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.

The Affordable Care Act and beyond

In today’s frenetic Information Age, the speed at which society is inundated with data leaves little time, or even inclination, to question operational definitions of terms at the center of the most significant social issues of our time—whether on Wall Street, where bankers use “credit default swaps” to bet against clients with their own money, or in health care, which, by definition, is the antithesis of what is provided to the American public. Many economists have stated that the current system is unsustainable. It’s time we get real about health care, before the current system bankrupts the economy of the United States.

We all perform preventive maintenance on things we acquire. From our homes to our cars to our children’s bicycles, all the things that “make life good” require preventive maintenance to perform their functions longer, thereby making life good for a longer period of time. The same is true of the human body.

It's not on my policy!
When was the last time you sent a bill for your oil change to your auto-insurance carrier? My guess is never. If you did, I’m confident your claim would be denied. Does that keep you from changing the oil in your automobile? I assume not. Factors that play into one’s decision to do preventive maintenance on a motor vehicle, which is nearly a necessity in most families’ lives, are that the cost is transparent and within reach of the consumer. I respectfully suggest that the same factors apply to health care. Until there is cost transparency and the most basic services—including an annual physical—are within the ability of 95 percent of the people in America to pay for out of pocket, our system for treating illness will remain on a collision course with collapse.

Nurses need to light the way! 

Photo credit: scyther5/iStock/Thinkstock

There is no doubt that the Affordable Care Act (ACA) has placed more Americans on an insurance plan and appears to be slowing the rate of cost growth, but is anyone receiving more health care? When I reviewed many of the health care exchanges, I found that, for the premiums to be within reach of the average American family, the deductible is so high as to discourage participants from seeking preventive care. (It is true that many of the plans do include an annual physical.) However, I have been unable to locate evidence—perhaps it’s not available yet—that indicates utilization of preventive health care services has increased following implementation of the ACA. I suggest we will not see that benefit in the near future, because the system that we are trying to move away from has not promoted preventive maintenance. It is imperative, therefore, that we, as nurses, promote and model wellness as part of our overall efforts to drive health care reform.

Health care reimbursement reform is not health care reform, regardless if that is how it was positioned. Although the ACA is well intended, without true care-delivery reform with an emphasis on prevention and a system that supports such a model, the ability of the United States, the economic powerhouse of the world, to deliver care on par with nations that have far fewer resources, will remain out of reach. As a nurse, I believe all Americans should have access to basic health care, that it should be as much within their means as oil changes are for their cars. I also believe that this right to health care comes with responsibilities.

Needed: Men and women of the lamp
Our responsibilities as nurses are clear. We must continue to advocate for migration away from the unsustainable system of the past to true health care reform that results in holistic health care, not just treatment of illness. Furthermore, we have the responsibility to educate the public that their right to health care comes with responsibilities and that they must be active participants in their own wellness and health.

The Affordable Care Act set the country’s system of disease treatment on the road to change. We have taken just the first steps on that road. Where that road leads is yet to be illuminated. To assure the health and wellness of our fellow citizens, a holistic approach must be taken. Who better than nurses to advocate for such a holistic approach?

To effect changes needed—delivery, financing, and legal—to stop treating disease and start providing for wellness, nurses must remain knowledgeable about the latest practice and policy evidence and be present everywhere, from the halls of academia to the front lines where care-delivery models are improved to board rooms where resource decisions about care delivery are made to legislative halls where regulatory laws are enacted. We were handed the lamp, and it is our duty to continue lighting the road, because the journey is far from over.

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.

What's not to like?

Everywhere we turn we are being asked to “follow” or “like” something on social media. We all understand that the more “likes” a site gets, the more “Google juice”—higher search ranking—it gets. Companies hope that higher search rankings will help them achieve business objectives. Our likes, follows, and other electronic activities allow profiles to be built on us by anyone from marketers to employers to government agencies.

In return for sharing information, our searches are optimized or we are given things. More importantly, we are given the opportunity to offer personal opinions on everything from politics to products.

Recently, language has appeared in the terms and condition statements of many websites—even service contracts—stipulating that any negative statements made by users or their associates, anywhere on the Internet, will incur monetary charges. What used to be “likes only, please” has become “likes only, or pay the price.”

Igor Stevanovic/iStock/Thinkstock

As net neutrality has declined, so too, it appears, has the right to free speech. Having paid for my “free speech” through erosion of my privacy, I now get to pay more to honestly say something negative about a product or service. What’s next, a sliding price scale based on how unkind my opinion is? What about web services that provide recommendations based on customer feedback? What will they do in a world of nothing but likes? I sense the edge of a slippery slope.

I recently came across an article in the British media in which a general-practitioner surgery facility requested that all comments be directed to the administrator and not be posted on social media. A sign to that effect was even displayed in the waiting room. I wonder how long it will be before that same language makes it onto the hospital’s consent form? And how long will it take for the practice to “cross the pond” to the United States and other countries?

Have we indeed come so far that we have to pay if we express a negative opinion about what is truly bad service or an inferior product? I have searched Facebook high and low. Can anyone tell me where that darn “unlike” button is?

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 few words on time

Once upon a time, I taught a course on budget and finance for nurses. In the first session, I would introduce the concept of scarcity and ask the class to provide real-world examples of the concept. Every year, the conversation immediately would become lively.

One example mentioned consistently was the “gas crisis” of the 1970s. Some in the class had no idea what was being talked about, but there were always a few students my age that recalled sitting in the back seat of their parents’ car, waiting hours for a few gallons of gasoline. When stories about entertainment devised to pass the time waned, I would burst the bubble of this walk down memory lane with the fact that the energy crisis of the 1970s was a man-made supply crisis and that, to this date, oil has flowed endlessly.

Usually, a student would then bring up the disappearance of the dinosaurs that “became the oil,” and I would acknowledge that, yes, such creatures are scarce—if you don’t include animals such as the alligator, caiman, crocodile, and komodo dragon. I would also acknowledge that, through genetic engineering, the possibility of a real-life Jurassic Park is not far beyond mankind’s reach.

Like sands through the hourglass ...

— Serggn/iStock/Thinkstock

Land was often cited as another example of scarcity. “Location, location, location” was a never-miss contribution. As I have watched the planet change over the years since teaching this course, my perception of location, location, location has altered a bit, supported by Steven Hawking’s recommendation that we find another planet to live on. Today, as then, my response to perceived issues of scarcity is that human ingenuity will overcome such problems.

Usually, about the time discussion closed on the topic of land scarcity, the class would become frustrated and press me for my definition of scarcity. I would agree with the concept, as defined in the textbook of the semester. However, as far as a real-world example that would impact me in my lifetime, I thought of nothing more proximal and more in my control—yet, at the same time, completely out of my control—than time. As they say, once it’s behind you, there’s no getting it back, and you have no idea how much is in front of you.

Now, one could make the case that the issue of time scarcity will also be solved through human innovation, that we’ll be able to extend life by hundreds of years through genetically designed replacement parts. But do you really want a 240-year-old me hanging around the joint? I think not. And where would we put all the other billions of 240-year-olds, not to mention those middle-aged 150-year-olds? A discussion for another day.

Given current realities, our time is scarce. There never seems to be enough of it, and when it’s gone, it really is gone. We give so much of our time to others through work and service, but often don’t take time for ourselves—a topic widely discussed in the nursing profession. Feminists such as Mika Brzezinski and Ariana Huffington make the case that, even in a world of glass ceilings and disparities in pay, one metric of success to strive for lies beyond the title, the corner office, and the package. It is control over one’s own time.

Although I agree with this position, I readily recognize that control over one’s time is not easily attainable. However, the emotional component of how I spend my time should be within my control, and could easily be the driver behind why so many of us have chosen to enter caring professions. But have we lost sight of the fact that control over the emotional component of our day-to-day lives is in our hands?

In our hometowns, we are bombarded constantly with images from around the globe of absolutely horrifying situations. As human beings, we rise to these crises and respond to the best of our ability. However, I doubt there is a person reading this blog who does not agree that the overall stress level of our world has increased.

So, given the world we live in, we can spend our time being fearful, frustrated, and stressed. Or, we can take control of the emotional component of the moment and make our workplace, and maybe someone else’s workplace, a better place—by turning a negative into a positive, a moment of frustration into one of growth, and a moment of anger into a teaching moment.

We have all heard it said, “If I had just one more hour to live, I wouldn’t want to spend it at work.” Given just one more hour, on what random act of kindness would you spend your time?

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.

Thank you, Eileen!

For this post, I would like to refrain from my usual stirring of the pot and, instead, in honor of the upcoming Nurses Week, share a story.

In May 2009, during Nurses Week, I was having lunch at my desk and reading the news online when I was struck by the headline ‘School nurse dies saving coach.’ I clicked on the link, and it took me to a clip on the website of a local news station in California. That’s where my relationship with Eileen Bowden and her family began.

Bowden, a school nurse for California’s Santa Clara School District, was responsible for covering five schools in the county. She just happened to be at the right school at the right time for one very fortunate soul. A softball coach collapsed on one of the fields of the school she was at that day. Nurse Bowden was summoned from her office and rushed to the scene where she performed CPR until paramedics arrived and transported the coach to the hospital. Minutes later, Bowden collapsed and died. The coach survived and is alive today, due to the quick action taken by Bowden. As a side note, the incident took place on the coach’s birthday.

Eileen Bowden

Not only was I moved to tears by this story; I was moved to action. Within minutes, I contacted the school where the incident had occurred, and the principal returned my call the following day. He was very kind and stated that he would make contact with the family on my behalf. Within a few days, Barbara Butler, Eileen Bowden’s sister, contacted me.

I explained to Barbara that I had seen Eileen’s story on the news. I also told her that, although I was not a runner, I was training for my first-ever half-marathon so I could experience running across the Golden Gate Bridge. But now, I said to Barbara, instead of running the San Francisco Half Marathon for the personal experience, I would like to do it to raise money to start a scholarship in Eileen’s memory. She agreed, and that call became the kickoff for the Eileen Bowden Memorial Scholarship, administered through the Foundation of the National Student Nurses Association, with which I have been involved ever since my days as a nursing student, 20-plus years ago.

I immediately went to work raising awareness of the need for school nurses and for funding students who have an interest in school nursing. I put up a website, emailed friends and colleagues, started blogging and tweeting, and, with my new purpose, rededicated myself to training for the half-marathon.

As I have stated, I am not a runner, and training was hard. Living in Austin, Texas, only compounded the difficulty. The race was to be held in San Francisco in July, where the average high temperature is 69 degrees Fahrenheit (21 degrees Celsius), but the average high in Austin in June, when I was training, is 92 degrees Fahrenheit. This meant getting up most mornings at 4 a.m. so I could get my training in before the Texas heat would get the best of me. Just about the time I was questioning my sanity and ability, my next round of motivation came. I received a handwritten letter and a check for $25. This gift—and it truly was a gift—was from an 80-plus-year old registered nurse on a fixed income. Her name was Betty Bowden. She is Eileen’s mother.

Well, the training didn’t get any easier, but my motivation was strong. Before I go further, I must acknowledge that my wife was with me on this journey every step of the way. The night before the run, we were sitting together in our hotel room contemplating a Wall Street Journal headline we had seen just days before—“The San Francisco Half Marathon, the race that real runners fear” —when the phone rang. It was Eileen’s nephew. Suddenly, I had no fear of what I would take on at 5 a.m.

The next morning, with my wife at my side, I completed my first-ever half-marathon, raising more than $4,000 for the newly established Eileen Bowden Memorial Scholarship. Little did I know it was the beginning of a journey to create a permanently endowed scholarship for students interested in pursuing a career in school nursing.

The following year, I was once again training to run in San Francisco to raise more funds for the scholarship when Tom Grant contacted me. Tom is Eileen’s brother-in-law. In 2010, he, too, was not a runner. However, inspired by my efforts, he had begun training for New Jersey’s Long Branch Half Marathon, which coincides with the New Jersey Marathon, and was calling to ask if I would help him replicate what I had done to raise awareness and funds. Not only did I say yes, I asked if I could run with him. I can’t begin to tell you what an honor it was to run by his side and cross the finish line together in his first-ever half-marathon.

To run a half-marathon (13.1 miles), you need all the help you can get!
Before running New Jersey's 2010 Long Branch Half Marathon together,
Tom Grant, brother of Eileen Bowden, and Ken Dion pose for the camera with
an energy product designed to help them make it across the finish line.

A highlight of making the trip to New Jersey was having the opportunity to stay with Tom and his wife Rosemary, Eileen’s other sister. And if the kindness they showed me was not enough, I had the honor of spending the evening with Betty Bowden, Eileen’s mother. We stayed up until late in the evening, sharing stories about the joys and sorrows we experienced as nurses. Mostly, the joys!

Eileen was the epitome of what nursing is all about. She was active in her community. She chose to work as a school nurse to assure health and health education for the future of our country. The single mother of an adopted daughter, she was a daughter, a sister, a friend. She was also a member of the Honor Society of Nursing, Sigma Theta Tau International.

So, on the fifth anniversary of Eileen Bowden’s passing, I would like to dedicate this Nurses Week blog post to her and others like her who have made the ultimate sacrifice in the service of others.

On behalf of all those you have touched—especially this nurse—thank you, Eileen!

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.

The provider side of big data

We have entered the age of “Big Data.” I’m not certain how this age differs from the Information Age, but a statement by Dan Ariely, James B. Duke Professor of Psychology and Behavioral Economics at Duke University’s Fuqua School of Business and director of Duke’s Center for Advanced Hindsight, provides an interesting perspective: “Big Data is like teenage sex: everyone talks about it, no one really knows how to do it, and everyone thinks everyone else is doing it, so everyone claims they are doing it.”

So, if we are in the prepubescent stage of health care informatics, what does the future hold?

allanswart/iStock/Thinkstock

The focus of big-data analytics today is on what I like to refer to as “patient-side data.” Investments being made to analyze patient-side data, evidenced by IBM’s recent agreement to implement natural language processing (NLP) in Cerner’s electronic medical record (EMR), are staggering. These data analyses run the gamut from genomic deconstruction for the purpose of individualized chemotherapy intervention to population-based trending of indicators beyond imagination. If these analyses result in actionable information, which I have no doubt they will, the actions required will not take place in a vacuum. More data is needed if these new discoveries are to reach their full potential.

I am a believer in Occam’s razor, a principle of parsimony. To paraphrase, the solution with the least number of variables is usually the one that should be employed. The Synergy Model, just one such parsimonious exemplar, provides a framework that may help us think about the other side of the big-data coin—“provider-side data.” The Synergy Model tells us that both patient and provider have specific characteristics which, when aligned, optimize patient outcomes.

We’re just beginning to scratch the surface in capturing and interpreting patient-side data, but we’re even further behind the curve when it comes to the provider side of the equation. Not long ago, the most we knew about members of our staffs is that they had licenses and could fog mirrors. With the advent of learning management systems (LMS), we can now track employee education. However, this remains a highly compliance-driven function. 

With the advent of the EMR, we’ll be able to aggregate provider-patient interaction data, such as the number of specific procedures completed by a practitioner. Data like this can be used for purposes such as credentialing and certification—in other words, quantitative data generated to support compliance-driven activities. Will the holy grail of improved patient outcomes be found in the check boxes of an EMR or the compliance report of an LMS? I think not.

Just as patient characteristics described by the Synergy Model relate to data found in the patient narrative, so too provider characteristics relate to data found in the provider narrative. Whether the professional narrative be found in the EMR (through documentation of patient interactions) or the professional’s development record (a narrative resource as rich as the patient's narrative), they are equally important in influencing patient outcome.

So, as we mature in the age of big data, what will the role of provider-side data be? Will it be purely regulatory, or will it begin to capture today the qualitative provider-side data we need to influence patient outcomes in the future?

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.

Hacked!

If you are reading this blog, you are being hacked! It is virtually impossible to live in modern society without creating a digital footprint. From cookies implanted in your browser from every website you visit to every credit-card transaction you make to every text, tweet, post, and email, you are being digitally deconstructed. The digital footprint you are creating is not only being followed, it is being backtracked to predict future behavior, as evidenced by Apple’s acquisition of Topsy.

The upside of being followed is that you are offered things based on your preferences, from coupons to returns on Internet searches. The more information you are willing to share with vendors, the more they are willing to pay you through various rewards and loyalty programs. Many of the rewards seem enticing but, as Grandma said, “Nothing in this life is free,” and, in this case, the cost is the dark side of the digital life.

We have all come to ignore pop-up ads. However, in their time, they achieved their goal. They manipulated our behavior and generated revenue for search engines through pay-per-click programs designed to drive traffic to specific vendors. Our “free” searches were then used to drive ads to us, which put us at risk for having our behavior manipulated. And if media or government used those searches to manipulate our behavior, frightening scenarios could be imagined.

As disconcerting as those scenarios might be, equally alarming is the hacking we have seen played out in recent months. From monitoring of electronic communications to credit-card hacks spawned out of Eastern Europe, which, by the way, is not a new phenomenon. (See “‘Dark Market’ Takedown.”) There is a very dark side to our digital lives. Your life is being hacked, and you are an active participant in the process. You didn’t think that reward or email account was really free, did ya?

As part of “Building a better planet,” IBM has tasked its supercomputer, “Watson,” to analyze treatment and practice patterns of oncology practitioners with regard to outcomes. Additionally, these efforts include use of genomic analysis for development of targeted chemotherapy intervention. At this point, we are, whether we like to think about it this way or not, being genetically modified by the computers we have created. Presumably, given time, those same computers will have the ability to predict the future, just as they did with relative certainty in the consumer-behavior model. Do you really want to know how long you are going to live? Do you want other people to know that? And what about the ability to manipulate it? Off to the scary dark side we go!

As we genetically engineer and reengineer the planet, we are also making great strides in biomechanical engineering. We have seen the quality of life of veterans returning from conflict improve, due to advanced prosthetics. Cochlear implants have enabled the deaf to hear. Implantable defibrillators have saved countless lives. Envisioning a future enabled by implanted technologies, politicians have dazzled us with stories of implanted devices that warn of an impending heart attack by sending an email to the owner’s cellphone and calling EMS. Sadly, as promising as this technology is—and it’s within reach—it, too, comes with a dark side.

All of these auspicious medical devices share a common element—a microcomputer. Taking the next step and actually embedding computers in our bodies has done great good. However, computers, by definition, can be hacked.

The preceding thought brings a frightening new possibility to the phrase “having your life hacked.” If you thought having to replace your credit cards because you shopped somewhere was an inconvenience, it’s a really bad day when your implanted defibrillator gets hacked!

So, I have two questions for you: Are we ready for the first time this happens? And what do you think the reaction and fallout will be?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.