Module VI - Reflection

The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.--Alvin Toffler

• What I like about online coursework:
1. Like the independence of doing my work when I canfit it in and according to my life/ work schedule.
2. Innovative IT that gives me ideas for what I do (personally and professionally). Loved Dr. Hanberg's summer class with his self-recordings and video. It helped personalize such a non-personal and technological education format.

• What I disliked about online coursework:
1. The class doesn't tend to develop support systems with each other so that "built-in tutors" are not available as they could be in classroom situations with a desk partner
2. Online courses can be an easy "offline" course for so many people because there is an innate need for human interaction and feedback in learning. I needed grading back in a more timely fashion so that I would know what style and expectations for the next assignment might be based on the feedback.
3. Difficult to self-motivate without deadlines. This class went well in that aspect though I found myself scrambling to finish this module...TOO BUSY!

• What topic did you learn the most about and what was your favorite topic?
I really enjoyed ALL of the content, though the blogging, the initial assignment, and the EMR information assignments probably had the most impact on me. The blog journaled beginning to end and shows me exactly what we were learning with the application to practice and health care. Module I helped me identify who I am and why I do what I do. The EMR assignment and readings were helpful to my practice as we are currently going paperless (Dec 15-- go LIVE!

• If you were the instructor, this being the first course for all DNP/ MSN students, what would you do the same or different?
I think that this course might be particularly difficult as a FIRST course for the cohort in that many of us might not have been going to school recently and don't have good study habits yet. I would have liked to have Dr. Hanberg's introduction of each module voiced/video like he did for his summer class. That was incredibly effective and would have been a great assignment for each class member to do. Also was looking forward to contributing to a website like Wiki to see how that really works. Might be a good assignment to include as a last assignment instead of the Module VI Worksheet which seemed redundant to a previous assignment. Liked the format for the modules in Objective/Read or watch/ ACT because it was layed out precisely. The format told me exactly what I needed to do without the verbal interaction usually necessary for Q&A in the classroom.

Thank you for a great class!
Melissa

Module V - Policy WITH Ethics

Policy and Ethics
What is AHRQ??? AHRQ is the Agency for Healthcare Research and Quality, a research arm of the US Department of Health and Human Services.
What, if any relationship do you see between the information available on this webpage and regulatory, accreditation, and reimbursement issues and healthcare information system use and design?
The AHRQ site is quite visually “busy” (there are so many subsites and linkouts that one can literally get lost on the Hansel and Gretel trail and forget what they were looking for in the first place) but is a virtual clearing-house of information that drives regulatory clinical practice based on current research best outcomes. The Agency for Healthcare Research and Quality's (AHRQ) mission is to “improve the quality, safety, efficiency, and effectiveness of health care for all Americans” (ahrq.gov, 2009) while simultaneously encouraging research by offering grants and funding. Based on the mission and the focus of this government funded agency, it is fairly obvious that research compilation is used to set national standards of care and is the primary link between what is reimbursable to Medicare and Medicaid by appropriate standards of care. For anyone who has been involved in billing services for any healthcare division, reimbursement issues are directly related to documentation (and we are talking about minutely detailed pieces of information) to care standards. This is a paradigm shift for those of us who have documented by exception for the past 15 years.
The A-Z menu offers a tab that links directly to Health IT which specifically highlights health informatics applications and the usability of electronic health records for the spectrum of health care -metropolitan to rural. There are certainly ethical considerations related to reimbursement, electronic charting systems, access to healthcare records and registries, and health information exchange legislation. One of the most debated issues with reimbursement right now is walking the line between reimbursements for services and maintaining integrity in the documentation circus. Electronic record systems (EMRs) can be a clinician’s best time-saving tool in practice by providing instant and real-time access to records and diagnostics, but force providers to take shortcuts in “templating” their documentation that may not accurately reflect their exam. Electronic prescribing has not entirely caught on with all physicians, but tracking patient prescription trends has become easier than ever if the patient “shops” within EMR access (the state of Utah has an electronic warehouse for narcotic tracking). While this is clearly a safety mechanism, electronic security to anything can be bypassed…it simply takes a provider’s password innocently given to an assistant. HIPPA, ever hovering, is not foolproof. Ethics must be based on a value system. Unfortunately, many folks naively, errantly, or blatantly believe that specifics don’t apply to them. And why should they? We have fostered a culture of rule-breakers…even encouraged that culture in some instances while we allow people to be irresponsible for themselves and even for their own health.
These examples are obviously not exhaustive, but are a sampling of some of the current issues that I see in our health care system in general and that are spilling over into the convenience of electronic health care systems. Believe, I am the first to support a global EMR based on collaboration and convenience, but we must always consider our personal values and how we will apply technology into each of our own practices. The government can legislate, guideline, research, and provide benchmarking data for us, but making the system safe becomes an issue of integrity. I am not exactly sure where all the holes are, but the vision looks fantastic on the front end.

Module IV - The Data

How does nursing data quality relate to decision support? Anderson & Wilson (2008) looked at evidence-adaptive CDSSs at the point of care (eg.; ED triage). Nurses learn by the age-old "hands-on" approach and base their decisions on objective data (which is subject to bias) or based on what someone else verbalized (heresay). This is the second stop point for practice errors and the need for decision support use (bias being the first). We've come to live with a certain amount of error and have built it into our statistical data as a p-score.

Anderson & Wilson discuss the use of CPGs (Collaborative Practice Guidelines) as a useful tool to bridge evidence and practice. If nurses were able to quickly find specific CPGs, accuracy in treatment and improved outcomes would most likely improve. Correct/quality nursing data (minimize cognitive errors)and education on use of decision support systems (CPG or other CIS tools) were shown to "significantly increase...diagnoses and management care." Why? There's no need to carry around drug books, diagnostic helps, flip charts. We have handheld PDAs that offer evidence-based information at the touch of a single finger now...

Module IV -

How did the readings influence your perception of your own clinical decision-making? How do we reconcile the value of nursing experience with known heuristics and biases used in human decision making?

Kahneman (1974) and the concept of anchoring is, as it were, a starting point for our subjective analysis...of ourselves. The reading discussed cognitive biases based on probability, historical repetition, and our own judgmental heuristics. Particularly in the ED where repetition sometimes taints our perception of probability, I have had to consistently re-evaluate my own biases and beliefs and realign them on an individual basis. Why? We are human. We base our opinions and perceptions on what we have seen or learned previously. We are susceptible to systematic errors in our thinking. We never have ALL the data to make an accurate judgment call 100% of the time. Kahneman's lecture and PPT showed a number of visuals that seemed to be one thing, but were quite another. As humans, we rely on our imperfect senses, primarily sight.
How do we reconcile the value of nursing experience based on this knowledge? As in personal life, we must be willing to look past our own noses. Yes, experience gives us foundational information by which we make decisions, but comfort lulls us into complacency and contributes to further cognitive errors. Reconciliation is based only on our willingness to allow our other senses to collect information, encourage communication, continually learn, and be open to introspective analysis about who we are and why we do what we do.

Module II - 3

Going backwards (as I sometimes do...principles of deduction), I think that doing a general "Google" search is sometimes easiest if I am looking for a broad definition of some particular piece of information, but I find myself wading through a number of links that may not be particularly related to what I'm looking for. Google doesn't allow for specific details as readily as the medical databases that we used for this assignment. There are some quick benefits to a Google search however. One can find common authors or frequent links to certain sites that might help in whittling down a topic idea. It's a good preliminary search.

A guideline index (NCG, even Medline) is great for identifying category searching and then drilling down to a specific topic, helpful if one has some idea about specifics but needs to get a little more about the issue and would like several medical links related to the topic.

For an actual literature search, the electoric index databases seem to fit the needs of the DNP student the best and allow for specific definitions, MeSH use and limits. I prefer PubMed because of this, but there is definitely a learning curve that takes some time to get past as opposed to a guideline index search or web-search.

Module II - 2

I have been using Endnote X for the past 3 years and have absolutely loved the feature of searching from within Endnote itself and then being able to create my library from my search results without having to import. Beyond the search strategies that I used, Endnote allows sorting by author name, publication date, article title or URL. It is much the same as the sort feature in Excel and makes it easy to find citations immediately. I used the abstract as a sort feature as well when I was looking for a particular article that I couldn't recall. The abstract helped me remember what the article was about and I could read it right there in my citation list without having to open the article to view. In addition, it's easy to import or export to other files, copy citations into other libraries or documents from the view pane below the selected citation, and insert citiations directly into a document that allows for immediate reference listings at the end of the document. Love ENDNOTE...although it took me a few tries and many "help" sessions to figure out how to do what the manual said I could do.

Module II - 1

I have 2 children with ADHD that I have been a "mother advocate" for as well as a patient advocate. I chose to search ADHD and risk for substance use because of social discussion related to substance use disorders and increased/decreased risk debate. I chose to use PubMed to search because of the access to multiple discipline journal archives.On my first generic search, there were several thousand articles. I was able to specify my search with MeSH headings (great tutorial video!)using AND, and OR to identify specifics and further created limits (research, human,recent 5 yrs), both of which took less than 10 minutes to do. Barriers for daily practice would be lack of familiarity with the database, knowledge on how to narrow searches and use the search tabs efficiently, and the overwhelming number of articles in general search terms if the user did not have a specific topic in mind.

I thought I was fairly proficient at information retrieval, but the tips presented in this lesson were very helpful. Thank you!

Module III - It's not about who I am, it's about "What" I'm like...

I did the multiple intelligence test today and was elated to see that my strengths were musical and interpersonal categories (I think I knew this about me). Actually, my scores ranged tightly between 33 and 38 across all the categories (Logical-Mathematical, Musical, Bodily-Kinesthetic, Spatial-Visual, Interpersonal, Intrapersonal) with the exception of Linguistics where I scored a 30.

As with all self-scored assessments, I believe that the outcomes are partially based on how I would LIKE to view myself, though I think that most people would very much agree with my scoring in relation to what I think I gravitate towards. Overall, I agree with the strengths in the test based on how I view my own learning preferences. As a side note, I notice that the assessment identifies the outcomes as "Intelligence Strengths" which might give the user the impression that their Intelligence, or Intelligence Quotient might be somehow related...nice!

Okay, it's not really related to my IQ. Based on this learning style assessment, teaching techniques and technologies that incorporate action, sound, touch, and individual attention to help solidify my learning. It's all about the kinesthetic learning for me. Love a little background music! Here's my interpretation of this assignment: Find out how you tick first so that you can help others tock...\

Module I, The Beginning of Discovery

My name is Melissa Hinton, MSN to DNP, FNP. I have been a nurse for 20 years (this year) and have been able to savor a sampling of many areas of nursing during that time. My first 5-10 years of nursing included experience in Med/Surg, Oncology, L&D, Peds, Psych, Ortho, Home Health, and I was an IV specialist for PICC placement/IV education (often with 2-3 jobs at a time). I have worked my last 15 years primarily in Intensive/Critical Care and Emergency/Trauma with several years of LifeFlight as an Invasive Nurse. In addition, I have also been a charge nurse, Clinical Educator, AHA instructor, adjunct faculty at Dixie State College and am currently the Emergency Department Manager at DRMC in St. George, Utah.

As graduate level nurses, we need to be familiar with, if not proficient in, information management as our current health care systems are turning to technology and computer interfacing to better manage information and data. As our population ages and is living for longer periods of time, patients are accumulating massive amounts of health information with multiple providers and specialists. We are constantly seeking out these pieces of information that have traditionally been housed somewhere in a provider's office and have not been accessible, piecing together a medical history that we know has been documented "somewhere." In addition, data-driven care based on best outcomes has become an integral part of our practice as nurses and helps us identify elements that must be addressed in practice. If we are to use "Best Practice" standards for the care that we deliver, a working knowledge of information management would serve each of us best - as the very role of the DNP involves the collaborative effort, research, and education that is being demanded by the patients we serve.

Information Technology development and implementation is fast becoming a necessity (and reality) in Emergency Departments across the nation. Though nurses and staff initially repel the very thought of process change, especially in EDs where time constraints and employee longevity/older workforce create natural resistance to change, there is much to be said for it's use. It is understood that there is a learning curve to every new program. Past the first several weeks of implementation, there is instant access to a patient's history, making assessment and treatment more timely and efficient. Our department doesn't use computer charting yet, but all the ED records are scanned and available through our "Help2" program, making all hospital information exchange easier and ultimately, saving time. In addition, most of our analytical reports are created off of the Help2 system and are used in tandem with our PTS (Patient Tracking System). While the use of two systems is not as efficient as a central repository, the programs are acceptable. Intermountain has spent millions of dollars trying to improve and streamline these programs for better interface and efficiency. I've also been able to work with the VA system. Though many of their programs are not as user friendly, there is a huge benefit in their complete conversion to information systems which creates a continuity of care that many systems are unable to provide. Of both systems, I must say that there is a huge deficit in that the information is not available to providers outside of the system by computer, leaving manual transmission of information and data the primary means of communication.

Dixie Regional Medical Center, part of Intermountain Healthcare (IH), has both computer and paper charting, both of which have pros and cons and both of which create difficulties (illegible writing, medical errors in interpretation, incorrect orders being manually entered into computer systems, repetition of procedures/meds/etc. from lack of documentation, coding left to interpretation, billing errors, and so on . . .). Our ED CC, admit times, census, etc. are on the PTS, but all patient care documentation is on a traditional paper form. As for coding, our ED coders and billers use outpatient ICD-9 coding which is quickly phasing over to ICD-10. Terminology includes NM(M)DS, NANDA and NIC. As an acute outpatient treatment area, our reimbursement corresponds to RVUs and DRGs which are monitored by Revenue Integrity/Accounting and ultimately drives our staffing FTEs.

As a floor nurse, I was wholly unaware what coding involved and how my charting related to both reimbursement and data that I didn't really care much about. I'm seeing a relationship now-a-days. Structured and coded clinical data promotes quality patient care because it can help give definition to procedures, skills and what the nurse writes in the chart if they become familiar with what is being expected. I firmly believe that we do a dis-service to our nurses by not teaching them basic coding to help them understand documentation standards, who is auditing the charts, what they are looking for and why. What they DON'T write ultimately means a dollar loss. Most nurses don't care about this until they realize that the benefit of documentation is that they are employed . . . their care quantifies their job! In addition, accurate documentation reflects more accurate data. Numbers are a reflection of the care we give, but if it is not documented, those numbers skew the data from the very beginning. There are also legal ramifications to data elements, collection and outcomes that nurses often dismiss as naught. If, however, data shows a certain negative trend that providers choose not to address, either because of complacency or ignorance to the meaning of the data, there is not much legal council can do for them. Naivety does not give us recourse. The data is the evidence. Likewise, positive outcomes and trends indicate "Evidence-Based" practice. Hence, best practice.

In all, I feel myself fortunate to be able to glimpse the [oftimes] overwhelming current of technology and information systems that is blowing through the front door of health care. I only recently began my role as the ED Department Manager at DRMC and it has afforded me trials, experience, and an awareness of the inner workings of politics that I have never been exposed to. In fact, I have actually been jealous of dear Heide because of her previous experience in management. I felt that I was missing out on some piece of elusive infromation that I really needed. And guess what?!? I did! I am not planning on staying in this role, but I can say that I have learned, and continue to learn another side of nursing that I had turned a deaf ear to because, as they say, "It's somebody else's job."

Bottom line . . . we can't look the other way anymore. It's coming like a tidal wave!

Introducing...Miss Hinton

Until today, I've been busy journaling my adventurous life on paper, in a hardbound book, scribed with ink and cluttered with bits of remembrances of yesteryear. Can my life be summed up in paragraphs, squished between 12 point Trebuchet Font on an inanimate object that does not endear like a comfortable and favorite old book on a shelf, just waiting to be picked up? Hardly. In fact, one can't even see the slant of my writing or the flourish of my letters...telling, if one looks closely.Without all these tiny glimpses into my life, you might wonder..."who, really, is Miss Hinton?"

Today, I begin a personal journey that I will share with those who have come in and out of my life. Here, on this non-paper page, an archive of experience will be added, click by click, as my continuing journey evolves. Welcome to Miss Hinton's Blog. Stay, share, laugh, cry, and spend a moment with me while we visit from miles apart and compare experience for greater understanding of life, love, and lesson at Melissa's Hinton Haven (or havoc, depending on the moment and circumstance).

Soon,
Miss H.