Author: Nurse Paola

eHealth in Clinical Judgement

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Technology has become a big part of healthcare and whether we like it or not, it is here to stay. So how will it affect the way we do things? How will it impact our decisions for treatment and interventions, and where will it lead us to in terms of making clinical judgement? These are just some questions that result from the advancement of technology in health care, better known as eHealth.

Of course, there is validity to these questions as more and more rely heavily on technology for answers. Some may even rely on what they read off the internet, or what they view over an electronic health record (EHR) about a patient to make decisions, which in and of itself is a scary thought. When used in such a way, it seems to almost degrade humans of their capacity to think and use sound knowledge to make decisions. This is far from the truth. In order to avoid the notion of eHealth becoming the be all and end all of our clinical decisions when providing care, it should not be relied on solely but instead utilized as a tool to help and guide us make better judgements for better patient outcome. When used appropriately and when given the appropriate training, eHealth can be used to enhance communication between the multidisciplinary team, create widespread acceptance of eHealth resulting in consistency within documentation and information flow, and to better care and treatment for patients (De Raeve, Gomez, Hughes, et al., 2016).

After reflecting on a recent clinical situation that I have experienced, it was further validated that eHealth can assist in decision making in many ways as explained earlier. That is, when used appropriately and in conjunction with clinical judgement. While reviewing Tanner’s (2006) clinical judgment model, the use of eHealth to collect information, and how the information flowed was evident within the steps of the model. In this particular experience, the use of eHealth enabled the provision of information to validate clinical judgement regarding appropriate, and necessary interventions for end-of-life care for a client. Based on review of recent clinical documentation by the physician to provide comfort measures only, and in-depth review of the resident’s clinical diagnosis, it was obvious that the need to address pain symptoms was necessary. This was determined based on the steps of noticing. Knowing the client and piecing together information through reasoning using analytical, intuitive, and narrative thinking (Tanner, 2006), and putting this all together with information retrieved through data stored in the EHR allowed for the ability to respond to the clients’ needs.

Tanner (2006) talked about how nurses should think in terms of making clinical judgement, illustrating this within the clinical judgement model. We then discussed how eHealth intersects with this model, however, the benefits of eHealth can be so much more. eHealth can assist in guiding health professionals make appropriate decisions in areas such as pre-operative and post-operative procedures (Govindasamy, Manickkam, et al., 2013), health teaching of patients, and as described, palliative and end-of-life care just to name a few.

References:

De Raeve, P., Gomez, S., Hughes, P., Lyngholm, T., Sipila, M., Kilankska, D., Hussey, P., & Xyrichis, A. (2016). Enhancing the provision of health and social care in Europe through eHealth. International Nursing Review, 1-9. Retrieved from http://www.efnweb.be/wp-content/uploads/Enhancing-the-provision-of-health-and-social-care-in-Europe-through-eHealth-Final.pdf

Govindasamy, R., Manickam, P., Gopalakrishnan, G., & Muralidhara, S. (2013). Technology: An aid to clinical judgement. Annals of Cardiac Anaesthesia, 16(2), 137-139. Retrieved from file:///C:/Users/pcmey/Downloads/Technology_An_aid_to_clinical_judgement.pdf

Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. http://www.ncbi.nlm.nih.gov/pubmed/16780008

Reflection of Darbyshire’s (2004) article:

Module 4: Blog 2

“Rage against the machine?”: nurses’ and midwives’ experiences of using Computerized Patient Information Systems for clinical information.

After reviewing Darbyshire’s (2004) article on the experiences of nurses’ and midwives’ experiences of using Computerized Patient Information Systems (CPIS) for clinical information, a common theme of concerns emerged. Many of the concerns seemed to revolve around the user-friendliness of the system, as well as communication gaps which affected the benefit that the system could have on patient outcomes. User autonomy is also one of the downfalls that is evident based on Darbyshire’s (2004) observations. As Mann (2008) explained in her response to Darbyshire’s (2004) study, frustrations regarding hardware functionality and access can be fundamental to dissatisfaction with CPIS projects (p.2090). This could not be truer!

Despite the evident lack of acceptance with the use of CPIS by nurses and midwives described in Darbyshire’s (2004) study, there are ways that can potentially aid in resolving some of the issues raised. The following are recommendations that could possibly address both the technical failure of the CPIS and impact the predominantly negative receptivity of the nurses and midwives to the CPIS. Of course, given the time of the study some of the following recommendations have more than likely occurred but may prove effective nonetheless:

  • Create super-users of the CPIS systems. As mentioned by Darbyshire (2004), those who reported positive experiences of CPIS tended to work in the ‘information-rich’ and technologically sophisticated areas (p.19). Peer-to-peer training can have a positive impact on nurses and midwives’ receptivity to the new system.
  • Create a committee. Creating a committee that consists of end-users, super-users, and management could open the door for open discussion on the impact that the CPIS has had on their workflow; bring-forth ideas for improvement; and address any concerns moving forward.
  • Ensure open communication between the users and the change management. As explained by DeZarn (2006), change management is everyone’s responsibility. Staff should communicate problems with the system and offer suggestions for improvement and what is desired, and change managers should listen to the problems, provide positive feedback, and address or implement suggestions made by staff (p.237).
  • Work with providers to explore ways to integrate systems. A problem that was observed in Darbyshire’s (2004) study is that the systems used by the nurses and midwives did not seem to talk to each other. Integrating systems would result in producing better data that can be reviewed by the team for quality improvement purposes.
  • Provide autonomy to end-users. Another concern brought up by Darbyshire’s (2004) study is that end-users were not able to retrieve information after data entry. This concern hindered their ability to see the effect of the use of the system to patient outcomes. Providing autonomy to end-users will increase participation and receptivity.

These are just few options that can be implemented or trialed to address some of the issues raised. As such, these are the same key elements that I would personally utilize to ensure success in implementation for any type of computerized information systems to be used in my workplace. As Darbyshire (2004) even said, introducing and developing computerization is about considerably more than installing new technology and training people it its use (p.18). Clearly, the solution is not about implementing the use of what we think is a useful system, but it is how we involve those who will be using the system that will show positive results.

References:

Darbyshire, P. (2004). ‘Rage against the machine?’: Nurses’ and midwives’ experiences of using computerized patient information systems for clinical information. Journal of Clinical Nursing, 13(1), 17-25. Doi:10.1046/j.1365-2702.2003.00823.x. Retrieved from http://resolver.scholarsportal.info.roxy.nipissingu.ca/resolve/09621067/v13i0001/17_atmnampisfci.xml

DeZarn, T.L. (2006). Darbyshire P (2004) ‘Rage against the machine?’: nurses’ and midwives’ experiences of using computerized patient information systems for clinical information. Journal of Clinical Nursing13, 17-25. Journal of Clinical Nursing, 15(2), 237-237. Doi:10.1111/j.1365-2702.2006.01180.x. Retrieved from http://resolver.scholarsportal.info.roxy.nipissingu.ca/resolve/09621067/v15i0002/237_dpatmnjocn11.xml

Mann, C. (2008). Commentary on Darbyshire P (2004) ‘Rage against the machine?: Nurses’ and midwives’ experiences of using computerized patient information systems for clinical information. Journal of clinical nursing 13, 17-25. Journal of Clinical Nursing, 17(15), 2090-2091. Doi:10.1111/j.1365-2702.2007.02104.x. Retrieved from http://resolver.scholarsportal.info.roxy.nipissingu.ca/resolve/09621067/v17i0015/2090_codpatciocn1.xml

Medication Administration Workflow in Long-term Care

Module 4: Blog 1

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Introduction

For those who have had experience working in acute care and long-term care, one would know that there is a significant difference in environment. Although some would argue that acute care such as hospitals have more complex patients, to which in some parts true, long-term care has its own unique complexities, whilst sharing some similarities in terms of eHealth. In my work environment, we do not use a computerized physician order entry (CPOE) system unlike many acute care settings, however the physicians and nurses utilize what we call a “digital-pen”. Although quite different from how CPOE’s work, its benefits in terms of reducing potential errors, and convenience is its shared commonality.

To touch on environment and demographics, the population in long-term care consists of elderly individuals of whom mostly require extensive, 24-hour care, with a few exceptions. Although most government owned long-term care facilities follow a much more institutionalized look, many smaller, privately owned long-term care homes, such as my place of employment, value the importance of making the environment feel like home. It is a one-level, 101-bed home with 4 units, with 3 dining rooms with 1 being shared. It is staffed with 1 registered practical nurse for each unit during days and evening, personal support workers, and a registered nurse 24 hours a day. Medications are stored in a medication cart, equipped with a laptop where the registered staff accesses the electronic medication record (eMAR), as well as the electronic health records (EHRs) of our residents/clients. Each unit also has a designated nursing station, with one being the main station where the digital-pen dock is located to allow the registered nurse to oversee the main entrance, and is also a convenient location for the physicians instead of going to each unit to review resident charts.

With that said, one can imagine that the workflow can be quite extensive just like anywhere else but with its own characteristic of busy. Each registered practical nurse is assigned up to 28 residents, while the registered nurse is responsible for all 101 in the grand scheme of things. Working with families, physicians, and other multidisciplinary persons are among some of the other responsibilities included with administering medications and treatments, without accounting for the unexpected.

Medication Administration Workflow

On a regular, non-eventful day, a typical medication administration workflow would consist of the physician writing a medication order using the digital-pen on a specific type of physician order sheet provided by the pharmacy. The physician would then insert the pen into the dock and the order would then be transmitted directly to the pharmacy. If the order is placed before a certain cut-off time as set by pharmacy which is 4:00pm, the order is inputted into PointClickCare physician’s order (which is our EHR system) by the pharmacy. The nurse would then check to see that the order has been entered, verify its accuracy, sign the physician order sheet and have a second nurse check and co-sign as a second check, always using the digital-pen. The pharmacy would then send the medication in the evening, which is received by the nurse. An ‘order received’ sheet would be signed which would be sent back to pharmacy. The medication would then be placed in the medication cart in its respective resident’s box, to be administered at the specified time and date by the registered practical nurse, based on review of the eMAR.

A simplified, typical-day workflow is described below:

Taking a Moment to Understand the Digital-pen

As explained by Woodford (2018), a digital-pen works in the following manner:

  1. The ink refill leaves an ink trail on the page.
  2. The infrared LED in the base of the pen shines onto the page.
  3. The light detector, also in the base of the pen, picks up the infrared reflected off recognition marks printed on the special paper. (Which would be the one provided by pharmacy in this case).
  4. The microchip in the pen uses the pattern of reflections to store images of the words that is being written.
  5. The Bluetooth antenna built into the pen transmits the stored data wirelessly and invisibly through the air.
  6. The wireless receiver in the computer picks up the Bluetooth signals and stores what has been written. (In our case, this is true but through cloud-based system, it is also automatically sent to the pharmacy, but both locations can have the ability to verify accuracy).

As you can see, based on the simplified workflow and understanding of how the digital-pen works, it can definitely reduce the risk of errors by eliminating communication gaps between the prescriber and the medication provider. It also takes away the time spent having to manually input the data into the computer, and is much more convenient. However, this is only on your typical day. In reality, there are varied situations that could take place to reach the same end result, with the medication being administered to the intended resident such as the registered staff writing a nursing measure order; receiving and transcribing a verbal or telephone order which is accepted within our facility; the nurse manually entering the order into the system if it is off-hours; as well as stat orders and use of emergency medications.

A slightly more complex workflow is described below:

As much as there are benefits to the eHealth system used in long-term care, there are also obvious flaws to the system that needs to be improved just as what was observed in Cheng, Goldstein, Geller, and Levitts (2003) study on the effects of CPOE on ICU workflow. Although different in possible resolutions, adaptation to the system and technological solutions would be of importance. A review of the different events that affects the typical-day workflow of medication/treatment administration would be of value in order to start on possible resolutions to potential barriers of the effectiveness of eHealth.

References:

Cheng, CH., Goldstein, MK., Geller, E., & Levitt, RE. (2003). The effects of CPOE on ICU workflow: an observational study. American Medical Informatics Association, 150-154. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1480350/

Woodford, C. (2018). Digital pens. Retrieved from https://www.explainthatstuff.com/digitalpens.html

A review of the ‘Future Vision’ and ‘1960s EMR’ video: We have come a long way!

Future Vision & 1960s EMR: Would the idea be feasible in the future?

‘Future Vision’ Video
Microsoft Office 365, (2011)

After reviewing the video ‘Future Vision,’ a short video about what we can expect in the near future that was released in 2007, I do not believe that the question, “is this feasible?” applies any longer. It is the year 2019 and that future “vision” is practically already here. Regardless whether this video is a marketing strategy for Microsoft, it is not too far-fetched considering what we already have in place in our current world of eHealth. From being able to make appointments online, keeping track of schedules using a phone, to fitness tracking using a watch (ex: Apple watch), most of what we have seen in the ‘Future Vision’ video is already in place. It may not be to the extent where we can tap on our bedside table to track our medication usage, but we are more than one step closer to that reality. In 2013, an article by Wickramasinghe and Kirn (2013) on the Business & Information Systems Engineering Journal discusses eHealth and the future of health care information systems. Wickramansinghe and Kirn (2013) mentions that there is evidence that numerous vendors in the highly fragmented market for health care software offer their applications in app stores and on Android markets, which could have direct bearing on the architecture of present information systems used in medical practices and hospitals. Jump seven years ahead to our current now, this may even be considered old news. Applications or apps is just another word in everyone’s vernacular, and the variety of applications that is readily available is endless.

The near, if not actual reality of the ‘Future Vision’ video by Microsoft can be further proven by comparison of the 1960s EMR video.

1960s EMR Video
ACMI2008, 2008

In the 1960s EMR video, the thought of an input-output terminal to be utilized with the goal of decreasing the usage of paper may have seemed far-fetched in that era, probably much like the ‘Future Vision’ video when it was released. However, since the idea came about, we have come a long way,that we can say this video is both outdated in terms of time and innovation.

eHealth in Healthcare: Personal Experience and Point of View

In my 10 year experience working in long-term care, I have had the opportunity to experience change in informatics or eHealth, and become extensively involved with the use of its nursing technology aspect. This experience has led me to become familiar with some of the pros and cons of the use of information systems within the field. The specific system we use is PointClickCare (PCC), as well as the digital-pen, better referred to as the “digi-pen” used in the transcription process of physician’s orders. PCC is a cloud-based electronic health record (EHR) system (PointClickCare, 2019) which includes care delivery management, financial management, and quality and compliance management (Software Advice, 2019) systems, which our facility currently utilizes. Still, PCC offers a variety of options to incorporate with the day-to-day functioning of long-term care management, at a cost of course. In terms of nursing informatics, we utilize PCC for all clinical management such as reporting client health records, to tracking indicators for quality improvement initiatives. Being responsible for implementing the use of the Quality Indicator Assurance (QIA) tab within PCC to track our quality improvement initiatives, the user-friendliness and usefulness of the system is evident but with further use, gaps and ideas for improvement also becomes palpable. Nevertheless, PCC has not only significantly reduced the use of paper and offered many resources, it has definitely improved communication between the multidisciplinary team and other stakeholders, as well as clients and families.

References:

ACMI2008. (2008, Jan. 7). 1961 electronic medical records. Retrieved from https://www.youtube.com/watch?v=t-aiKlIc6uk

Microsoft Office 365. (2011, Oct. 24). Health future vision. Retrieved from https://www.youtube.com/watch?v=C4LbAUa4ZwY

PointClickCare. (2019). About Us. Retrieved from https://pointclickcare.com/about-pointclickcare-software/about-us/

Software Advice. (2019). PointClickCare – long-term care software. Retrieved from https://www.softwareadvice.com/long-term-care/pointclickcare-profile/

Wickramasinghe, N., & Kirn, S. (2013). E-health and the future of healthcare information systems. Business & Information Systems Engineering, 5(1), 1-2. Retrieved from https://link.springer.com/article/10.1007/s12599-012-0245-1

“Informatics” What is it really?

Nursing Informatics

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Initial thoughts on “informatics”…

In all honesty, when initially coming across the word “informatics” in the current course called Nursing Informatics, I simply associated this to the use of information in some way or another, with of course the focus being related to nursing. Specifically, the notion of informatics in nursing meant the use of technology to record, share, and analyze data in conjunction with providing care to patients. In 2019, the use of technology in healthcare has become more significant. It is even surprising to learn that some healthcare facilities still use paper documentation to maintain patient records. So, what exactly is nursing informatics?


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What is Nursing Informatics?

After further research, informatics is much more than the use of information technology. Informatics is the study of the structure, behaviour, and interactions of natural and engineered computational systems (The University of Edinburgh, n.d.). Nursing informatics then, as defined by Staggers and Thompson (2002), is the use of technology such as computers to collect, store, process, display, retrieve, and communicate timely data and information in and across health care facilities that administer nursing services and resources, manage the delivery of patient and nursing care, link research resources and findings to nursing practice, and apply educational resources to nursing education (p.256). In simpler terms, nursing informatics is the science of taking information and technology and understanding how it integrates to support the practice of nursing in all its aspects (Stagger & Thompson, 2002). According to the Canadian Nurses Association (2019), the goal of nursing informatics is to improve the health of people and communities while reducing costs. Of course, there is no doubt that a handful of benefits comes with informatics in nursing, but with anything else, there is anticipated disadvantages that should also be considered which may be discussed in a later blog.

Thoughts on Nursing Informatics

In terms of the discipline of Nursing Informatics, this personally is also new to me. Although there is much more to learn about this discipline, the significance of its role in our current healthcare as well as in future is undeniable. As mentioned before, our healthcare system has become technologically advanced and it will only grow in complexity, alongside patient health and treatment, and other essential healthcare services. From personal experience with using technology in healthcare, the benefit of nursing informatics varies, but there remain gaps that need to be addressed to make use of the information effectively. Therefore, to put focus on the study of nursing informatics is vital in ensuring its effectiveness.

The following video briefly describes the profession of nursing informatics:

References:

Canadian Nurses Association. (2019). Nursing informatics. Retrieved from https://www.cna-aiic.ca/en/nursing-practice/the-practice-of-nursing/nursing-informatics

Staggers, N., & Thompson, C.B. (2002). The evolution of definitions for nursing informatics: A critical analysis and revised definition. Journal of the American Medical Informatics Association, 9(3), 255-261. Doi: 10.1197/jamia.M0946. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC344585/

The University if Edinburgh. (n.d.). What is informatics? Retrieved from https://www.ed.ac.uk/files/atoms/files/what20is20informatics.pdf