Realistic and optimistic

I recently attended a meeting of global nurse leaders convened by the Honor Society of Nursing, Sigma Theta Tau International. Several speakers touched on the topic of equity, a concept all too often confused with equality. Sharing something equally does not mean that this distribution is equitable.

For instance, a person paid $20 an hour in San Francisco cannot support a family above the poverty level whereas the same salary—$20 an hour—would make life bearable in other parts of the country where the cost of living is less. Do both individuals make an equal amount of dollars? Yes. Is their buying power the same? No. This is a very simple example of equality that is not equitable.

This kind of inequity plays itself out in healthcare across the globe every day. Because variables that complicate this reality are as numerous as the stars in the sky, I will limit myself here to three observations.

hocus-focus/iStock

Nursing innovation is often co-opted or outright appropriated by other disciplines. That statement is based on years of personal observation. As a service profession, nursing often does not step up and take credit when credit is due. When simple recognition is not given—never mind monetary reward—value created is co-opted or wrongly acknowledged. When it comes to innovation, could nursing be the source of its own inequitable treatment?

Nursing has only recently begun to be represented in a manner that impacts equitable allocation of healthcare resources. Initiatives are underway in many countries to place nurses on governing boards of healthcare providers and consumer organizations. Imagine if nursing was equitably represented on these boards in proportion to the population nursing serves and the healthcare spending it influences. Keep in mind that nurses and midwives make up 87 percent of the global healthcare workforce. To have an equitable voice at the table and articulate its value, nursing needs to communicate in the language of business. We have a ways to go.

I am not disheartened by these realities or the challenges that lie ahead for nurses in improving global health—quite the opposite. Nurses who are out in the world advancing global health inspire me! At a meeting in Washington, D.C. recently, I had the honor of meeting leaders who represent these nurses, and the foundation for nursing equity that these leaders are laying on behalf of nurses around the world will result in greater healthcare equity for the populations they serve.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

A bottle of water

I’m back. I was off the grid for a while doing some reflection.

While I was gone, I took time to read the blog entries I have posted over the last several years. Sadly, they have generated very little dialogue, their original intent. I also realized that most of them focused on challenges faced by our society or profession. To say they have been negative is, I hope, too strong. I prefer to say that, in an effort to spawn conversation, I have pointed out challenges.

It may have been the challenges I see at every turn that resulted in my writer’s block, which brought me to this reflection. It would be easy for me to go on a tear about the state of the current electoral process in the United States or cruelties being inflicted around the globe. Either of these topics, as well as many others, could get ugly very fast. Who knows, they might even generate some discussion.

Ugliness seems to be one of the few things that gets people engaged these days. Sadly, getting to the ugliness does not seem to move us to the open and honest dialogue we need to have about so many topics. So, rather than adding to the negativity that abounds, I am using this edition of “Does this strike a chord?” to share a short story of optimism.

I was on a lengthy motorcycle ride recently. For safety, I wore my black leather jacket. To say it made for rapid warming anytime I stopped would be a major understatement. It turns out the route I took, which was desolate, was under repair. At one point, I was stopped in traffic for 45 minutes just before noon hour. I was caught totally off guard when the gentleman in the minivan in front of me stepped out of his vehicle to walk back to my bike. Rather than asking about my bike or complaining about the traffic, he simply handed me a bottle of water and returned to his vehicle without a word.

I was caught totally off guard by 16.9 fluid ounces!

I was so stunned that the words “Thank you” barely made it to my lips before the door to the minivan closed. I am not sure if the driver even heard me. I vowed I would pay his kindness forward three-fold daily. I would do one thing for a person, one for an animal, and one for the planet. I’m not going to tell you what I have done because that is totally unimportant. What is important is that the world is hurting in a bad way for the type of kindness that was shown to this stranger on a highway.

I shared my story about the minivan driver on Twitter. I asked others to share their stories about being the recipient of a random act of kindness. I did not receive a single like, retweet, comment, or post about that random act of kindness. I can only hope this lack of response has to do with my vast Twitter following. Not! As for me, three random acts of kindness a day don’t seem too much to ask. I may not always be able to complete my three acts of kindness per day, but hope the world will be a better place for my trying.

Have you been the recipient of a random act of kindness lately? Have you paid it forward?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Something else to lose sleep over, health data held for ransom

Data breaches have become as commonplace as men walking on the moon at the end of the Apollo program. They’ve become white noise, and people aren’t paying attention. Millions of personal credit records can be exposed, and it’s barely a blip on the evening news. The personal email of the CIA director has been hacked. Really?

First-generation cyber criminals followed a similar pattern when committing their crimes. Using some form of malware that was downloaded to a computer via email or website, they accessed sensitive data, such as personal credit information, including U.S. Social Security numbers. To complete the transaction anonymously, they downloaded a copy of the data by bouncing it off several servers around the planet and then sold that data on the dark internet using an electronic currency known as bitcoin. The recipient of this valuable information then committed fraud by creating as many transactions as possible before the account was shut down. In response to these data breaches, the custodians of our digits generously provided us with one year of credit monitoring.

From strips to chips
To decrease credit card fraud, credit card companies have recently begun replacing our traditional, magnetic-strip credit cards with so called “chipped” cards,” a practice that has been in place outside the United States for years. The user of a non-U.S. chipped card is given the opportunity to select a personal identification number (PIN). The merchant presents the card processing machine to the cardholder. (The card never leaves the sight of the cardholder.) The customer then enters his or her PIN, and the transaction is complete.

– kaptnali/iStock

Until recently, the U.S. model did not provide this level of security, and most vendors still do not offer that protection. Instead, normal practice often required cardholders to relinquish possession of their cards for brief periods—your server taking your credit card to the register for swiping, for example. But even when your card remains in your possession—or sight—during a transaction, your personal data can still be acquired through the use of “skimming” technology. When installed in a transaction device—a gas pump, for example—a skimmer harvests data free of detection.

Now broadcasting from your credit card
Instead of protecting us, the chips that have been added to our credit cards now help criminals steal our data by accessing signals broadcast from those chips. Millions of dollars are being spent on migrating to chipped cards in the United States that are inferior and already outdated, compared to those used in other developed countries. Omission of a feature as simple as the ability to enter a PIN has made our data less secure.

Enter the second-generation cyber criminal. He or she is not a fraudster. No, they have taken the game to the next level. They kidnap data and hold it hostage. The software used by these evildoers is known as ransomware. Like malware, it is downloaded to your computer, as discussed earlier, but a ransomware virus, once downloaded, does not copy your data. Instead, it locks up your system, blocking access to its data and functions. To have your system unlocked, simply fork out a ransom—payable in bitcoin—as instructed by your infected computer.

The first report of a U.S. healthcare system being held hostage by ransomware recently hit the headlines—a full three days after it was reported in the international media, I might add. The victim hospital had to resort to using a paper-based system for more than a week. In the end, the hospital system reportedly paid the ransom, and their systems were freed. It is safe to say this will not be the last of this type of attack on healthcare systems and the valuable data they hold.

Questions in search of answers
Knowing that the evolution of most information technology systems in healthcare lags behind that of the banking industry, I shudder to think about the many difficult questions that lie ahead, all of which require innovative answers.

Have we reached the point in time when the client must be the custodian of his, her, or its own data? If so, what technologies will be used? Some PIN-driven smart card? What does this mean for system interoperability? What about amassing big data for research? Is the client responsible for any untoward outcomes resulting from the client not keeping records up to date? What about …? What about …? And what about …?

If the patient is not the custodian of his or her own health data and a healthcare organization is, is that organization liable for any untoward outcomes suffered by the client during a period when the client’s health data is unavailable? Is the healthcare system responsible for a more robust backup system than in the past? Is the healthcare system responsible for providing an updated copy of the client’s medical record at every encounter?

In the face of ever more innovative cyber threats, answers to these questions and many others will ultimately determine where the liability for security lies.

Your thoughts?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

How real is the danger of artificial intelligence?

Year after year we see amazing advances in health care with many of them driven by technology. From surgical robots to ingested cameras to cochlear implants to nanites that carry out tasks at cellular levels, technology is invading our bodies. These technologies currently share one common factor—there’s a human in the loop. But for how long?

In an open letter to world leaders and the public, business magnates that include Elon Musk, CEO of Tesla Motors and SpaceX; Warren Buffet, CEO of Berkshire Hathaway; Bill Gates, former CEO of Microsoft; and others, have requested that artificial intelligence (AI) not be used for military purposes. I believe this is a reasonable request. 

If technology takes over in health

care, is it still health care? 

— Photo by Danil Melekhin/iStock

Just imagine—drones equipped with facial recognition capability (now commonplace) that stay aloft and search for targets 24 hours a day with no human involved. The idea of machines usurping man’s authority has been present in my consciousness since I saw the film “Colossus: The Forbin Project” (1970), and the theme has been repeated in novels and more recent films, such as “The Terminator” (1984) and “The Matrix” (1999). The question is not if the theme will continue to be repeated, but rather if fiction will become reality.

Science fiction of the past very often becomes the reality of the day. Nearly 50 years after men traveled to the moon, man-made probes are exploring the current state of the universe and orbital telescopes are visualizing its past while, here on earth, physicists are unlocking its foundational elements. The ability of technology to collect and interpret data is quickly outpacing human ability to do the same.

So far, man has remained in the loop to make corrections in situations that computers, in our human opinion, are unable to adapt to, but we are slowly giving over control to technologies under the guise that machines are more precise. I wonder how long it will be before Moore’s Law catches up with us and the first lawsuit is filed in response to a plastic-surgery robotic laser gone wild, à la the science-fiction classic “Barbarella” (1968), starring Jane Fonda.

British scientists recently demonstrated that the brain of one primate is capable of controlling the motor function of another primate when mediated by a computer. Using 36 electrodes, the researchers connected a conscious monkey that had an implanted brain chip to the spinal cord of an unconscious avatar—another monkey—to measure responses to various stimuli. Ninety-eight percent of the time, the master correctly controlled the avatar’s arm. Upon hearing this news, the report continued, “The scientists from Harvard Medical School in the U.S. envisage their findings could go towards creating machinery to help patients.” Machinery to help patients? Sounds like another very slippery slope!

As technology pervades every aspect of our daily lives, personal privacy is disappearing as rapidly as the technology propelling society forward is advances. Our ability to map and manipulate the human brain is being refined equally as rapidly. Will we see the day where excess capacity in the human brain is used for secure storage of data because it is the only private place left (Gibson, 1986)?

I shudder to think about the brain being manipulated for nefarious reasons. Imagine, implanted “machinery to help patients” being hijacked by a computer virus that can be triggered by something as simple as an image, leaving the source of the virus undetected. The undetectable computer virus part already exists. Assisted by technology and artificial intelligence, it appears we are well on our way to external manipulation of the brain and nervous system.

You hold in your hand today a communicator thousands of times more powerful than that used by Captain Kirk in “Star Trek” or the computers that sent man to the moon. If science fiction is as close a predictor of the future as it has been in the past, we as health care professionals and as a society will be facing some very difficult decisions about the boundaries of AI, some of which may already have passed us by.

Where do you think the boundaries should be in use of artificial intelligence to explore the human brain? Do you think AI-assisted exploration of the human brain will lead to taking us completely “out of the loop?”

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Can health care and capitalism coexist?

Recent news of a hedge fund manager purchasing a small pharmaceutical firm and raising the cost of a medication 5,000 percent thrust the rising cost of health care back into the headlines—for a few days. The medication in question was developed in the 1950s and has served the world well for the more than 60 years it has been on the market. The CEO’s justification for raising the price so outrageously? The profits will be used to develop new and better drugs.

What is this 30-something former hedge-fund manager’s motivation? I find it difficult to believe that it is altruism. Given his background, I suggest it is, as Pope Francis calls it—“the dung of unfettered capitalism,” otherwise known as profit.

Pogonici/iStock

Until recently, one of the few sectors doing well in the current economic environment was the pharmaceutical industry, and stocks leading the pack have been, by far in that sector, the small companies. This is because, as in many other sectors and has been the case for decades in the United States, it is the small companies that innovate.

People like this former hedge fund manager turned CEO purchase these small companies speculating that large pharmaceutical companies will purchase them at an obscene price in hopes that one of the drugs in the smaller company’s pipeline will be the next multibillion dollar seller. When this inexperienced CEO raised the price on a newly acquired drug so dramatically, however, stock prices of most pharmaceutical companies tanked. Why, you ask. The answer is simple—fear of regulation.

Since passage of the Affordable Care Act (ACA), the cost of pharmaceuticals in many cases—if not most—has risen more than 100 percent. These are commonly used, effective drugs that have served—and will continue to serve—humanity well. Examine stock market trends and you’ll find that on any day there is some affirmation that the ACA will remain in place—Supreme Court rulings and the like—stock prices across the health care sector jump. Why, you ask. Again, the answer is simple—profits. Investors know that events that affirm the ACA prompt the U.S. government to throw more unregulated cash at a health care system that ranks 37th in the world—based on outcomes—at a cost dwarfing its closest competitor.

There is, without a doubt, need for innovation in health care, but innovation should not be solely for innovation’s sake and increasing profits. Why do we need new and improved drugs if an existing product works well? When there is need for innovation, it needs to be incentivized. Expectation of profits is one way to do that. However, in other sectors, innovation funded by capital markets results from expectation that a product will stand on its own in being adopted and creating profits. You don’t see Elon Musk, founder of Tesla, buying a small car company for the purpose of raising prices to fund development of electric-powered cars. Why, you ask. Another simple answer: These sectors can’t count on unfettered capital being bestowed upon them by the government.

We can no longer allow capitalism to run roughshod over our health care system. The result, predicted by many moderate economists, will be bankruptcy of our nation. Along about now, you may be asking yourself, “Who is this guy making these claims?”

I am a capitalist and an entrepreneur. I am the former CEO of a high-tech company telling you that innovation can still occur the old-fashioned way. I created jobs. I founded a successful—and profitable—health-care IT company that positively impacts patient outcomes. We built our company the old-fashioned way, through hard work. We did not raise capital, thereby becoming beholden to investor whims and quarterly-earnings expectations. Yes, it still can be done. The American Dream is still alive. And that dream does not—and should not—have to come on the backs of the American taxpayer.

I could share my thoughts on finding a solution to what is truly a crisis, a crisis below the radar of the average citizen, but that has never been the purpose of this blog. I want to hear from you.

What are your thoughts? How can the United States, leveraging a capitalist system that has made it the most innovative country on the planet, but which also may contain the seeds of its demise, repair its broken health care system?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

How the system SHOULD work

At a recent South by Southwest (SXSW) music venue, Phil, my friend and fellow musician, was unloading his drums from a van when a keyboard fell on his hands fracturing both thumbs. Not a good thing for a drummer with 12 gigs booked in seven days. So, Phil visited his local clinic.

X-rays confirmed he had bilateral thumb fractures and the nurse practitioner attempted to refer him to a “hand specialist.” However, after some dialogue, Phil was referred, as he desired—and acceptable, given the type of injury—to an orthopedic specialist.

Moodboard/Thinkstock

In discussing treatment options with Phil, the orthopedic specialist told my friend that his thumbs could be splinted. In addition to banging his oversized thumbs into everything, this approach would result in stiffness, which would require physical therapy, and there would be increased pain, for which pain relievers could be prescribed, although they could result in addiction requiring further treatment.

The alternative? Phil could continue drumming and “let the pain be his guide.” The increased blood flow associated with this treatment would promote healing and the movement would result in greater long-term flexibility. Withholding the analgesics would keep Phil within his limits and potentially out of rehab—not that Phil is predisposed to addiction or has any such history. And the downside? Besides having pain as a governor, recovery time would be slightly prolonged.

I share this story because it’s easy to remember painful situations but hard to remember that pain has its purpose and can be a good thing. It can help us grow in ways we had not considered. In addition to continued musical performance, Phil is adapting a previously scheduled workshop to include dealing with adversity, so others will benefit from my friend turning a negative and painful situation into a positive.

Kudos to the nurse practitioner who listened to the patient and considered his needs and desires—and for convincing the powers that be to allow the patient’s desired referral. That the orthopedic specialist listened to the patient about his needs gives me hope that we truly are on the road to health care reform.

We must celebrate such stories of success so they can serve as models. When all the players come together and assume responsibility for their respective roles, the system can work.

Do you have a story to share?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Looking back while moving ahead

The purpose of this blog has been and always will be to stimulate scholarly dialogue. To that end, topics have fallen into two main categories: controversial and inspirational. Locating controversial topics is never much of a challenge. From the tinderbox that is the Middle East to the British aligning with the Chinese to form an energy bank that could move the world off the petrodollar and destabilize the economy of the United States to the never-ending political cycle that continues to reveal the lack of honesty and integrity in most of our political leaders, who can’t answer a simple yes-or-no question, to issues that affect us more directly, such as implementation of the Affordable Care Act, controversy abounds.

Inspirational topics are a little harder to come by these days—or so it seems. It’s not that inspiration isn’t all around us. It’s just harder to discern above the constant din of bad and scary news. About the time I was ready to give into temptation and pick easy, low-hanging controversy for this post, I was reminded that inspiration can often be found by reflecting on the past, this time prompted by a letter I received:

Pamela Holland, student in the Department of
Nursing at California State University San
Bernardino, is president of Coyote Nurses,
the school's student nursing organization.

“My name is Pamela Holland, and I am honored to say I was chosen as a recipient of the Dion Scholarship for Nursing Informatics. [Awarded by the Foundation of the National Student Nurses Association.] Before continuing with my letter, I want to first send a big ‘Thank you!’ your way. Beyond the general help the scholarship money provides in paying for my education, I consider it a great honor to be recognized. After reading a bit about you and your company, Decision Critical, I have to say I got a bit excited about the changes you are influencing within the healthcare field.

“As a current nursing student, I see a need for education on a daily basis—not only in hospital policy, but also in best-practice methods, in general. It pains me to see that, in an age where technology is in everyone’s hands, nurses are still performing their duties based on old information. I know that there are a lot of moving parts in getting policies changed, but I envision some sort of auto-update and training on evidence-based care of our patients, rather than relying on the nursing educator to decide what policies to act on and to initiate change. I know it’s a little more complicated, but this is certainly an idea I wish to explore further as I gain more education and familiarity within the healthcare setting.

“As I’m sure you can tell, I am very much excited about the role technology plays in the (proper) care of our patients and look forward to the role it will play in future healthcare. I only hope I am as successful in influencing change as you have been. Again, thank you so much for this amazing honor.”

Looking back

I can honestly say that, had it not been for others who saw qualities I did not see in myself and who nurtured those qualities intellectually, emotionally, and financially, I would not have had the amazing nursing journey I have had, nor would I have been as well positioned to give back to a profession that has given me so much. During my tenure as a firefighter and paramedic, we used to have a saying, “As soon as you give a guy a white shirt, he becomes management and forgets where he came from.”

When the opportunity presents itself, pay it
forward, even if it means looking back.

— Vladans/iStock/Thinkstock

A special thank you to this student for reminding me why I support nursing education and that doing so keeps me in touch with where I came from. As Pamela has demonstrated to me, inspiration can be found in those who will follow us in this honored profession. Despite the controversies of the day, we must not lose sight of that.

Upon receipt of Pamela’s letter, I was compelled to respond to her with the same advice I share with you: Remain actively engaged in your professional organizations, because they are as important to your professional growth as you are to the growth of the profession. When the opportunity presents itself, pay it forward, even if it means looking back. Never forget where you came from.

P.S. Attention, Constituent Services Department: I think we have a future member here!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those the promote products or services will not be posted.