Archive for the ‘health information technology (HIT)’ Category


Telehealth as ‘Disruptive Innovation’ in Nursing

April 18, 2014
A patient uses telehealth equipment to communicate with his nurse. Photo courtesy of Janet Grady.

A patient uses telehealth equipment to communicate with his nurse. Photo courtesy of Janet Grady.

“Telehealth: A Case Study in Disruptive Innovation” is a CE article in AJN‘s April issue. The author, Janet Grady, vice president of academic affairs and chair of the Nursing and Health Sciences Division at the University of Pittsburgh in Johnstown, Pennsylvania, describes the concept of disruptive innovations in nursing and delves into the evolving field of telehealth as a current example.

The article considers the following:

  • uses and potential uses of telehealth in chronic and acute care, home care, and rural medicine, and the evidence supporting its use.
  • obstacles to wider use and acceptance of telehealth, which include cultural resistance within nursing, licensure issues across states, reimbursement challenges, and the need to adapt nursing curriculum to these new ways of delivering care.
  • forces that drive or obstruct disruptive innovations like telehealth.

Here’s the article overview:

Technologic advances in health care have often outpaced our ability to integrate the technology efficiently, establish best practices for its use, and develop policies to regulate and evaluate its effectiveness. However, these may be insufficient reasons to put the brakes on innovation—particularly those “disruptive innovations” that challenge the status quo and have the potential to produce better outcomes in a number of important areas. This article discusses the concept of disruptive innovation and highlights data supporting its necessity within health care in general and nursing in particular. Focusing on telehealth as a case study in disruptive innovation, the author provides examples of its application and reviews literature that examines its effectiveness in both nursing practice and education.

And here’s a snapshot of some uses already being made of telehealth, an umbrella term that encompasses a broad range of activities: Read the rest of this entry ?


Health Technology Hazards: ECRI’s Top 10 for 2014

January 15, 2014
hazard/jasleen kaur, via Flickr

hazard/jasleen kaur, via Flickr

It’s that time of year again—the ECRI Institute has released its Top 10 Health Technology Hazards for 2014 report, and with it come new (and old) hazards to keep in mind.

Alarm hazards still posed the greatest risk, topping the list at number one for the third year running. Other repeat hazards included medication administration errors while using smart pumps (in at number two), inadequate reprocessing of endoscopic devices and surgical instruments (number six), and, at number eight, risks to pediatric patients associated with technologies that may have been designed for use in adults (such as radiology, oxygen concentrators, computerized provider order–entry systems, and electronic medical records). For an overview on these, see our posts from 2012 and 2013.

And here’s a snapshot of new hazards that made the cut, along with some of the report’s suggestions on how to prevent them.

Radiation exposures in pediatric patients (#3)

The risk: Although computed tomography (CT) scans are valuable diagnostic tools, they are not without risk, and children, who are more sensitive to the effects of radiation than adults, are more susceptible to its potential negative effects. According to the report, new empirical studies suggest that “diagnostic imaging at a young age can increase a person’s risk of cancer later in life.”

Some suggestions: The report suggests that health care providers take the following actions: use safer diagnostic options, when possible, such as X-rays, MRIs, or ultrasounds; avoid repeat scanning; and use a dose that is “as low as reasonably achievable.”

Occupational radiation hazards in hybrid ORs (#5)

The risk: Hybrid ORs, which bring advanced imaging capabilities into the surgical environment, are a growing trend. However, with these angiography systems comes exposure to radiation—a risk to both patients and OR staff.

Some suggestions: According to the report, a radiation protection program is a must. The program should include training for staff, who may not have experience with imaging technology; the use of shielding with lead aprons or other lead barriers; and monitoring of radiation levels. Read the rest of this entry ?


The Not Good Nurse – Some Dark Holiday Reading

January 2, 2014

By Shawn Kennedy, AJN editor-in-chief

GoodNurseHaving some down time over the holidays can be a good chance to catch up on some reading. Because so much of my work entails reading manuscripts submitted to AJN about nursing practice and research, I look for my leisure reading to be something not connected to nursing.

Well, the book I recently read—a quick, engaging read—was about nursing, sort of. The book was Charles Graeber’s The Good Nurse: A True Story of Medicine, Madness and Murder, the story of nurse-turned-serial-killer Charles Cullen. While I find the title to be a bit sensationalist, the book is not. There’s no real answer as to why Cullen did what he did—Cullen apparently had a miserable childhood, was often a target of bullies, had failed marriages and made many suicide attempts to gain sympathy or attention. Graeber doesn’t really seek to answer the why of what Cullen did but instead focuses on his behavior and relationships.

The chilling aspect of the story is how easy it was for Cullen to get away with his killing through the use of essential technology relied on by nurses for the care of hospital patients. The medication and computer systems that he manipulated to cover his tracks also eventually allowed an intrepid nurse colleague to help police prove their case—only a nurse knowledgeable about the day-to-day use of the systems could uncover the wayward patterns.

But the real issue that comes through is how hospitals, fearing litigation, would simply dismiss Cullen when other nurses voiced concerns about his practice, allowing him to find work elsewhere and become someone else’s problem. That’s something I think many nurses might relate to—I certainly can. I worked with a couple of nurses early in my career who, when we reported to the administration that there were consistent errors in the narcotic count or missing medications when they were working, were given a chance to resign or be fired. Neither was ever reported to the board of nursing. Read the rest of this entry ?


Tightly Scripted: One NP’s Experience with Retail Clinics

November 1, 2013

By Karen Roush, MS, RN, FNP-C, AJN clinical managing editor

Retail health clinics (walk-in clinics that are in a retail setting such as a drugstore or discount department store)KarenRoush have become an effective mode of providing increased access to care for many people and a growing source of employment for nurse practitioners (NPs). Their place in the health care arena may take on even more significance as the Affordable Care Act (ACA) increases access to care for previously uninsured people.

I worked as an NP in a retail clinic for about six months while working on my PhD. I left because of concerns I had about the model of practice. It didn’t have to do with the fact that I had to mop the floor at closing time or collect the fees and cash out the “drawer” every night. Nor because I spent eight hours alone in a small windowless room tucked away in the back of a drugstore. Those aspects were not great, but they weren’t deal breakers.

What was a deal breaker was the rigid programming of my practice. The computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer.

The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence. And as much as they insisted the programming was guided by evidence, it was clearly also guided by what would result in the highest level billing code.

From the moment I entered the chief complaint in the computer, it directed me on what to include in the history and what to do for the exam. The problem was that unless I filled out all the information, I couldn’t go on to the next screen. Say I have a feverish four-year-old with tonsillitis, screaming in her mother’s arms, and the computer insists I take her blood pressure. Why? Because there is strong evidence that strep throat is associated with pediatric cardiovascular disease? Nope. It’s because the more systems you include in your exam, the higher the billing code. As a result, I find myself struggling to take an unnecessary blood pressure, causing unnecessary distress for a sick toddler. But unless I put a value in the box asking for the blood pressure, I can’t proceed with the exam. Read the rest of this entry ?


Do EHRs Rob Nurses of Voice and Oversimplify Description of Patient Care?

September 23, 2013

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology. Editor’s note: this post has been slightly revised for clarity since its initial publication a day ago.

 Heroines of Nursing, mixed media collage by julianna paradisi, 2013. Text by Florence Nightingale

Heroines of Nursing, mixed media collage by julianna paradisi, 2013. Text by Florence Nightingale

Previously I’ve written that I have a new employer. Part of this transition is relearning how to use the electronic health record (EHR). Fortunately, this new employer uses the same program as my last. However, that version was EHR-lite compared to the one we use now.

For instance, the new system contains an abundance of “smart phrases” that are used to lessen time spent writing nursing notes. If you are unfamiliar with smart phrases, an uncomplicated explanation is that they are preconstructed phrases chosen from those commonly found in charting, such as “The patient arrived ambulatory for IV infusion.” Instead of typing in this phrase, nurses can click on it from a computer screen menu, and voilà! The entire phrase is electronically inserted into the notes.

Smart phrases, like charting by exception (in which a nurse clicks on boxes to document a patient’s assessment, IV status, and more) are intended to allow nurses to spend more time at the bedside providing patient care, rather than writing about it. In theory, this is a good idea. However, something about using smart phrases makes me balk. Reflecting on this feeling, I realized that:

a) I write more descriptively than the authors of smart phrases, and
b) I want to chart in my own words.

On further reflection, I finally realized why so many nurses react negatively to exception-based charting: Checking boxes doesn’t allow nurses to describe what we actually do in our own words. I hadn’t understood this until now. Evidently, for me the line of tolerance is drawn at smart phrases.

Not all nurses are compelled to write as I am, but most take a great deal of pride in their work. For some, charting in the nursing notes is the only recorded evidence of their special talent for making a nursing diagnosis, implementing interventions, and reporting the outcome in the natural arc of a story.

For instance, a nurse could have a patient who is also a violinist whose chemotherapy has left her with profound peripheral neuropathy in her fingertips. She is no longer able to play the violin, which she’s long considered her life’s purpose. She relates this information to her nurse. Both patient and nurse are aware that despite this loss, the patient will not survive. They discuss the situation, maybe reaching a philosophical or spiritual peak for the patient, or maybe finding that the patient no longer wishes to continue treatment. Or maybe the patient inquires about Death with Dignity, because for her, life without the violin is not worth living.

A nurse would not chart this as I have written it above, but would include enough information to back up a need for further assessment and consultations perhaps with palliative care, spiritual care, or social services. Perhaps an antidepressant medication would help.

A template reduces the note to a report of peripheral neuropathy, and does not capture the patient’s true story, nor for that matter, the role the nurse plays in it. Read the rest of this entry ?


Health information Technology, EHRs, Meaningful Use, and Nursing

August 15, 2012

By Maureen Shawn Kennedy, MA, RN, AJN editor-in-chief

If you’re like most nurses working in a health care organization, you’ve been involved in a migration to electronic health records, computerized physician order entry (CPOE), or bar code medication administration.

If you’re lucky, nursing input was considered during the planning stages of all this health information technology (HIT). We’ve heard from many nurses (and have had a few submissions from nurses about their experiences—see for example the Reflections essay “Paper Chart Nurse”) who have had “issues” with the systems or who wonder, why the big push?

In the August issue of AJN, which is available online and on the iPad (download the app here), Susan McBride and colleagues John Delaney and Mari Tietze debut their three-part series on HIT. The first article, “Health Information Technology and Nursing,” examines the federal policies behind efforts to expand the use of this technology, the importance of meaningful use, and the implications for nurses. Subsequent articles upcoming in the fall will take a closer look at the use of HIT to improve patient safety and quality of care, and the important role nurses are playing—and could play—in this system-wide initiative.

It’s crucial for nurses to understand HIT. As the authors note,

“If HIT systems are going to truly improve care, nurses need a voice in their planning and development to ensure patient safety and system usability. The success of this technology depends on nurses informing the industry—at all levels, from influencing federal policy to providing feedback to their department and facility leaders—about what works best for the patient and the clinician. If wisely implemented, HIT may eventually free up more time for nurses to spend at the bedside . . . ”

We’d love to hear your experiences: Were nurses consulted and included in planning the implementation of HIT at your facility? Was there a thoughtful plan to “roll out” adoption? Do you see computerized health records as a help or hindrance? What would you change? Let us know how it is in your practice area.

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AJN’s August Issue: A Metaphorical Prison, a Found Manuscript, a Nurse Carries the Torch, More

July 27, 2012

AJN’s August issue is now available on our Web site. Here’s a selection of what not to miss, including two continuing education (CE) articles, which you can access for free.

Nurses play a crucial role in inpatient programs for anorexia in adolescents, but how do the patients view them? Our Original Research article, “An Inpatient Program for Adolescents with Anorexia Experienced as a Metaphorical Prison,” describes the experience of adolescents in an Australian inpatient behavioral program and how both nurses’ and patients’ perception of the program as a metaphoric prison negatively affected the development of therapeutic relationships between them. This CE article is open access and can earn you 2.5 CE credits.

Health information technology (HIT) is a central aspect of current U.S. government efforts to reduce costs and improve the efficiency and safety of the health care system. But what does this really mean for nurses? Health Information Technology and Nursing,”  the first article in a series of three on HIT and nursing, will examine the federal policies behind efforts to expand the use of this technology. This CE article is open access and can earn you 2.1 CE credits.

Accord­ing to the U.S. Department of Labor’s Bureau of Labor Statistics, more than 348,000 unlicensed as­sistive personnel were employed in the hospital set­ting in 2011. Our Cultivating Quality article, “Continuing Education for Patient Care Technicians: A Unit-Based, RN-Led Initiative,” explores how one teaching hospital in New York City implemented a hospital-wide upgrade of nursing attendants to patient care technicians.  

Tonight is the opening ceremony of the London Olympics, and one nurse helped get the torch to its destination. Debra A. Toney, the immediate past president of the National Black Nurses Association, was selected to carry the Olympic Flame with 22 other inspiring Americans by Coca-Cola, one of the relay’s sponsors, “in recognition of her personal and professional dedication to promoting healthy lifestyles and for empowering civic engagement in communities.” Read more in this month’s Profiles article, “Nurse Lights the Way at London Olympics.”

And if you’re a history buff, check out “My Grandfather’s Unpublished Manuscript,” by Greta Krapohl. After her grandfather’s death, Greta discovered a manuscript that he had written in the late 1960s, but was never published—until now. This manuscript provides the voice of a male nurse at a time when men in nursing were virtually silent.

There is plenty more in this issue, so stop by and have a look. Feel free to tell us what you think on Facebook or our blog.

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That Acute Attention to Detail, Bordering on Wariness…

November 21, 2011

via Wikimedia Commons

By Kinsey Morgan, RN. Kinsey is a new nurse who lives in Texas and currently works in the ICU in which she formerly spent three years as a CNA. Her last (and first) post at this blog can be found here.

It seems that nursing schools across the world subscribe to certain mantras regarding the correct way to do things. Different schools teach the same things with utmost urgency. Hand washing is one of the never-ending lessons that comes to mind. How many times do nursing students wash their hands while demonstrating the correct way to perform a procedure? I vividly remember actually having to be evaluated on the skill of hand washing itself.

Another of the regularly emphasized points of nursing school is double-checking. One of my first clinical courses required students to triple-check patient identification before giving medications. We were to look at the medication administration record, the patient’s wristband, and then actually have the patient state their name.

As a new nurse learning several new computer systems for charting, etc., I’ve noticed that the old attention to detail, ground into my soul during my school days, now seems easy to overlook, since computers do so much of the work. Of course, computer charting and electronic MARs* have simplified tasks and made time management much less daunting. But sometimes I worry about the hidden cost of such improvements.

I intend, vow, resolve to make an effort to remain aware of how easily errors can happen when we don’t double- and triple-check things. I want to always retain that astute attention to detail, bordering on wariness, so that I can practice as safely as possible, even with the advent of electronic methods.

*MARS = medication administration records

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AJN’s Top 10 Blog Posts for the Last Quarter

August 2, 2011

At this blog we’re not always devoted practitioners of the art of the list. Used too often and too cynically (some of the more mysterious nursing blogs consist entirely of lists of articles and excerpts from other blogs), lists can be just another form of journalistic cannibalism.

But it sometimes occurs to me, as I publish a new post that takes its place at the top of the home page and pushes all those below down another notch (until, after a few such nudges, they gradually fall off the page, entering the purgatory of the blog archives), that this isn’t entirely fair.

While blogs allow for quick reaction to a news story, a public health emergency or controversy, a new bit of published research, they are also places for writing that isn’t so narrowly tied to a specific date and event. Many thoughtful posts by excellent writers have been published here in the past couple of years. With this in mind, here’s a list of the 10 most read blog posts for the past 90 days. It doesn’t mean that these are necessarily the very best posts we published in that time, or that they were even published in the last 90 days . . . but it’s one way of measuring relevance.—Jacob Molyneux, senior editor/blog editor 

1. Dispatches from the Alabama Tornado Zone
This one is actually a page with links to a series of powerful and thought-provoking posts by Susan Hassmiller, the Robert Wood Johnson Foundation Senior Adviser for Nursing, who volunteered with the Red Cross after the devastating Alabama tornadoes in late April of this year.

2. Notes of a Student Nurse: A Dose of Reality
This honest account of a first semester of nursing school is by Jennifer-Clare Williams, a student at Cox College of Nursing and Health Sciences in Springfield, Missouri. We hope to have more of her posts in the future.

3. Bullying Wars: Theresa Brown vs. ‘the entire physician profession’
AJN‘s editor-in-chief Shawn Kennedy comes to the defense of nurse and author Theresa Brown, who dared to write about physicians who bully nurses.

4. New Nurses Face Reality Shock in Hospital Settings – So What Else is New?
We ran this one two years ago, but it’s as relevant as ever for nurses who’ve just graduated from school and are starting out in a new job—and for the nurses who work with them.

5. Don’t Cling to Tradition: A Nursing Student’s Call for Realism, Respect
By Medora McGinnis, a student at Bon Secours Memorial College of Nursing in Richmond, Virginia, this post got a lot of attention with its assertion that “nontraditional” nursing students may be the new normal.

6. What Is Meaningful Use? One Savvy Nurse’s Take
By Jared Sinclair, an ICU nurse in Nashville who has a blog about health care and technology, this post demystifies for nurses some of the issues associated with electronic health records.

7. Workplace Violence Against Nurses — Neither Inevitable Nor Acceptable
A look at some helpful articles that have addressed aspects of this perennially troubling issue. Read the rest of this entry ?


Today’s Notes from the Nursosphere

December 7, 2010
Image of Japanese Attack - Pearl Harbor, Hawai...

Image via Wikipedia

As noted today by Joni Watson at Nursetopia, it’s Pearl Harbor Day, and nurses were (surprise) key players in that day’s awful events. Here’s how the post begins:

My heart was racing, the telephone was ringing, the chief nurse, Gertrude Arnest, was saying, “Girls, get into your uniforms at once, This is the real thing!”

Speaking of safety, “Top 10 Health Technology Hazards for 2011″ (pdf), from the ECRI Institute, gives us a list of hospital patient safety risks that, according to the authors, “reflects our judgment about which risks should receive priority now, a judgment that is based on our review of recent recalls and other actions . . . , our analysis of information found in the literature and in the medical device reporting databases of ECRI Institute and other organizations, and our experience in investigating and consulting on device-related incidents.” These include “radiation overdose and other dose errors during radiation therapy,” “alarm hazards,” and eight others.

And now to electronic charting vs. doing it the old-fashioned way: we have a comment thread going on at AJN‘s Facebook page about whether or not EHRs save nurses time or not. Go there to comment, or leave a comment here.

Also noted: Stephen Ferrara at A Nurse Practitioner’s View wonders whether the preceptorship model is still adequate for training NPs. Or is it time for a residency model instead?

I’m not necessarily referring to the typical residency training of physicians which takes place in hospitals but a residency-type of program in an out-patient setting (ironic that we use the term residency). We realize that healthcare is not exclusively delivered in hospitals. It takes place in independent providers offices, in community health centers, in mobile health vans, and in retail settings. It takes place in people’s homes and places of employment. It takes place in many of the health decisions that we make on a daily basis. I found this NP residency program in Connecticut that claims to be the first NP residency in the US. The programs admits 4 NPs each year and trains them to handle scenarios encountered in Federally Qualified Health Centers (FQHCs). The residency lasts 1 year and appears to be a wonderfully structured program and setting.

Just a few items of interest. As always, we welcome your comments.—JM, senior editor/blog editor 

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