographic databases such as PubMed have more advantages over generalized search engines like Yahoo and Google in that they offer more selective search filters, e-mailing of search updates and storage of search histories and records. I found PubMed, MEDLINE and UpToDate very valuable resources when searching for EBM. The articles come from peer reviewed journals and have “limits” or “filters” that help one conduct a high-precision search.

When I entered my query into the National Guideline Clearinghouse (NGC), the search tools were clear and easy to navigate but led me to guidelines that were too specific and did not really address the clinical question. Instead of examples of RCTs to support clinical practice, the NGC is more devoted to guidelines and practices. I found it difficult to identify the studies upon which these guidelines are based. While each of the above strategies have value, use of the systems will be based on what question is being asked, how much time one has to devote to the exploration of the answer and how thorough one needs to be in assuming they have the answer to their question.

Time is a valuable commodity when seeing patients. Maviglia, Yoon, Bates and Kuperman (2006) note that if a provider has to spend more than 30 seconds trying to find the answer to a clinical question, the information will most likely not be adopted into practice. Sources of information need to be readily available to the provider instead of conducting hours of online searching. Context sensitive information retrieval may be one approach to help solve this challenge. As with any great endeavor, a well thought out plan can be advantageous. One alternative strategy is outlined by Poynton (2003), where she counsels the researcher to strategize with paper and pencil, outlining the topic needed and orienting yourself to what it is you exactly want. It is easy to click buttons one after another, but like any road map you have to orient it first or you can easily get lost.

The course I am currently enrolled in at the University of Utah asks me to respond to two questions related to informatics in the healthcare arena. The two questions are as follows:

1. Why do you as a graduate level nurse need to know about information management?

As a graduate level nurse I have the opportunity to assume the role of an advanced practice healthcare provider. This role carries with it greater responsibility and accountability including that of making appropriate clinical diagnoses, prescriptive recommendations, safe and effective clinical interventions, timely decision making strategies and accurate billing practices. The primary reason why it is imperative that I know about information management (IM) is to provide safe, effective and efficient care to the patients entrusted to my care.
Several of the articles in Module 1 identify the overwhelming volume of data collected by the healthcare system. An attempt at identifying, collecting, tabulating, deciphering and condensing all the pertinent data into useable information and then translating it into applicable knowledge without the assistance of a sound information management infrastructure is not only impossible in today’s society, but could be considered negligent practice.
Colleagues, consumers of healthcare and yes, even lawyers are expecting us to accurately manage a stream of constant flowing and changing information. The Institute of Medicine (IOM) report reshaped the delivery of healthcare in this country by mandating safety and quality in the delivery of care. Since the release of the IOM findings, IM theories, strategies, systems and tools are being invented and refined at a pace never before seen. It is through skillful use of such IM knowledge that both the internal and external customers/consumers of healthcare will benefit from evidence based medicine when evidence is seen as a constantly moving target.

2. Describe what is happening related to IT in your clinical or practice setting.

After seeing Dr. Sward’s nursing graduation picture on her blog site, I could not resist putting mine on as well. It reminds me of how far we have journeyed since the days of counting on one or two textbooks to get us through the nursing program. My practice area is currently as an educator in a baccalaureate nursing program. I have the distinct pleasure of working with some of the brightest and enthusiastic nursing students in the country. I facilitate a leadership and management course and oversee students in several clinical settings including Medical, Surgical and Cardiovascular ICU, ED, Med/surg, and OR. As one can imagine it is a challenge to keep up with the latest and greatest in one area of healthcare let alone a variety of settings. In the not too distant past, faculty questioned whether or not allowing the use of laptops in class was more a distraction than a learning opportunity. Today’s students have sources of information flowing to them at the speed of light. Laptop computers connected to the world wide web, PDAs and cell phones packed with applications related to healthcare, podcasts, Facebook, Skype, YouTube and the entire arsenal of healthcare literature are just a few ways in which today’s students are expected to find data, gather information and discover knowledge. As an educator, I am expected to keep up with the pace at which my students are learning and discovering new knowledge. In order to accomplish this, I must be familiar with the current IT resources available. “PowerPoint by Death” can quickly close the window of learning opportunity in this new generation of students. They are a “techno-savvy” generation and demand the latest in IT. Within the classroom environment I have begun to use podcasts, incorporated training videos and examples from YouTube and incorporate the use of student laptops into classroom work. IClickers, a device used for instantaneous feedback within the classroom allows ongoing evaluation and feedback from students. Complex simulation lab models benefit the student prior to actually experiencing real patient hands on activities. The examples go on and on and on….but I shouldn’t.

I guess this is too long winded as well…..hmmm…the older we get, the longer our story becomes!

My name is Jim and I welcome you to my first blog. I currently teach at Brigham Young University in the College of Nursing and attend the University of Utah where I am enrolled in the DNP/Acute Care NP program. I have been a nurse for more than 30 years and am continually amazed in the technological advances being made in healthcare. I graduated from a 3 year diploma program in Green Bay, Wisconsin at a time when a single computer filled an entire room and the internet was only being used by the military. When I graduated from the University of San Diego with my BS degree I actually had a computer, but alas, if I wanted to save any information, I had to save it to a 5 1/2 inch floppy disk. In the 80's, I was able to graduate up to an internal hard drive and could actually surf the internet while I attended the University of Maryland for my MS in nursing. It was here at the University of Maryland where I truly began to appreciate the power and influence informatics could have on healthcare. My cadre of fellow nursing students were the first to actually develop interactive nursing case scenarios for the internet.

I currently call Washington state my home, but since I teach at BYU it is more like my home away from home. My wife and I love the island life north of Seattle so much that after I retired from a 26 year career in the Navy we cannot part from the salty sea air so I do a long distance commute. Living on an island affords me the opportunity to feed several of my passions in life which include ocean kayaking and scuba diving. In fact, I enjoy scuba diving so much that last year I decided I needed more to keep me occupied and became a diving instructor. My wife and I have four kids who makes everyday a joy to experience.

In case you are wondering what tsua bing is.....it is the greatest snow on earth. OK...it is shaved ice with a variety of fruits. I am partial to fresh mango, pineapple, kiwi and banana. The mountain of ice is then topped with mango fruit jam and condensed milk. Some people prefer to go the healthier route and top the ice with just a variety of beans....but my sweet tooth loves the fruit!

My new found friends in Tainan, Taiwan. They make the best tsua bing in all of Taiwan.....and believe me, I have eaten my share of tsua bing.

Taiwan

Less then one week left before I have to leave my students and friends behind in Taiwan. It has been a great month and once again the great hospitality of the people in this country continually amazes me. I will miss my good friends at Chi Mei Hospital and my diving buddies down in Kenting.