The Technology Train

In an early scene of the movie "O Brother Where Art Thou" three fugitives, bound together by chains, are chasing a moving train. The wheel's rhythm chants a siren call to freedom and the way to a better life. The three men run hard and finally catch up to the train. The first two prisoners manage to drag themselves into an open boxcar. But the powerful pull of the train proves too much for the third to climb aboard, and so the other two men are abruptly yanked out of the boxcar, crumpling into a connected heap onto the cruel hard ground of repression.

This scene mimics the truth with respect to technology. There are many sectors in our society, such as education and healthcare, who are bound by the chains of tradition, fear and choice, and are trying desperately to catch the technology vehicle as it whizzes by in a blur of progress. The moving train of technological advancements has often far outpaced the ability of organizations to keep up. The healthcare industry, specfically, is scrambling to catch the train in many ways. The lure of the ride, the hope of arrival at a destination superior to the place of departure, and the risk involved is seductive enough for some, but not for others in the industry. Questions loom. Is the ride worth it? Will the results be beneficial?

There have been incredible technological advancements in healthcare, many which have greatly improved patient outcomes. But the transformation has been a mixed blessing, with some negative side effects. One of those, due to the pervasive computer use has been a loss of effective communication and personal connectivity between patient and providers. Since the earliest days of medicine, healthCARE has been founded upon relationships. Some would argue that technology, especially computers, have de-personalized the patient / provider interaction and decentralized the patient-centric model, which was prevalent in the days when providers made house calls. Now with the emergence of social media (SM) and mobile technology, the ability to improve communication and re-connect with patients has infused the patient-care paradigm with new possibilities. SM may be conducive to increased personalized care.

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What is the BUZZ about?

Wondering what all the Buzz is about?

Google Buzz is a way to spread the love: updates, photos, videos and more. And talk about the things you find interesting. It sends everything to one central location {your gmail inbox} so it's easy to keep the conversation going. The Buzz is a great way to spread the word about your blog and other blogs you love.

Blogger has now made it easy to share to Google Buzz via the Share button in the Blogger navigation bar. Just click “Share”, choose Google Buzz, and you’ll be able to customize your message before posting to Buzz.

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Here is a helpful website for dealing with all things BLOGGER.

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Flock

Flock is a social media web-browser that I am trying out here. It lets me blog, FB, Twitter, Flickr and TwidL my thumbs all from one singular dashboard.

Blogged with the Flock Browser

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Module 6: Evaluation of Course

What did you like or dislike about taking an online course?

Let's just get it out there right now. I love on-line asynchronous courses. Having instant and ubiquitous access to instructors and curriculum is a privilege and technological marvel. Although a few challenges exist, the benefits outweigh the difficulties.

I love that through access to a laptop computer, my virtual classroom can be on a bus or waiting in a doctor's office. Learning can take place anywhere. This has been a huge advantage for me as a busy mother of four children who lives 300 miles from campus. The convenience and flexibility of online learning is unparalleled. Going to class in my pajamas at 10:00 p.m. is a comfortable and necessary way to attend school.

My family Nov. 2009. Missing is my oldest son, currently living in Florida

Another advantage is that one cannot slip into complacency or laziness with this method. It requires active participation, a superior learning method substantiated in the literature. For example, blog postings and discussion boards (heavily used in on-line courses) encourage self-reflection and exploration, critical thinking, analogy and analysis, debate and reason. Each of these characteristics is carried out to a greater degree both in quality and quantity than in a traditional classroom. In the impromptu setting of a traditional classroom, many students feel ill prepared, or unwilling to share their viewpoint because they are intimidated for a variety of reasons. Both blogging and discussions allow students time to think and formulate a well-thought out response, which in many cases is more insightful than if it had been in a spontaneous situation. Anonymity seems to invoke a sense of intimacy and a boldness rarely experienced in a classroom. This produces stimulating, engaging, thought-provoking postings. In other classes with discussion boards, I have learned so much through the exploration of student experiences, thoughts, and opposing viewpoints of my classmates. I am convinced that taking a similar class in a traditional format would not have rewarded me with such rich dialogue and enriched learning.

Another advantage is that the online structure requires initiative, motivation and a certain degree of self-directed learning. This has bolstered my confidence and improved skills for lifetime of learning beyond graduation.

Arguably, learning from a computer may seem cold and impersonal. But the great irony of learning at a distance is the potential for greater closeness among students than in a traditional classroom. The ability to communicate with both students and faculty at any time of day or night gives one a sense of community and support. Instructors have the opportunity to make a concerted effort to reverse the impersonal predisposition, and successfully turn the computer and virtual classroom into a highly effective and rewarding learning environment. I have thoroughly enjoyed my online distance learning and I thank the University for the opportunity and privilege to be a part of their student body no matter where I hang my hat!

What topic did you learn the most about and what was your favorite topic?
My favorite topics were learning EndNote, information retrieval and analyzing a clinical decision support system. I also loved making the blog. Modules 2, 3 & 4 were the powerhouses where I learned the most. Now, I don't feel anxiety about EndNote lurking in the shadows.

If you were the instructor, and this being the first course for all DNP and Master students, what would you do the same or different?

If this were the very first course, I would require either a visit to campus, or a webcam session for the first class only so that the students and teachers can meet face to face. This helps to humanize the course. I enjoyed at least being able to watch a video of Dr. Poynton and Hanberg at the beginning.

The other thing I would do as a professor is make a telephone call or have a Wimba session with each student mid-semester to touch base and decrease the [cyberspace] void that students may feel swallowed up in. Although the course is on-line, students still need to feel connected and validated. And besides that, we pay BIG tuition bucks to have access to the expertise of the instructors.

Strengths of this course were the organized modules, and clearly defined assignments, expectations and due dates. The materials provided to complete the assignments were adequate, applicable and worthwhile. Another strength was the variety of learning tools offered such as articles, podcasts, websites, etc. The variety was fun and held interest. The assignments all seemed about equal in terms of the amount of time spent on them.


If I would do anything different, it would be greater professor-student interaction (as mentioned above). 


Overall, it was a great course! We got hit with HIT and I digged it.

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Module 5: Ethical Considerations

As I carefully consider the relationship between information (such as that found on the AHQR website), reimbursement and HIT, I realize this trio is a three-legged stool and without any of the three spindles, the stool would suffer from instability. Health information technology is the backbone of the AHQR site: making possible information exchanges on quality, patient safety / medical errors, research, and standards of care. The government is taking full advantage of the information age, providing a wellspring of information for both professional and lay consumers. But the question arises: where should the line be drawn between opacity and transparency in regards to health / patient / provider information?

In the powerful photo editing program called Photoshop, there is a tool whereby the range of color can be manipulated with a slider from either 0 to 100% transparency.  Finding the right balance is dependent upon many issues such as artist preference, style of the art, and end-user preference. Such it is with the accessability of information in today's highly-technological-instant-information-web-2.0 age. The ethical dilemmas regarding transparent information sharing are of paramount concern.

As the guests on the Diane Ream show discussed, activated patients are a great strength. Now the real challenge is to muscle up discernment strength. I loved the analogy of comparing web consumers to that of first year medical students. Both med students and many people reading scientific / medical information have the cognitive ability to understand it. However, what both groups lack are the ability to make not only educated inferences, but intuitive inferences based on experiential evidence, and the ability to fold in prior experiences, low likelihoods of disease and other nuances gained only over time.

Based upon the topics found on the AHQR, it is clear that the government is moving towards increased accessibility: making information such as quality data and standards of care available to the public. This is necessary if pay-for-performance (P4P) programs are going to implemented. Thinking about the government trying to become more accessible makes me chuckle. This flies in the face of the nature of government both past and present. In fact, isn't the phrase government transparency an oxymoron? Well, ok...that is just my editorializing.

Which brings me to the next ethical consideration:  confidentiality. There is a great movement afoot to increase data sharing, not only such as seen on the AHQR website, but also in the arena of patient to patient sharing. Again, development of HIT lies at the epicenter. The challenge will be to come up with ways to allow data sharing while still protecting sensitive data. Technology is way out ahead magnetically pulling us to move healthcare delivery towards using web housecalls, telemedicine, twitter, e-consults, and emails. The technology exists to use all of these, but as usual, practice and payment lags behind. Therein lies the challenge to utilize the technology, and convert patient experience into measurable, usable data while maintaining confidential integrity. 

And finally, rampant spread of information sharing and increased use of HIT subsequently increases the risk of plagiarism. Both users and producers must sport accountability in avoiding the misuse and misproduction of information.

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Module 4: Question 2

How does nursing data quality relate to decision support?

Nursing data is an important component of an overall picture of the patient's clinical condition. Therefore the quality of data is reflected in the ability of the decision support to arrive at an appropriate conclusion. In other words, the conclusion is only as strong as the evidence to support it. Hedba and Czar confirm this notion and explain that attention must be paid to ensuring data integrity.

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Module 4: Question 1

Photo: Daniel Kahneman

How did the readings influence your perception of your own clinical decision-making? 

After reading the two assigned articles, I realized that I am not an anomaly. I use heuristics just like many, many other health care professionals. The video by Daniel Kahneman was interesting and highlights the important role of iteration. Decision-making requires practice, just as any other skill such as playing basketball or the piano. Kahneman suggests that 10,000 hours of practice is required to reach expert stage. I feel like advanced practice nurses are at a greater disadvantage than physicians. We do not have access to as much practice in decision-making than they do. In our program, we had 720 hours of clinical practice. I don't know of the specific hour requirement in medical school and residency, but it is much, much, much more. It probably doesn't reach 10,000 hours however.

So, what do we do in the meantime until we get 10,000 hours of practice and become experts in clinical decision-making? After reading these articles, as well as the book "How Doctors Think" I realize that the ability to make decisions is complex and that there is no one method that ensures the correct decision each and every time.

How do we reconcile the value of nursing experience with known heuristics and biases used in human decision-making?

There is no substitute for experience. There is no substitute for discovery by doing. There is no substitute for intuition. Each has value. Experience especially is invaluable and should not be discounted or displaced through clinical standards and/or algorithms. Clinical algorithms are useful for average, standard diagnoses and treatment. But when the provider must think "outside the box" such as when symptoms are vague, tests unclear, diseases are rare or multiple problems exist, we need the ability to move beyond the constraining decision-tree and become independent thinkers, supported by a woven tapestry of intuition, experiential learning and evidence-based data. Research has shown that sole reliance on heuristics and experiential conclusions predispose us to traps and errors of thinking. So I reconcile it by accepting the valuable use of bias and heuristics while also realizing its implicit limitaions.

Medical decision-making is taught to aspiring physicians and nurse practitioners. However, healthcare providers are not the only professionals interested in the process of clinical judgment and recommendations. The process whereby decisions are reached are a source of great interest to teachers and psychologists. Additionally, information technology professionals are equally vested in the topic. Interest is so high, in fact, that a medical society was developed to promote methodological evidence as well as proactive systematic approaches to decision making (SMDM, 2007).  It has been documented over and over that heuristics, an oft-used method for arriving at a mental destination has value, but it can lead to systematic errors (Tversky & Kahneman, 1974). Therefore, methods for reducing errors are continually being sought, developed and refined. One such way is through the use of computer-aided programs that guide providers in a systematic, thorough and evidence-based tree for guiding diagnostic decisions.

Society for Medical Decision Making. (2007). Welcome to SMDM. Retrieved on 20 October 2009 from http://www.smdm.org

Tversky, A., and Kahneman, D. (1974). Judgment under uncertainty: heuristics and biases, Science, 185(4157), 1124-1131.

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