Nurse KTech's

Monday, September 15, 2014

Clinical Vignette - Grief

"If I had known what the grief process was like, I would never have married, I would have prayed every day of my married life that I would be the first to die," reflects Margaret, 9 years after the death of her husband.

She recalls her initial thought, denying and acknowledging reality simultaneously, when James was diagnosed with multiple myeloma in October 1987: "It's a mistake... but I know it isn't."

For 2.5 years, Margaret and James diligently followed his regimen of treatment while taking time for work and play, making the most of their life together in the moment. "We were not melodramatic people. We told ourselves, 'This is what's happening; we'll deal with it.' "

For Margaret, it was a shock to realize that some friends who had been readily present for social gatherings were no longer available. She waited alone in the wee hours of the night when James had emergency surgery. Again, she was shocked when she told a priest who came into the room, "My husband is having surgery," and his reply was, "Oh, sorry to bother you; I'm looking for the paper."

Margaret began to undergo a shift in her thinking: "You begin to evaluate your perceptions of others. I asked myself, 'Who is there for me?' Friends, are they really? It can be painful to find out they really aren't. It frees you later, though. You can let them go."

When James died, Margaret remained "level-headed and composed" until one day shortly after the funeral when she suddenly became aware of her exhaustion. While shopping, she found herself in protest of the emotional pain and wanting to shout, "Doesn't anybody know that I have just lost my husband?"

Surprised with how overwhelmed she felt, one of her hardest moments was putting her sister on the plane and going home to "an empty house." It was at this time that began to feel the initial shock of her loss. Her body felt like it was "wired with electricity." She felt as though she was "just going through the motions," doing routine chores like grocery shopping and putting gas in the car, all the while feeling numb.

Crying spells lasted for 6 months. She became "tired of mourning" and wouldd ask herself, "When is this going to be relieved?" She also felt anger. "I was upset with James, wonderingwhy he didn't go for his complete physical. Maybe James' death may not have happened so soon."

After a few months and well into the grief process, Margaret knew she needed to "do something constructive." She did. She attended support groups, traveled, and became involved with church activities.

Her faith in God was a plus. Exercising this faith, she trusted that eventually her emotions would catch up with the intellectual understanding of all that had transpired in James' dying. She developed an "inner knowing that God is all-seeing, all-knowing." This belief gave her spiritual strength and empowered her as she grieved.

Nearly a decade after James' death, Margaret views the grief process as a profound and poignant, "search for meaning in life. If he had not gone, I would not have come to where I am in life. I am content, confident, and happy with how authentic life is."

Even so, a sense of Jamess presence remains with her as she pictures the way he was before he became ill.

She states, "This is good for me."

An Informatics Nurse Speaks

My mother introduces me these days as "my daughter who used to be a nurse." But that's not true - I am and always will be a nurse. I'm just practicing in a different area. Advances in technology have improved our ability to care for patients. What nurses (or others, like my mother) don't often think is that these technological advances also include computer systems. All nurses need to have skills to be able to use a PC, a monitor, or other equipment, just like they need the skills to do a physical assessment. You cannot keep up with the information or reports needed in today's world unless you have some system (besides paper) to help you.

I got into the field of nursing informatics several years ago when I was manager of a hospital ambulatory services department. Being responsible for the business aspects of the department as well as the clinical, I was on the project team for implementation of the new computer systems. I found that my innate curiosity and need to always ask "Why" proved very useful in this endeavor. I also discovered that computers are only a tool; it takes humans to analyze information needs and to plan how to best meet them – a discovery that led me to the field of nursing informatics.

I have never regretted the move! Just as in clinical nursing, you never know what to expect. Although you anticipate what you need to do each day, anything can happen to interrupt those plans and change your priorities. The next thing you know, it’s 5:30 PM and you haven’t been able to do one thing on your to-do list.

I start out each day by turning on my PC. Then I open my email system. I read my new messages and respond when necessary. This usually takes an hour or two. Sometimes an email I receive will require a telephone contact for follow-up, or users may contact me by telephone. Much of the time in my office [is] spent either answering a question, providing clarification, explaining how a function works, or troubleshooting. When I am troubleshooting, I often access the software system with which the caller is having difficulty. This allows me to try to do what the user has done or attempted to do, so I can access whether the caller is using the right function or routine, and using it correctly. If the function is being used appropriately, I try to recreate what the user has done to see if I can elicit the same response or responses that she or he did. This method gives me a better picture of the difficulty and allows me either to solve the problem or to pinpoint a software problem. One day, I logged 6 hours and 45 minutes of telephone time; the majority of which was nonstop.

Sometimes I need to contact one of the vendors to get a problem resolved. Talking with vendors may also include discussing product enhancements, a new product or feature that they are developing and releasing to clients, or an upcoming class or meeting. Software testing is another function of the job. New features or updates may be released that need to be tested. This process involves creating different scenarios in which you enter data and print reports to make sure the software does what it’s supposed to do. This can take hours, days, or even weeks to complete.

Reports are the end result of information processing. When you buy software, you sometimes get standard reports (those that the majority of all users need) but you usually have to write custom reports. Users give me requests for reports that they would like to have. To create them I may be able to modify an existing report, or I may need to create a new one. This involves determining which file or files the information resides in, how the output of the report should look, what fields the report needs to include, what to name it so that the users will know which report to run, and perhaps which menu to put it on. Writing reports can take anywhere from a few minutes to several days, depending on the complexity, as well as the amount of time you can devote (Remember all hose interruptions!). Testing a report is also part of modifying or creating one. As the creator, I need to test it to be certain that it produces what the user wants. Then I need to have the user test it to see if the data and design meet his or her needs.

Another role of the informatics nurse is one of teacher. I develop lesson plans and teaching materials to train the staff on the use of computer systems. Training is done formally or informally, depending on the situation, and can take a few minutes to several days. In addition, I attend meetings, both in my department and with other departments. Many times, I am the leader of the meeting, which also involves putting together the agenda and handouts, and doing minutes. There are also user group and informatics organizations to which I belong.

A key element in this role is communication. When you are working in nursing informatics, you are providing help and support to end users; staff, managers, directors, directors, and vice presidents, as well as the programmers/developers (Very often, the programmer or developer is at your vendor’s location and not in-house). Nursing informatics is extremely dynamic, and I love the challenge. It offers me the opportunity to work with many different people, do many different things, and be creative. This role is never boring!

Judith Hornback, RN, BSN, MHSA

Informatics Nurse Specialist

Senior Consultant, RHI, Inc.

Highland, Indiana

Thursday, September 11, 2014

UPM.MSHI.MI227: Road Blocks

You have been selected to be the project manager for a DOH project with the task of implementing a national EHR that all government hospitals will implement. Select at least three barriers to EHR implementation from the article that you believe to be the most important ones that might adversely affect your implementation. Explain and provide supporting cases/articles/information.

Translation: You are to run am EHR system across the whole country. Explain why it will fail. Go.

The research article by Boonstra and Broekhuis, which discusses the barriers to acceptance of electronic medical record systems by physicians, proposed a search and organization of problems and obstacles perceived by most medical practitioners. Below is an outline of their resulting taxonomy of issues:

A. FINANCIAL

1. High startup costs

2. High ongoing costs

3. Uncertainty over ROI

4. Lack of financial resources

B. TECHNICAL

1. Physicians and/or staff lacking computer skills

2. Lack of technical training and support

3. Complexity of the system

4. Limitations of the system

5. Lack of customizability

6. Lack of reliability

7. Interconnectivity/Standardization

8. Lack of computers/hardware

C. TIME

1. Time required to select, purchase, and implement the system

2. Time to learn the system

3. Time required to enter data

4. More time per patient

5. Time to convert patient records

D. PSYCHOLOGICAL

1. Lack of belief in EMRs

2. Need for control

E. SOCIAL

1. Uncertainty about the vendor

2. Lack of support from external parties

3. Interference with doctor-patient relationship

4. Lack of support from other colleagues

5. Lack of support from the management level

F. LEGAL

1. Privacy or security concerns

G. ORGANIZATIONAL

1. Organizational size

2. Organizational type

H. CHANGE PROCESS

1. Lack of support from the organizational culture

2. Lack of incentives

3. Lack of participation

4. Lack of leadership

Given that the project would entail managing the implementation of an electronic health record system in public and government-affiliated health institutions throughout the country, I would perceive a series of major of barriers that could appear to hinder the operation.

TECHNICAL

A quick personal study of curriculums[1] designed by the Commission on Higher Education for allied health and medical professionals revealed that there is very little to no inclusion of basic concepts in information technology. Though there have been some efforts in recent years in terms of the BSN program’s Nursing Informatics subject, most of these subjects do not appear to be adequate to prepare healthcare professionals in handling complex information systems, including electronic health records.

Personal experience [2]has taught me that the provision of opportunities for users to fine-tune the system to better suit their individual needs is a significantly essential factor in the success of the implementation. In one of my internship programs, I have encountered an instance where the mere problem regarding user interface was enough for more than half of a department’s staff to lose faith in an information system.

What I would consider as a limitation of the system, power supply in the country is rather unstable, even in recent days[3]. Brownouts still occur, prompting extensive formulation of backup and failsafe systems built around the electronic health record systems to be implemented, including the option of resorting back to full manual and paper records with it.

CHANGE PROCESS

Partly due to the above technical barrier, especially with regard to computer skills, there would be a resulting degree of hesitation and resistance from the information system’s target users – the doctors and other healthcare professionals. Pre-implementation measures [4]have been suggested in order to avoid such issues from occurring among end users, regardless of age, gender, or any other demographic information.

Support from management also provides a good level of advantage in favor of the implementation. Personal experience again has taught me that it would take a great deal of convincing from higher-ups to have systems put into place. Such was the case with a certain hospital I visited as a prerequisite to MI207. It was revealed that most staff members of the emergency department already have a penchant for technology, especially mobile medical applications. All it needed was approval from top management to release policies regarding the use of such apps for it to potentially become a legitimate part of everyday practice in the institution.

Change management [5]issues in terms of a lack of leadership would also be very likely during implementation of the system as responsible parties for such a relatively uncommon project is still to be determined.

The lack of incentive programs [6]in the country, whether on an organizational or even national level, also attributes to the problem. Without any highly perceivable sense of benefit in sight, there is very little motivation for most healthcare institutions to actually adopt information technologies into their day-to-day practices in providing patient care.

ORGANIZATIONAL

With strong relation to the previous major barrier, taking into consideration the type organization running is crucial in the success of the electronic health record system to be implemented. Not only does its culture significant, but also the very structure of the organization itself is essential.

Size of the organization [7]tends to matter as well, especially in larger healthcare institutions, where it was observed that healthcare staff members employed tend to make use of available functions and features present in implemented EHR systems, not like those employed in smaller facilities. There is a considerable upper management influence involved.

It has also been noted that small health institutions situated in rural settings face a relatively different set of obstacles when implementing technology, emphasizing the need to consider details such as upfront buy-in, phased approach toward implementation, among others[8].

CONCLUSION

With so many other issues that could be brought on to the table with every project implementation, there will always be the tendency that the above three will be mainstays in discussions. Problems regarding resources such as time and money would have, at some point, been much more manageable if not outright solvable if issues such as mastery of the system, facilitating proper implementation, and taking note of the organization to be implemented on were addressed.