Module #1

1. Introduce yourself to the group. Include your graduate area (e.g., teaching, acute care NP, etc.).
Hello everybody! This is Sam Sloan from the DNP-FNP program.

2. Why do you as a graduate level nurse need to know about information management?
I need to know about information management because health care delivery is becoming increasingly dependent upon technology and information management. In order to be an effective PCP you need to know more than just the basics. You should know how to integrate the latest evidence based practices, equipment, data collection/retrieval methods, and management techniques into your practice in a seamless manner. One should also know as much as possible about information management because Obama says so.

3. Describe what is happeing related to IT in your clinical or practice setting.
I work in the ED at the U and we are sort of the late technological bloomers in the hospital. The nursing staff in the ED do very little computer documentation compared to other units in the hospital. We do not use CPOE, PowerChart, etc. We use FirstNet to document triage assessments and access patient charts for labs, H&Ps, imaging, etc. Within the last 2 weeks we started documenting blood sugars and urine pregnancy screens in FirstNet. Management has said "We'll be going live with full computer charting by the end of the year" for the last 2 years. I wonder when we will really "go live".
The ED does have the distinction of being one of the only units in the hospital to use Vocera. We were the first to start using it and now xray, ct, and ekg techs are using them. Social work, interpreter services, and pharmacy are also using Vocera. Vocera is great when it works.

4. What structured documentation, standards, and/or coded terminologies do you see within your practice setting (if none--where might they be applicable)?
The MDs in the ED are using computer documentation for their charting. Their documentation is pretty slick. It's easy to access, interpret, and use. The format has standardized charts for different patient complaints and allows the physicians to use their own language through free-text options but , most importantly, it has standardized a great deal the vocabulary and made it easier to pull out data for future purposes.

5. How are structured/coded clinical data useful in promoting quality patient care?
Without structured/coded clinical data we would not have a quick way to review, interpret, utilize, and communicate patient data. One of the biggest challenges we face in delivering quality health care right now is the overabundance of information available. Much of this excessive information is not easily accessible due to differences in vendors, computer networks, terminology, and structure. Promoting a standardized structure/code for clinical data that is easily accessed and interpreted by health care providers would greatly increase the quality of care that patients receive. There would be no need to repeat labs, imaging, and other expensive diagnostic studies because the results would be readily available. PCPs could easily see what specialists were thinking. Patients would feel that all their providers were on the same page. Providers may feel less frustrated by the increased transparency standardization and structured/coded clinical data would yield. The bottom line is things will only get better for the patient and the patient is why we are all here.