Nicholas's hand before GHD he released it

Nicholas's hand before GHD he released it
" I do; I know I do," he replied. " I will tell you the reason one day, but not now. I hate myself for this; you are all so good and kind. But I cannot help it. My heart is very full;you do not know how full it is."He wrung Nicholas's hand before GHD he released it; and glancing for a moment at the brother and sister as they stood together, as if there were something in their strong affection which touched him very deeply, withdrew into his chamber, and was soon the only watcher unto that quiet roof. The little race-course at GHD Hair Straighteners Hampton was in the full tide and height of its gaiety, the day as dazzling as day could be, the sua high in the cloudless sky and shining in its fullest splendour. Every gaudy colour that fluttered in the air from carriage seat and garish tent top, shone out in its gaudiest hues. Old dingy nags grew new again, faded gilding was re-burnished, stained rotten canvas looked a snowy white; the "very beggars' rags were freshened up, and sentiment quite forgot its charity in its fervent admiration of poverty so picturesque.It was one of those scenes of life Hair Straighteners and animation, caught in its very brightest and freshest moments, which can scarcely fail to please; for if tl eye be tired of show and glare, or the ear be weary with a ceaseless round of noise, the one may repose, turn almost where it will, on eager happy and expectant faces, and the other deaden all consciousness of more annoying sounds in those of mirth and exhilaration. Even the sun-burnt faces of gipsy children, half naked though they be, suggest a drop of comfort. It is a pleasant thing to see that the GHD Straighteners sun has been there to know that the air and light are on them every day, to feel that they are children and lead children's lives; that if their pillows be damp, it is with the dews of Heaven, and not with tears; that the limbs of their girls are free, and that they are not crippled by distortions, imposing an unnatural and horrible penance npon their sex; that their lives are spent from day to day at least among the waving trees, and not in the midst of dreadful engines which make young children old before they know what childhood is, and give them the exhaustion and infirmity of age, without, like age, the privilege to die. God send that old nursery tales were true, and that gipsies stole such children by the score!
Read more [Medical Informatics Blog]

Increasing Nursing Student Communication Skills Through Electronic Health Record System Documentatio

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 06-15-2010 at 04:02 AM
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Nursing informatics: the intersection of nursing, computer, and information sciences.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 08-03-2010 at 05:47 AM
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Nursing informatics: why nurse leaders need to stay informed.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 08-03-2010 at 05:47 AM
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[Computers in nursing: development of free software application with care and management]

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 08-17-2010 at 04:35 AM
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[Research on computerized nursing documentation]

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 06-09-2010 at 06:24 AM
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eHealth and nursing Informatics.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 06-19-2010 at 04:43 AM
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[Evaluative study of nursing consultation in the basic networks of Curitiba, Brazil]

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 07-07-2010 at 05:50 AM
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Ania-caring 2010 annual conference re-evolution in nursing informatics.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 06-24-2010 at 04:09 AM
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HIT: what's the value for nursing?

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 06-15-2010 at 04:02 AM
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Nursing professional development: stories, tips, and techniques.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 06-18-2010 at 05:50 AM
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Pediatric nursing: tech matters.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 08-21-2010 at 12:34 PM
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Patient Loses Appeal of HIV Disclosure Verdict

Jeff D. Gorman reports: A hospital and one of its nurses are not liable for disclosing a woman’s HIV-positive status to family members who visited her, the Missouri Court of Appeals ruled. Candy Ziolkowski sued the Heartland Regional Medical Center for violation of a Missouri law that keeps the HIV status of patients confidential. She claimed [...]
Read more [Personal Health Information Privacy]

Transforming to a computerized system for nursing care: organizational success within Magnet idealis

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 05-29-2010 at 04:10 AM
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A Series of Tubes

Recently in the NYTimes, an interesting look into the simplest of medical errors: connecting the wrong tube to a patient. Devastated families and regulators ask, why should it even be possible to connect feeding tube contents to an IV? Or IV fluids to a nasal O2 cannula? Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible -- just as connections to piped hospital oxygen, medical air, nitrous oxide and vacuum are incompatible with each other. ... action has been delayed by resistance from the medical-device industry and an approval process at the Food and Drug Administration that can discourage safety-related changes. Hospitals, tube manufacturers, regulators and standards groups all point fingers at one another to explain the delay. Hospitalized patients often have an array of clear plastic tubing sticking out of their bodies to deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders. Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — sometimes with deadly consequences. “Nurses should not have to work in an environment where it is even possible to make that kind of mistake,” said Nancy Pratt, a senior vice president at Sharp HealthCare in San Diego who is a vocal advocate for changing the system. “The nuclear power and airline industries would never tolerate a situation where a simple misconnection could lead to a death.” Tubes intended to inflate blood-pressure cuffs have been connected to intravenous lines, leading to deadly air embolisms. Intravenous fluids have been connected to tubes intended to deliver oxygen, leading to suffocation. And in 2006 Julie Thao, a nurse at St. Mary’s Hospital in Madison, Wis., mistakenly put a spinal anesthetic into a vein, killing 16-year-old Jasmine Gant, who was giving birth. Amazing stuff. The article goes into more detail on the FDA device approval process, if that sort of thing is as interesting to you as it is to us... More from a recent FDA warning about oral med capsules being given IV...... Nicholas Nicholas
Read more [Medgadget]

Importance of nursing leadership in advancing evidence-based nursing practice.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 05-22-2010 at 04:29 AM
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The future of nursing. How HIT fits in IOM/RWJF initiative.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 05-05-2010 at 04:09 AM
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More than 30,000 Pharmacists Now Administering Flu Shots in Neighborhood Drug Stores

Pharmacies and pharmacists seem to be evolving into neighborhood healthcare centers. I have posted previous notes about this phenomenon (see: Local Pharmacies Emerge as Centers for Care of Diabetics; Pharmacist-Staffed Coagulation Clinics in a Large Health System). I have also discussed the deployment of retail, walk-in clinics staffed by physicians and nurses in retail pharmacy chains like CVS and Walgreens (see: Cleveland Clinic Partners with Minute Clinic in Retail Health Services; Growth of Walk-In Clinics Slows Down; Study of Patients Patronizing Walk-In Retail Clinics). However, I have not been tracking the extent to which pharmacists have been trained to administer flu shots. Some details about the trend were revealed in a recent article (see: Suntan Lotion, Flip-Flops... and Flu Shots; registration required). Below is an excerpt from it:

I have been a little surprised that the evolution of chain drug stores into mini-heath centers has not proceeded more rapidly. I attribute part of this slow-down to the general lack of success of some of them. Some of these in-store clinics are now in the process of refining their business models to a more appropriate mix of services and staffing. However and as emphasized in the excerpt above, the poor economy is causing pharmacy chain executive to look for new medical services to raise revenue and increase foot traffic -- flu shots seem to fit the bill.

The question then remains whether retail pharmacies will seek to expand to other healthcare services such as blood drawing for lab testing. The local drug stores could operate as convenient patient service centers (PSCs) and draw blood for the national reference labs such as Quest and LabCorp. LabCorp has already used such a strategy within Duane Reed drug stores in New York City (see: LabCorp To Offer Medical Tests At Duane Reade Drugstores In New York City). Of course, these national reference labs are a high-volume, low-margin business and already have their own blood-drawing facilities. They may have no incentive to expand into higher-priced drug stores merely for the sake of greater customer convenience.

IBM's Cloud Computing Coming to a Hospital Near You

IBM and Aetna's ActiveHealth Management subsidiary have unveiled a new clinical information management system based on cloud computing architecture. The Collaborative Care Solution, as the product is called, aims to bring together information from disparate sources like "electronic medical records, claims, medication and lab data" for easy access by any relevant party during a patient's clinical regimen. Additionally, the system features ActiveHealth's evidence-based clinical decision support CareEngine which can signal to clinicians when suspected abnormalities creep up in the data. Some details from IBM: With all healthcare data and IT resources managed in a cloud environment, the system will enable the coordination of patient care among teams, so doctors, nurses, nurse practitioners, aides, therapists and pharmacists can easily access, share and address information about patients from a single source. The solution can also show trends in how patients are responding, for example, to treatment for chronic asthma or adhering to drug regimens and automatically alert doctors to conflicting or missed prescriptions. For one fixed monthly fee, healthcare organizations have access to all the tools and services without having to make significant upfront investments – avoiding the challenge of updating systems when clinical guidelines or reporting requirements change or when patient loads grow. Additionally, the solution provides advanced analytics that help physicians or entire healthcare organizations measure their performance against national or hospital quality standards. Press release: ActiveHealth and IBM Pioneer Cloud Computing Approach to Help Doctors Deliver High Quality, Cost Effective Patient Care...... Michael
Read more [Medgadget]

Paper: Patel et al. (2009) Clinical complexity and medical education

The following item about a paper from last year was posted by Rakesh Biswas on the COMPLEXITY-PRIMARY-CARE list. After Rakesh's comments I have included a quotation.

The paper in question by Patel, et al. will be an important reference for me, even though the definition of domain and discipline remains problematic. (A glossary for the health career model will follow on the new site.)

Suddenly, the passing of time is also clear given that:

Shortcliffe, E.H. (et al.) Ed. (1990) A History of Medical Informatics, Wokingham, Addison-Wesley Publishing Co.

- appeared twenty years ago. Ten years ago I cited Shortcliffe et al..

Twenty years! How long is that in technology / internet terms?

The bold text below is my emphasis:

From: Rakesh Biswas
To: COMPLEXITY-PRIMARY-CARE@JISCMAIL.AC.UK
Sent: Thu, 12 August, 2010 16:41:06
Subject: Clinical complexity and medical education

As our society progresses in the accumulation of knowledge and as the complexity of this knowledge increases, it becomes more important to determine how to structure education to provide individuals with the most comprehensive base of knowledge without sacrificing either depth and complexity or broadness of material.

Human beings have an extraordinary capacity for storing large volumes of organized information in memory. How does one apply such detailed knowledge to practical, real-world problems and situations?

What is the optimal mode of learning that will promote flexibility and transfer of general knowledge across domains during problem-solving?

For more, see the article by Dr Patel whose focus area is Medical Cognition (how doctors think and develop their so called expertise).

Regards,
Rakesh

Here is a quote from the paper:
Much of the early research in the study of reasoning in domains such as medicine was carried out in laboratory or experimental settings. There has been a shift in more recent years toward examining cognitive issues in naturalistic medical settings, such as medical teams in intensive care units [2], anesthesiologists working in surgery[89], nurses providing emergency telephone triage [90], and reasoning with technology by patients [91] in the health care system. This research was informed by work in the area of dynamic decision-making [92], complex problem-solving [93], human factors [94,95], and cognitive engineering [44]. Naturalistic studies reshaped researchers’ views of human thinking, as expressed in ‘‘situativity” theory’s terms (as described in Section 2.1.4) [23–26], by shifting the onus of cognition from being the unique province of the individual to being distributed across social and technological contexts. p.186.

Whilst as Rakesh points out Dr. Patel's focus is medical cognition, then through the health career model it would appear my interest is nursing cognition. As per the legacy of models of nursing - which did recognize the patient through the concept of patiency (Stevens, 1979) - we realise that now all disciplines must demand much more of their respective models in the 21st century.

Patel, V.L., et al. (2009) Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education, Journal of Biomedical Informatics, 42, 176–197.
doi:10.1016/j.jbi.2008.12.002

Stevens, B.J. (1979) Nursing Theory: Analysis, Application, Evaluation. Boston: Little, Brown and Company.
Read more [Hodges' Model: Welcome to the Quad]

Development and evaluation of a nursing portal.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 04-22-2010 at 04:00 AM
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Prediction About the "Next Gen" EMR: Emphasis on Coordination and Communication

I came across a recent interview of Dr. Peter Stetson, CMIO, Columbia Doctors, in which he discusses, in part, the "next generation" of electronic health records (EHRs) (see: HIStalk Interviews Peter Stetson, CMIO, Columbia Doctors). Columbia Doctors is a multi-specialty physician group of about 1,000 physicians in New York. The company has about 150 practice sites in the Tri-State area of New Jersey, Connecticut, and New York, with its primary base at Columbia University Medical Center. Here's the portion of the Q and A interview that interested me the most:

Q: What should the next generation of EHRs do that the current generation doesn’t?

The connection between the EHR/EMR and diagnostic accuracy is a topic of great interest to me. I have previously commented on the topic of the high mortality associated with diagnostic adverse events (DAEs) (see: New Attention Being Directed toward Diagnostic Adverse Events (DAEs)). Here's a passage from that note;

The causes of DAEs [diagnostic adverse events] were mostly human, with the main causes being knowledge-based mistakes and information transfer problems. Prevention strategies should focus on training physicians and on the organization of knowledge and information transfer. We can do little to correct a "knowledge problem" on the part of a clinician who has received timely and correct diagnostic reports from pathology and radiology. However, there is much work to be done in terms of timely reporting from these two diagnostic services and also better integration of the diverse diagnostic reports from them.

As emphasized in this paragraph, the contribution of the major diagnostic services (pathology, clinical labs, and radiology) to diagnostic accuracy, and the reduction of DAEs, will consist of timely and accurate reporting from the LIS, RIS, and PACS to the EMR plus, at some later time, integrated diagnostic reporting. By this latter term, I mean that diagnostic specialists (i.e., pathologists and radiologists) will collaborate on challenging cases and render diagnoses back to clinicians based on a multiplicity of information inputs. These would include imaging studies, molecular diagnostic studies, and the analysis of stained thin tissue sections.

A key question, though, is how are we going to arrive at the Next Gen EMR described by Dr. Stetson that will include "workflow solutions that enable [efficient and effective] communication and coordination." In my mind, this will not be possible without an effective set of computerized rules operating in the background of EMRs that automatically manage the majority of such communication and coordination tasks. For example, if there is any significant change in the status of a patient or new diagnostic information acquired, the key members of the team caring for the patient should be automatically notified. The development and testing of such a comprehensive set of rules for an EMR is a daunting task. Moreover, the tendency when deploying such rules in the past has been to err on the side of distributing more information rather than less for medicolegal reasons. This results in information overload for the recipients and causes nurses and physicians to turn off the alert system or ignore the alerts, making the system meaningless.

Toward clarification of the doctor of nursing practice degree.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 04-09-2010 at 04:51 AM
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Research Scientist – Nursing

Forum: Recruiter Posted Informatics Jobs Posted By: aurorahealthcare Post Time: 04-08-2010 at 02:15 PM
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Nursing Researcher, Informatics - Aurora Health Care (Eastern Wisconsin)

Forum: Recruiter Posted Informatics Jobs Posted By: aurorahealthcare Post Time: 04-13-2010 at 08:36 AM
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Baby MedBasics App -- When Your Mind Goes Blank

RN Tara Summers was inspired to make an iPhone app after a frightening episode where she saw her infant child choking. Because she was a nurse, she sprang into action and gave the Heimlich maneuver, but worried about parents (or babysitters) without the same training. So, along with her emergency medicine physician husband, she created MedBasics -- a readily accessible information packet for the home about things to do in an emergency. Now, they're announcing an iPhone app called BabyMedBasics, for emergencies when you're not at home. More from MedBasics... iTunes Link to the iOS app...... Nicholas Nicholas
Read more [Medgadget]

Nursing students' perceptions of their resources toward the development of competencies in nursing i

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 04-07-2010 at 04:32 AM
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Nursing Informatics and ASPAN: Clinical Decision Support Through the Perianesthesia Data Elements.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 04-03-2010 at 05:22 AM
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How Do Future Nursing Educators Perceive Informatics? Advancing the Nursing Informatics Agenda throu

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 03-23-2010 at 04:40 AM
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BYOMD: Bring Your Own MD When Hospitalized

As a physician, I have often been drawn into situations by family and friends in which I have served as an informal medical consultant about care and treatment issues. This has usually involved only telephone calls but, for immediate members of the family, hospital visits were commonly involved. On some occasions, I engaged in discussions with the treating physicians. On a small number of occasions, some of these conversations grew heated regarding the type and quality of care being given. One incident in particular stands out in my mind when a family member was clearly expressing a choice which was ignored by the treating physician who was interested. and insistent, on performing a procedure. He backed off reluctantly when I told him that my family member did not want the procedure and had been clearly stating that preference (see: Teaching Consumers to Say "No" to Physicians' Recommendations).

I am sure that my experience is not unusual. In my opinion, it is essential that family members provide close oversight over all aspects of healthcare delivery to avoid errors and improve the quality of care in their families. One blogger is referring to this phenomenon as Bring Your Own Physician (BYOMD). A recent article discussed the phenomenon (see: Going to the hospital? BYOMD):

I fully understand that many families do not have ready access to a doctor friend or other skilled healthcare professional to provide advice when and where it is needed. I can also say with assurance that advice from family members about the care of hospital patients is frequently not appreciated by overworked hospital doctors and nurses. My only advice in these situations is to be courteous but firm when possible errors are spotted. This not only requires close surveillance by family members but, in many cases, some knowledge about the nature of the disease being treated as well as hospital procedures. Some of this knowledge can be obtain with deliberation and caution using quality web sites (see: Paging Dr. Google! We Are Waiting for a Second Opinion).

The Alliance for Nursing Informatics: A History.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 02-26-2010 at 04:16 AM
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Docs struggle with slow clinical information systems

A new survey has found that nearly half of healthcare professionals are dissatisfied with their clinical information systems, frustrated by response times that can last a full minute, or even longer.

Compuware Corporation this week announced the findings of the study, which polled 99 healthcare professionals at large and small hospitals in the United States – including nurses, doctors, CMOs and CMIOs – to better understand the availability of their clinical information systems.

The new fundamentals in nursing: introducing beginning quality and safety education for nurses' comp

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 02-24-2010 at 04:10 AM
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Unintended consequences of clinical automation and EMRs

One of my favorite new blogs is healthsystemCIO.com. There is some terrific reporting and more importantly unique and value-added coversations going on between healthcare CIOs. I ran across the recent “Dissecting Physician Resistance to CPOE” posting and thought it was worth sharing. Timothy Hartzog, M.D., Medical Director of IT, Medical University of South Carolina said the following about how implementing Computerized Physician/Provider Order Entry has unintended consequences but all the lessons are applicable to any clinical automation. Here’s a flavor of what he said:

Implementation of clinical informatics creates emotional aspects and unintended consequences, such as the following:

• More/New Work for Clinicians – work unit secretaries use to do, now requires physician time to complete

• Unfavorable Workflow – hard stops in CPOE are just a bad idea and lead to angry physicians.

• Never Ending Demands for System Changes – physician hate when the user interface changes too often, so have an educational plan for when changes are made.

• Problems Related to Paper Persistence – many complex items like TPN, CHEMO, etc., must be ordered on paper.

• Untoward Change In Communication Patterns and Practices – with CPOE, physicians can enter orders from anywhere in the hospital and the nurses never know.

• Negative Emotions – when Computers do not work at stressful moments, physician get angry.

• Generation of New Kinds of Errors – computers can change how meds are ordered, and confusing interfaces can lead to mistakes.

• Unexpected and Unintended Changes in Institutional Power Structure - physicians have always prided themselves on being able to treat patients their way. With CPOE, physicians are forced to use certain meds and protocol restrictions.

• Over-Dependence on Technology – one of my rules to all clinicans is: “IF the medication dose does not look right, it is NOT right until to prove otherwise.” Just because it is on a computer screen does not mean it is always correct.

• Shifts in Power Control and Autonomy – power shifts to committees like Pharmacy and Therapeutics, Medical Directors etc. Physicians loose the freedom a blank sheet of paper provides.

It’s a great posting and worth reading.

[Promoting nursing competitiveness: introduction to the digital divide.]

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 02-04-2010 at 04:08 AM
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The Falling Chart – Another Case for EMR

Sometimes when we think about EMR, I think we forget about the subtle nuances of paper charts that make them so undesirable. Check out this story which I got in response to my post called “Think About the Problems with Paper Charting.” It’s a a good illustration of some of the more simple things we often forget about:

I was recently visiting a relative at a major teaching hospital in the Midwest. While in the hall I noticed that they had charts in binders stored in boxes affixed to the wall. Just as I was wondering why such a prestigious institution relied on paper charts a nurse went to re-insert a chart into its box. She was in a hurry and missed, the chart dropped to the floor and binder opened and paper went all over the hall. What was even more surreal was the nurse did not at fist notice her mistake and was at leas 6 feet away before she noticed it and fixed her error.

Sometimes it’s not what you get from an EMR, but what you don’t get that matters.

Related posts:

1. Paper Chart Disposal After Implementing an EMR I’d be planning on posting about this for a while...
2. A Case for EMR Implementation – Multiple Locations I’ve been discussing the case for EMR implementation recently both...
3. Thinning Out the Chart for Scanning I saw someone give a great idea about which part...

Baby-Boomer Doctors and Nurses Near Retirement; Implications for Healthcare Reform

One of the many challenges we are facing in the clinical lab industry is a shortage of medical technologists as well as an aging of this group (see: Comments on the Medical Technologist Shortage). This aging phenomenon is not restricted to med techs but also applies to baby-boomer doctors and nurses as well, according to a recent article (see: Retirements by baby-boomer doctors, nurses could strain overhaul). Below is an excerpt from the article

I am sure that many of you have picked up a prescription lately at one of the chain retail pharmacies. The staffing model in these stores is that a single, well-paid pharmacist oversees a large group of pharmacy technicians. These latter personnel handle all of the routine prescription transactions including most telephone calls. A similar staffing model is used for inpatient hospital care with registered nurses overseeing squads of LPNs and nursing aides. A recent article in the NYT discussed how the innovative Geisinger Health System, functioning as a health insurer, is paying to staff physician offices with nurses. These nurses focus on patients with chronic diseases with the goal of saving money by avoiding expensive inpatient care (see: A Health Insurer Pays More to Save). I have been an advocate of using nurse clinicians as replacement for PCPs in most office and ambulatory care settings (see: Have PCPs Become Obsolete?). Here is a passage from that note:

I believe that most of the common ailments seen in an office practice can and should be addressed by physician's assistants and nurse clinicians, the latter being defined as a registered nurse who has received special training and can perform many of the duties of a physician....[T]his will include the following: [any task]  that can be reduced to a guideline, a template, or treatment algorithm. The job description of PCPs should be to solve...complexity and clinical conundrums....PCPs should manage the critical first steps in the diagnosis of complex disease prior to referring patients to medical specialists. The care of complex chronic diseases should also be the responsibility of the PCP.

I can't argue with the idea of training more physicians and nurses, particularly given the fact that healthcare reform will provide access to the healthcare system of an increased number of patients. However, I also think that it's inevitable that there will be greater emphasis on the use of physician, nurse, and pharmacist extenders. I have recently commented on the emerging types of such personnel such as patient coaches, nurse information triage[ists], and patient navigators (see: Yet Another Type of Healthcare Professional Who Focuses on Patient Support).

Philosophy of information empowers philosophy of care

The moral and ethical dimensions of nursing quickly become apparent to individual practitioners and professional associations. Philosophy in nursing boasts specific courses, journals and groups, for example:

International Philosophy of Nursing Society (IPONS)

Nursing Philosophy (journal)

International Centre for Nursing Ethics

Here on W2tQ, in papers and on the website I have stressed the importance of the health career model as a framework that can utilise information as a fundamental and potentially unifying concept.

Expanding on the post last week about the philosophers' magazine [tpm50] let's look at Floridi's piece on the philosophy of information (PI). The 50 ideas featured are each only granted two pages, but this has a definite philosophical equivalent twitter-styled appeal. On page 42 (- 43) Floridi notes that:
... PI possesses one of the most powerful conceptual vocabularies ever devised in philosophy. This is because one can rely on informational concepts whenever a complete understanding of some series of events is unavailable or unnecessary for providing an explanation. Virtually any issue can be rephrased informationally. Such semantic power is a great advantage of PI, understood as a methodology. ...

It shows that we a dealing with an influential paradigm. But it may also be a disadvantage, because a metaphorically pan informational approach can lead to a dangerous equivocation, namely, thinking that since any x can be described in (more or less metaphorically) informational terms, then the nature of any x is genuinely informational. (Luciano Floridi, 2010).Admittedly Floridi's context is the position and status of PI as an emerging discipline within philosophy. As he notes the vocabulary while powerful lies in the discipline of philosophy.

Given my preoccupation with information, Floridi's observation above is a timely warning for me and the many nurses who in the past saw a concomitant risk that in adopting the nursing process, patients (and carers) would be processed. Ironically, this processing concerned information. The workflow - form and layout of the documentation - was prescribed. This is an old tale, with the nursing process being subsumed within the routine work of nursing. Perhaps though this also demonstrates a need for a new debate?

My interest in information is as a trope to explain the significance of the care (knowledge) domains that underpin Hodges' model. Crucially, though these can stand on their own as nursing philosophy issues. Joining the efforts of the nursing philosophers above, this can bring information and philosophy out of the academic realm to include a more practical and grounded variety of topics:

FROM: personal identity,
definitions and ownership of computer based records,
utility versus security of information (summary care record ...),
definitions of information (data, knowledge) - through
TO: patient information and patient informatics, ...
where is collective informatics# heading?

Taking Floridi's lead - which of the above .... are core nursing (health) information concepts (and not just freeloading info-masqueraders along for the ride)? Well, that is a question for a new community of scholars to decide?

Philosophy resources: Interpersonal care domain

#Collective informatics = all the claimed informatics disciplines combined?
Read more [Hodges' Model: Welcome to the Quad]

Collaborating to optimize nursing students' agency information technology use.

Forum: Nursing Informatics Journal Articles Posted By: Nursing Informatics News Post Time: 01-29-2010 at 04:45 AM
Read more [Nursing Informatics News]

Yet Another Type of Healthcare Professional Who Focuses on Patient Support

I have been developing a list of of new types of healthcare professionals who interact directly with patients. Here's how it currently stands: coach, counselor, telephone booster, and nurse-information-triage(ist) (see: The Emerging and Expanding Role of Counselors in Healthcare; Telephone Calls and Emails as Key Components of Primary Care). To this list, we can now add patient navigator (see: Patient Navigators: A Different Viewpoint), Quoted below is an opinion piece by an oncologist, Dr. Barbara McAneny, who reacts to a previous article in the Journal of Oncology Practice that advocated the use of patient navigators in physician office settings:

The authors suggested that patient navigators would be a valuable addition to any practice and described their use in several settings. If we are not careful, we may be witnessing the birth of a new allied health provider. Practices today cannot afford additional staff providing unreimbursed services, but this is only one of the reasons I am bothered by the navigator trend....It is crucial to have another friendly set of ears present to help the patient recall the discussion. I feel this role is best played by a family member, loved one, or close friend, not a stranger assigned as the patient navigator. The untrained friend or family member may get details wrong.... It is the job of oncologists to educate patients and families at their levels and to realize that emotional reactions are part of patients' hardwiring. We can set up another appointment, take the time to overcome that barrier, or provide the patient and friend or family member with written materials. Abdicating this function to a patient navigator will work only if the navigator has sufficient medical training and specific qualifications. The services provided by navigators become expensive quickly and are not reimbursable, adding to the already burdensome overhead of oncology practices. If we were to decide to employ patient navigators, how many patients could one navigator navigate?....The other aspect of patient navigation involves helping patients get all the appointments, tests, procedures, and information needed and ensuring that the insurance companies pay for all of these....This is the part of patient navigation I find most alarming. We have created such an inefficient system that we need to invent a new medical specialist to help us cope with it. If our system necessitates navigators, we need a new system.

I must admit that I find myself generally sympathetic to the concept of a patient navigator working in the office of an oncologist. Ideally, and as emphasized in Dr. McAneny's comments, the role of sympathetic patient advocate is best filled by a relative or friend of the patient. However, not all patients understand this need or have ready access to such people. Therefore, having a member of the office staff who can function as a patient advocate and second set of ears strikes me as an advantage. Now you may well ask at this point, why do you not consider physicians themselves as the key and sufficient patient advocates? My response is that I believe many, if not most, oncologists view their goal as treating cancer patients, often with chemotherapy. How much latitude is there in an oncology practice for a patient who does not want to be treated at all or does not place the same value as the oncologist on extending his or her live by a couple of months.

The general tone of Dr. McAneny's comments is somewhat imperious. She is distressed by "the birth of a new allied health provider." She concedes that "emotional reactions are part of patients' hardwiring." She also appears to be overly concerned that the "services provided by navigators become expensive quickly and are not reimbursable." Finally and perhaps most inappropriately, she suggests that the need for patient navigators is based on our "inefficient system." Although I would not doubt that this is frequently the case when scheduling new appointments, lab tests, and imaging procedures, I also believe that the need for the new patient intermediaries discussed above is largely the result of the complexity and aloofness of modern care, particularly for cancer patients.

Nursing Facilities Join Indiana Network

Golden Living skilled nursing and assisted living facilities in Indiana will join the Indiana Network for Patient Care.

Group Health Talks eHealth on Microsoft Health Tech Today

Our June program of Microsoft Health Tech Today is now live on the web.  This month’s program includes four segments.  Featured topics include an amazing service, Would Technology Network , that helps community nurse specialists cure patients...(read more)
Read more [HealthBlog]

A Bite of the Apple

Yesterday, with much fanfare, Steve Jobs took the stage at Apple’s annual developer conference and announced the pending release of the next iteration of the iPhone. While there has been plenty of press regarding this release, both before (and Apple’s Dark Lord tactics) and after, Job’s presentation also highlighted a number of facts and figures worthy of quoting here as Chilmark Research sees Apple’s portfolio increasingly being a leading indicator of future innovations and subsequent adoption in not only the consumer market, but the healthcare sector as well.

iPad:
Over 2M sold since its release 2 short months ago.
8.5K native iPad apps now available.
35M apps downloaded => ~17 apps/iPad.
5M books downloaded

Some analysts are now projecting that 8M iPads will be sold by end of 2010; would not be at all surprised if that number is exceeded.  On a recent trip to Martha’s Vineyard, while taking the ferry over, I saw two, separate elderly people (had to be at least 80+ years old) using iPads.  This product is a hit and its popularity will drive continuing developer interest to build out new apps for the iPad.  Having spoken to a number of healthcare workers though, the utility of the iPad in the healthcare setting has yet to be determined as many still question the ruggedness and ability to disinfect an iPad. Really do not see this as a big hurdle to overcome as such has been the case for many previous computing platforms and the iPad comes in such a compelling form factor, it really is hard to resist for numerous applications including bedside patient education, that the healthcare sector will be an important market for the iPad.

AppStore:
Over 5B apps downloaded.
A whooping 225K apps are now available.
15K apps/wk are submitted to Apple for approval (95% are accepted within a week).
Top 3 reasons for apps being rejected:

1. Does not function as advertised.
2. Uses private APIs.
3. App is buggy and crashes.

By end of June’10, over 100M devices using the iOS (iPhone, iTouch, iPad) will have been sold.

The AppStore has created a completely new model for app development and delivery that has been highly successful for Apple in driving sales for its ever expanding portfolio of devices.  Google is a distant second with the Android OS and the Android store of some 30K apps. In healthcare, with a few notable exceptions (e.g., ADAM, Epocrates, iTriage, LiveStrong, WebMD, etc.) most of the mHealth apps in the AppStore are pretty simplistic, what Chilmark refers to as mHealth 1.0 apps (for more info, mobihealthnews has a nice little report on mHealth apps).  But what Chilmark is more interested in is seeing how the concept of an AppStore-like environment (platform) will allow for the development of a wide range of mix and match clinical apps, which some have begun referring to as “Clinical Groupware.” Big question here though is how will meaningful use be achieved through use of a certified EHR if the certified EHR is actually a collection a disparate apps running on an iPhone or iPad?

The New iPhone:
For healthcare, a couple of new features are notable (beyond multi-tasking which was announced earlier this year as part of new OS4.0).

• New “retinal” display that Apple claims will provide unmatched resolution.  This will be particularly valuable in reviewing images.
• Video camera on both sides of iPhone combined with video conferencing app, FaceTime.  This could be particularly useful for telehealth applications wherein a remote clinician (say a nurse) is providing at home care, notices a new rash on a patient and confers with doctor at clinic or hospital, in real-time on what appropriate action (bring them in, apply slave, order Rx) should be taken.

Apple is clearly in the driver’s seat today setting the standards and benchmarks by which others will follow.  How these developments may impact the healthcare sector is something we will continue to monitor closely.

Think About the Problems with Paper Charting

Back in April, Evan Steele, CEO of SRSsoft, wrote an interesting post about EMR adoption and he asked the question, “Why Are You Still on the Fence?” It’s a very good question. Plus, he adds some value to the conversation by listing some of the problems with paper charts versus an EMR. Here’s a section of his post:

So why are these physicians, who have determined that government incentives are not relevant or achievable, still on the fence about adopting an EMR solution that will deliver measurable benefits? Staying with paper charts is not a good business strategy because there is nothing more inefficient!

• The costs associated with the excess staff needed to manage these medical records are massive and wasteful—these positions can be eliminated or the employees can be more effectively used in revenue-generating or patient-care roles.
• Paper charts hinder practice growth because adding physicians requires a proportional increase in support staff—medical records, billing, nurses, and medical assistants—and because physicians can’t see more patients without lengthening their work hours.
• Slow responsiveness to primary care physicians limits referral volume.
• Profitability is further affected by billing bottlenecks that delay revenue collection.
• The chaos associated with trying to manage paper charts has a damaging effect on staff morale and creates rampant frustration among patients, physicians, and staff.
• Paper charts are a malpractice nightmare—prescriptions are not consistently documented, orders are not easily tracked, and medical decisions are often made without complete clinical information.

So, why are doctors on the fence with EMR? The sad thing for me was the pre-EMR stimulus money, I felt a shift in the tone of conversation around EMR adoption. Doctors had mostly moved from wondering if they should implement an EMR to how they should implement an EMR and which EMR they should implement. They were off of the fence and I saw the tide shifting.

And then in one anti-stimulative swoop, the HITECH act rolled out and doctors decided to go back to the sidelines and see this government incentive play out. Now they’re waiting for meaningful use to be defined. While the HITECH act has increased EMR awareness 10 fold, it’s also done much damage on the short term EMR adoption. I’m not sure that the increased awareness will overcome the damage that it’s caused.

Of course, the damage is done and so we have to go forward from here. I suggest we go back to pre-EMR stimulus times and focus more effort back on the benefits of EMR and the costs of paper instead of the government handouts. If we do that, we’ll see a fantastic shift to more widespread EMR adoption.

Related posts:

1. Problems with ARRA EMR Stimulus Money I recently read a Healthcare IT article that talks about...
2. EMR Technology Exacerbates Problems One thing that I’ve mentioned many times in the 4+...
3. Benefits of Converting from Paper Chart to EMR Today, I decided to start a new web page that...

The Emerging and Expanding Role of Counselors in Healthcare

A recent article listing and describing the fastest growing jobs in healthcare caught my eye (see: Fastest Growing Jobs in Health Care). Below is the list from it that I have edited for the sake of brevity:

• Physician assistants
• Medical secretaries
• Physicians and surgeons
• Registered nurses
• Counselors
• Licensed practical and licensed vocational nurses
• Billing and posting clerks and machine operators
• Social workers
• Receptionists and information clerks
• Clinical laboratory technologists and technicians
• Pharmacists

I was pleased to see that clinical laboratory technologists and technicians made the list. but just barely. However, the  category that I found to be the most interesting, and that I have placed in boldface, is counselor. Here's how the job is described in the article: Counselors work in various health-care facilities to help clients overcome physical or mental health obstacles they are encountering. I recall the title of genetic counselor going back many years in hospitals. The reason for the emergence of this group of professionals, often with Ph.D.'s in genetics, was that the field was very complicated and most physicians and nurses were not trained to offer such advice to patients.

One conclusion that can be drawn from all of the above is that medicine is growing more complex and that the counseling function. previously performed primarily by physicians and nurses, is now being undertake by a new and growing set of professionals called healthcare counselors. To get a better understanding of this new category, I Googled the term and got 3,890 hits. One person whose web site showed up near the top of the search retrieval page described himself as a Vegan Lifestyle Coach and Holistic Healthcare Counselor. Quite a mouthful and a job description obviously designed to appeal to a broad swath of potential clients. It seems to be that on the basis of my search the terms coach and counselor are frequently being used interchangeably. In a recent note, I began to explore the differences among telephone boosters, health coaches, and web support groups (see: Enlistment of Telephone Boosters for Improved Chronic Disease Outcomes). Clearly, counselors now need to be added to this list.

Take

Hi,


Lots done - A ward round covering every single surgical patient in the entire hospital, telling a patient on said ward round that they likely have cancer; clerking in abdominal pains, one of which included an argument between mother and daughter based around sexual activity (catholic mother) and then an argument around smoking, the situation resolved by getting the mother to leave briefly. Ward rounds not enough, I also saw surgeries including a scrotal exploration (looked as nasty as it sounds); an orthopaedic trauma surgery on a fractured hip and a surgery where someone had swallowed a biro and it had perforated their small intestine. On top of these surgeries I also clerked in a patient with a large gluteal abscess, performed a very bad attempt at taking blood and was part of the admittance procedure for a patient who had been bitten by an adder. All this with a twist at the end - could it be any better!

Starting with the ward round. It was long, I was on it for hours and it continued for hours after I had left. It took place at the weekend, meaning that there was just this one consultant surgeon to cover the hospitals surgical patients, meaning he wanted to see all of them. This is a very large hospital, and as such this as a mammoth task, especially given he was not the consultant for many of the patients. Despite this, the ward round was well organised and slick, with perfect interaction from the nurses. Often I do not see nurses on the ward rounds, but having them there was very helpful, as they tend to know the patients the best, and have an experienced and valuable viewpoint. They are also the people who dish out much of the care, so knowing what should be medically done for the patient is very important.
On this ward round, one of the patients was suffering from obstructed bowels, meaning she hadn't passed any motions in some time, and had a distended abnormally enlarged belly. After examination, the consultant decided that the cause must be a caecal tumour (how he knew this is impressive, just based on a mass in the lower right quadrant), and ordered a CT scan to confirm this. Despite the fact that this was a busy ward round, and there was no confirmation of the diagnosis, the consultant then proceeded to tell the patient that they probably had cancer of the colon, which was causing their symptoms, and that they had two choices - they could try operations on it to fix it, or 'just leave it be'. The patient was a very lively 90+ lady, whose son had also died of colorectal cancer. She was asking whether this meant that she would just be left to kick the bucket, and the consultant had to admit it depended very much on the imaging results. The lady was obviously somewhat upset, and we moved on to see another patient. All of this without a definite diagnosis - no imaging results, no blood tumour markers, just obstruction and a mass in the abdomen. I thought at the time that that was a risky thing to say. Why blurt it out in the middle of a busy ward round, when you cannot offer her any care or support, and it is not a definite diagnosis. Why not wait for it to be confirmed and let the normal consultant or registrar give the bad news when more time is available. I suppose I am not in a position to question a highly qualified consultant, perhaps he was trying to make his colleague's lives more easy.

Whilst clerking in patients whilst on surgical take, I saw a variety of cases, mostly to do with abdomens. There are plenty of things which can go wrong with your abdomen, most of them can be dealt with surgically, so surgeons tend to deal with abdomen pain in the hospital. One of said people I was clerking in was a 17 year old girl, who was presenting with recent onset right iliac fossa pain. This is a typical presentation of appendicitis, but can also be mixed up with other diseases as well, such as pregnancy and other problems with your 'woman's bits'. After the history and examination, we had to perform some tests to try and help us determine the cause. If it was something critical such as acute appendicitis, this would mean that the patient would need an operation fast. If it wasn't then it was a lovely sunny weekend, and I am sure the patient didn't want to be wasting her time in the hospital. A urine test is used to look for UTIs and pregnancy, along with bloods to look at markers of appendicitis. When the urine test was mentioned to the girl, the mum chimed in with "that's not necessary, we are Catholics, no sex before marriage and all that". I am sure I do not need to explain to you that many children do not follow parent's wishes, and this was not a good reason to exclude pregnancy or an ectopic from the differentials list. It was attempted to explain to the mum that this was a routine investigation, and everyone of childbearing capability (pretty much 12 upwards) who presented like this had this, but the mum was insistent.

[Blog continued at http://internal-optimist.blogspot.com/ ]
Read more [Medical Informatics Blog]

EHR Software Market Share Analysis & UK residential care / nursing home sector musings

Last month (20th May 2010) Chris Thorman, who blogs about EMR systems at Software Advice, e-mailed me (copied below). Could I mention his recent EHR post on my blog?

Well thanks Chris! It is very encouraging to learn that W2tQ is seen by others as an infocare centre and valuable media avenue. It is very difficult for me to comment on this USA based analysis which is detailed at:

EHR Software Market Share Analysis

- but here are some thoughts. ... This is a great piece of work-in-progress which acknowledges the problem of being 100% comprehensive and coherent given the task, plus the market's spread and dynamics.

My perspective is UK and my full-time work as a nurse gives me a limited outlook on health IT markets as a whole. Nonetheless I value efforts to capture such data in order to better understand the health informatics industry and grasp the bigger picture. As Chris notes this project is challenging, the post is also an appeal for help. While a great proportion of surveys are commercial in motivation, the e-community and e-media can now add value by pointing out the gaps and other data sources. The comments that conclude Chris's post ably demonstrate this.

I would very much like to read something similar for the UK, including the use of information systems in the residential and nursing home sector (any suggestions welcome). It still amazes me how many care homes - including those that are part of large business groups - do not use a 'resident' information system.

Perhaps the new - post-election - health ICT market in England will see new opportunities?
(See post re. 1 July 2010 NW England BCS - British Computer Society meeting).

In ICT terms the care / nursing home sector to me seems passive; it is content to be waited-upon by primary care and the hospital based systems. If they are not engaged on this level can they (and others, e.g. commissioners) argue that they are integrated? I think not.

Care homes need to realize that a dedicated information system could pay dividends in terms of assessment; continuity of care (transfer of care); quality of care; client, family and staff engagement, reporting to inform commissioning, inspection and marketing. When we talk of a patient's viability, there is also the question of the future viability of this market sector amid competition, economics, standards and costs ... ?

Buyer sought for Loyd’s Nursing Homes Group’s 64 care homes
Catherine Boyle, Times Online, 21 May 2010.

Chris' focus is the EHR market, very much concentrated upon physician, medical and billing applications. This is reflected in the search facility on the Software Advice website. The search is constrained and directed, driven of course by the underlying database of companies, their applications and reviews. Markets are, however, defined by their boundaries and the way they change over time. Anticipation of that change is a gift indeed.

The personal health record (PHR) lies outside the scope of this Software Advice post, since as per WikiPedia:
It is important to note that PHRs are not the same as EHRs (electronic health records). The latter are software systems designed for use by health care providers. Like the data recorded in paper-based medical records, the data in EHRs are legally mandated notes on the care provided by clinicians to patients. There is no legal mandate that compels a consumer or patient to store her personal health information in a PHR.This work by Chris and respondents helps to establish and define the boundaries. The EHRs in question are not purely institutional (e.g. hospital-based), the vendors cater for varying numbers of users, in different care settings as you can see on the site's 3-stage search. So while I cannot add anything as such, I wonder if there could (should) be scope for residential care in there?

Or perhaps the EHR market is not viable when it comes to older adult* residential care?

Heaven forbid that the transatlantic (and global) EHR market is ageist!

Thanks again Chris.

*Residential care is also needed for younger adults too.

From: Chris Thorman
To: " Peter,"
Sent: Thu, 20 May, 2010 18:57:41
Subject: Blog post idea for your blog

Hello Peter,

I hope you've had a good week. I just finished a blog post about market share in the EMR industry and I wanted to give you a heads up about it. Here is the link:

http://www.softwareadvice.com/articles/medical/ehr-software-market-share-analysis-1051410/

In the article, I broke down:

• The size of the outpatient EMR market;
• What EMR vendors have the most physicians using their system; and,
• What EMR vendors have the most practices using their system.

WVBOM: Policy Statement - Guidelines for Physicians in Collaborative Relationships with Advanced Nurse Practitioners

On May 10, 2010, the West Virginia Board of Medicine has issued a new Policy Statement - Guidelines for Physicians in Collaborative Relationships with Advanced Nurse Practitioners or Certified Nurse Midwives; Standard of Practice.

The new Policy Statement provide West Virginia physicians with guidance on the role and responsibility they play in the collaborative relationship with advanced nurse practitioners and certified nurse-midwifes. In summary, the guidance provides:

A. The physician must be permanently and fully licensed in West Virginia without restriction or limitation.

B. There should be a written collaborative agreement should should include certain specific provisions as outlined in the Policy Statement.

C. Other considerations that are outlined in the Policy Statement

The Policy Statement indicates that the failure by a physician to adhere to these minimum requirements and guidelines may result in discipline by the Board of Medicine.
Read more [Health Care Law Blog]

Hospice laptop with personal info stolen

Park Ridge-based Rainbow Hospice and Palliative Care is alerting patients after a laptop computer containing patients’ personal information was stolen during a nurse’s home visit in April. The theft occurred April 12 in Chicago, Rainbow Hospice announced publicly last week. The computer contained patient names, addresses, social security numbers, insurance information, medications, [...]
Read more [Personal Health Information Privacy]

Six Things Hospitals Need to Know About Replacing Pagers With Smartphones

Resource Central Making the decision to replace pagers with smartphones is certainly a weighty consideration for your hospital. Lives are at stake, and there is no room for error. This timely report, “Six Things Hospitals Need to Know About Replacing Pagers With Smartphones,” provides a valuable tool to help you determine the right path for your organization. Amcom

Many doctors, nurses, and administrators now request all communications - including code calls - to be sent to their smartphones. They wish to shed their tool belt of onsite and wide-area pagers and cell phones, preferring to simplify their lives and communications with a single, all-encompassing device.