Meaningful Use: Your prescription shouldn't have to look like this

I spent a year studying medication safety at the Institute for Safe Medication Practices, the nation's only patient safety organization devoted solely to medication error prevention and safe medication use. So I'm always on the lookout for ways to help others see what I learned to see.

My friend had a friend-of-a-friend deliver a load of pine straw to her home the other day. The delivery man left an invoice, and my friend asked me to interpret the name of the company so that she could write a check.


Take a look and see what you think.

I guessed "Chevrolet" (even though it seemed like a weird name for a handyman service.) My friend frowned. She's a middle-school math teacher, and she's detailed-oriented. "Leave it blank," I suggested, "and mail it. Mr. Pinestraw can fill it in." More frowning. (This suggestion was clearly not welcomed by my friend, one of the most reliable people I know, someone who dots her i's and crosses her t's and is not in the habit of leaving things blank.)

Several days later, my friend mentions she's going to drop the check for Mr. Pinestraw off, having finally tracked him down via telephone and clarified the name. "Cherokee!" she says triumphantly!

To average Walmart shoppers like myself, health policy and IT discussions about how $20 billion dollars in economic stimulus funds are going to be put to meaningful use sound a lot like Charlie Brown's teacher: "Waoao waoaoa waoaoa wah woaoao."

So, let me draw on the med safety expertise and call out a few suggestions for how I think monies spent for meaningful health IT should be visible to healthcare consumers:

1. People who prescribe medications should use a system more sophisticated than the pine straw delivery guy's to communicate high-stakes drug information. 1,400 commonly prescribed drugs have names that look-alike or sound-alike. People can, and do, die when drug names are confused with one another.

2. Pharmacies should be able to receive prescription data in a format that does not require the tenacity of a middle-school math teacher on summer holiday to decipher.

3. Your electronic medication history--housed with your physicians, pharmacy, and any consumer portal you choose--should move seamlessly into hospital data repositories and be accessible, with your consent, during planned and emergent encounters.

Meaningful Use: What Flo Knows

The term "meaningful use" describes the way health information technology should be put to work to improve population health, individual health, and system efficiency. Stakeholders have been aTwitter (search #MU) because IT applications/solutions that meet "meaningful use" criteria will be able to snag a piece of the $20 billion ARRA monies.

If you're new to how the delivery of health care impacts outcomes, you can join those of us who have been screaming and clawing our faces for some time by perusing these dismal stats:

• 2009 estimates of infant mortality rates (considered a reliable indicator of the level of health in a country) show the US at 6.26/1,000, behind Sweden's 2.75/1,000, Germany's 3.99/1,000, and the U.K.'s 4.85/1,000. (We're 2 notches up from Croatia, which posts 6.32/1,000)


• For every $1 spent on health in the US, our G-5 competitors spend $0.63

Meaningful use should not define health IT. It should define what health IT enables: meaningful use of information technology to achieve desirable outcomes. This is what IT has done for every other sector of the economy, including the Amish micro-economy, in which people--who are as-off-the-grid as you can get--manage their agriculture and cabinet-making businesses (albeit with generator-powered computers).

If the Amish comparison is too far out for you, here's what Ivan Seidenberg, Chairman and CEO of Verizon Communication, said in the The Business Roundtable Health Care Value Comparability Study, published earlier this year:

"When it comes to scientific advances, medical technology and the quality of our doctors and hospitals, the American system is robust. But health care is beyond the reach of an increasing number of Americans. From our perspective, the problem with the U.S. health care market is that it doesn’t really function as a market – it leaves major consumer needs unmet, costs unchecked by competition and basic practices untouched by the productivity revolution that has transformed every other sector of the economy." (emphasis mine)

I've got to believe that the productivity deficit Seidenberg calls out has something to do with how IT works (or doesn't) to achieve operational efficiencies. IT doesn't move us toward a healthcare whole although it's certainly been harnessed to great benefit for individuals lucky enough to be able to access high-end care (just ask me or any other parent who talks to their cochlear-implanted kids on a cellphone).

When patients seek care or healthcare workers go to work, IT doesn't show up in the ways we've become accustomed to. Oh, it works in the piecemeal, "best of breed" way that we've asked it to, supporting the piecemeal "best of breed" health system we've concocted. But IT, as currently designed and implemented, is wholly insufficient for the complex tasks-at-hand.

Yesterday, a preliminary report from the Health IT Meaningful Use Workgroup was made public. Not everyone is happy. And there may be opportunity to improve on the first stab. But so far, I've found the preliminary Meaningful Use materials to be true to the IOM's Six Dimensions of Care, elements seen as the backbone of a healthy health care system.

Safe, effective, timely, efficient, patient-centered, and equitable. The Big 6, first defined in Crossing the Quality Chasm, the road map to healthcare improvement we've been asked to follow for the past 8 years. Only now, we may have meaningful IT vehicles to help take us there.

Grand Rounds: Searching for meaning

Flo & Bo are pleased to be hosting Grand Rounds, the weekly carnival showcasing the best of the medical blogosphere, on June 23rd.

Since healthcare is abuzz with talk about "meaningful use" this week, send us something you think is meaningful, and we'll fit the pieces together.

Submissions welcomed until 10 pm (EDT) on Sunday, June 21. Send to: blynnolson at gmail dot com & include "Grand Rounds" in the subject line. (This will help me differentiate what's meaningful to you from what's meaningful to the people who seem to think I've won the lottery when I peruse the Spam file.)

Here's the e-prescription:

• name of blog
• URL of blog
• title of post
• URL of post
• blog (or post) author
• twitter URL (if you tweet)
• brief description of what makes your post or perspective meaningful

See you next week!

Change of Shift: A Virtual Care Plan for Effective Communication

Welcome to Change of Shift, nursing's vibrant blog carnival! I'm thrilled to be your guest host this week and hope you'll find the posts embedded here as interesting as I have. If you're visiting my blog for the first time, I should warn you that I channel Florence Nightingale. I don't take extreme liberties with Miss Nightingale, just try and figure out what her work might say about ours. Sometimes I hit, sometimes I miss. Today, I'm weaving the voices of front line clinicians, consumers, and other interested (and interesting) bloggers around the theme of communication, showing, perhaps, where we are ("Can you hear me? Can you hear me now?") and what enhanced communication might do for us in the future.

Here's a story about engaging patients in their plan of care. It happened to me several years ago when I sought care in my local ED for unrelenting chest pain of 3 days duration, was diagnosed with bilateral pulmonary emboli and admitted for 5 days of inpatient anticoagulation. (This account, by the way, does not constitute medical advice from either Flo or Bo.)

In the early days, mostly spent waiting for a therapeutic INR to bubble up in my errant body-turned-chemistry set, I noticed a large whiteboard opposite my bed. The labels affixed to the board led me to believe that the date, weather, names of the people caring for me, plus key elements of my plan of care, could be written there. My boredom, spirits, and activity level increased in a linear fashion, and by day 3, I couldn't resist messing with the whiteboard which had remained uncluttered by any data save the preprinted labels. So I documented, as best I understood it, my plan of care: vegetate; oxygenate; medicate; anticoagulate; educate; ruminate; irritate; agitate; & dissipate.

Since that appeared to be an effective way to engage others (it certainly seemed to hasten my discharge), I thought I'd categorize words of wisdom from the blogosphere in a similar fashion.

If you haven't met e-Patient Dave, I'm happy to introduce you to this remarkable gentleman. Dave blogs about his personal journey surviving kidney cancer at The New Life of e-Patient Dave and e-patients.net. An IT professional, Dave recently attempted to interface his complicated medical history, housed in a patient-accessible hospital e-record, with Google Health. The outcome? A personal health record riddled with serious and significant errors. Dave's experience is being used to illustrate the primitive state of electronic medical records, even when high-end institutional and consumer products are used by an IT professional. You can read about his testimony at the National e-Health board meeting here. (Be sure to click on the slide show for a quick re-cap of Dave's compelling story.) Since I believe consumers and front line clinicians share many of the problems that arise when IT solutions perform poorly, I thought I'd put "automate" at the top of the communication care plan. I'd also like to acknowledge the efforts of Dave and others who share their personal journey in hopes of improving the system. So we could add "advocate" here, too.

I was happy to see a piece about proper use of pulse oximeters from AJN's Off the Charts blog. So, in a nod to the A-B-C's I decided to put "oxygenate" near the top of the plan of care. RehabRN's War Stories post talks about things that, while not oxygen, deserve top billing on a priorities list. (You'll have to take a deep breath while reading this one, another defense for indexing it here.)

See Jane Nurse adds "medicate" to the plan (or maybe she doesn't) in a post entitled No More Nitro for You. Ross, a Nurse in Australia, writes Medication Errors: Behind Closed Doors, putting the issue of medication errors on the chart (or, if you read what he correctly notes about under-reporting of errors and disclosure, maybe he doesn't).

If "medicate" hasn't yet made the care plan for improving communication, I'll add it myself. Really. I blog about medication safety on Medscape (at On Your Meds), where High-Alert Drugs: Eating the Elephant One Bite at a Time advises how to avoid mix-ups involving the most commonly confused drug name pair. (Spoiler alert: it's morphine and hydromorphone.)

Staying true to his "can do" approach, Sean Dent at My Strong Medicine puts his addition to the care plan to work, evaluating two new television shows about nurses: Nurse Jackie vs. HawthoRNe: The Battle of the TV Show Nurses Continues.

Sandy Summers at The Truth about Nursing also takes on Nurse Jackie in a detailed piece that includes a link to the first episode.

Shauna shares what it's been like to be handed a painful diagnosis, examining the best way to proceed when the words on the plan of care are unwelcome in The Six Words I Never Wanted to Speak.

And if you're looking for comprehensive ways to evaluate, check out 50 Fascinating Online Psychology Tests provided by The Forensic Scientist Blog. (Flo & Bo thinking, "TMI." But, hey, please yourself.)

While healthcare is full of interesting challenges, we're not short on thinkers contemplating solutions. Over at Digital Doorway, Keith, a seasoned blogger and mentor to many (including Flo & Bo), examines health coaching as a natural place for nurses to apply their knowledge and skills in Health Coaching and Multiple Chemical Sensitivity. Thanks for modeling out-of-the-box ways to nurse while dealing with personal health challenges. You get the first, but not only entry, under "Cognate," Keith!

Mother Jones at Nurse Ratched's Place considers the merits of microblogging and online networking in The Twitter People, while fessing up, Nurse Jackie-style, to a small addiction problem. (Okay, Twitter-addiction may not be in the same league as Nurse Jackie's problem.)

Kim at Emergiblog, the mothership of Change of Shift, offers words of wisdom in the "just think" department, too. She points to the value of civil discourse when communicating in the virtual realm. If you didn't know what, Jane, you ignorant $^&*! meant before now, you're in for a treat! Pick your words carefully when documenting on the care plan, too!

Finally, if you want a textbook approach for maximizing your cognitive abilities, check out The SharpBrains Guide to Brain Fitness.

Over at Nurse Connect, Nurse Kathy provides a spot-on list of things she thinks could transform nursing and asks, What's on your nurse's dream list?. Read it (especially if you need a laugh). I'll simply say I could have squeezed her into the care plan under "automate," "medicate," or "cognate." But since she's exceptionally creative, I'm going to give her a special place in the communication plan of care: innovate.

The systems we rely on (Paging, e-Patient Dave! Paging e-Patient Dave!) often don't set up healthcare workers to win. In My Garage, Your Checklists & Patient Safety, Joe Bormel at Healthcare Infomatics illustrates how other industries apply principles from human factors engineering to determine when and whether humans benefit from prompts. Flo & Bo are always interested in spreading the word about "the science behind the compliance" (e.g., Joint Commission standards).

I somehow felt "procreate" should fall near the bottom of the care plan. (And may your fingers turn black and rot off if you enter it on mine!) But the topic is surely on the minds of bloggers. As a long-time perinatal nurse, I'm always interested in these conversations. My engineer's mind simply cannot wrap itself around processes that yield such highly variable results as Cesarean birth rates (spanning from 20% to 40% in the course of my 25 year career). What's up with that?

Chris, from The Man-Nurse Diaries, sums up what's being said about home birth in the blogosphere with Home Birth Bonanza. And a host of communication-sensitive strategies for promoting healthy birth experiences can be found In A Maternity Care Utopia at Rebirth.

Over at Reality Rounds, we get to see how incomplete unit-to-unit communication impacts staff in The Pregnancy Secret (or as the author aptly observes, "how nurses get outed at work when they are pregnant").

Dave at The Back Pain Blog sends words of evidenced-based wisdom about Back Pain and Your Mattress setting the tone for "rejuvenate," a key component needed to communicate. Finally, Nurse Laura from Nurse Connect adds her prescriptive advice. You'll know exactly what should be next on your "to do" list once you've read Nurses: It's Time to Reorient Ourselves.

Thanks for visiting! Use the comment space to add to the virtual plan of care!

Change of Shift happens again on 6/25, hosted by RehabRN. Send submissions to hotelrehab@nyms.net.

Disruptive behavior: Why this dog don't hunt

A hound dog lays in the yard and an old man in overalls sits on the porch. "Excuse me, sir, but does your dog bite?" a jogger asks. The old man looks over his newspaper and replies, "Nope." As soon as the jogger enters the yard, the dog begins snarling and growling, and then attacks the jogger's legs. As the jogger flails around in the yard, he yells, "I thought you said your dog didn't bite!" The old man mutters, "Ain't my dog."

That's disruptive behavior.

Since January 1, 2009 , The Joint Commission has begun addressing hostile behaviors using two new performance expectations:

• The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.


• Leaders create and implement a process for managing disruptive and inappropriate behaviors.

Disruptive behaviors include the easy-to-recognize ("you-better-duck") kinds as well as passive-aggressive varieties that tend to dog morale, undercutting intention and outcomes. A short, but salient, discussion of disruptive behaviors can be found in "Behaviors that undermine a culture of safety," a Joint Commission Sentinel Event Alert published last summer. The document (and reference list) is chock-full of negative organizational outcomes that can be predicted to arise from disruptive behavior. Irrespective of your stake in the healthcare system, you'll recognize them: medical error; patient dissatisfaction; diminished recruitment and retention; litigation; and increased costs. The document also acknowledges that disruptive behavior is endemic in healthcare settings.

The relationship between disruptive behaviors and highly reliable performance is interesting to me, as are most variables that inform patient safety. I think there are valid reasons, rooted in what's good, right, and just, for people to treat one another with civility and respect. But what "respect," "civility," and "disruptive" look like to large populations of diverse people is subject to cultural nuance, and has always struck me as being exceedingly difficult to operationalize. (I was once a participant in a focus group where someone defined a "nice family meal" as one in which no one stabbed another diner.)

So my engineer's mind wanted to know this about disruptive behavior: "Does managing it lead to better performance?"

Significant barriers prevent this question from being studied in a linear fashion, but work done in commercial aviation over the past 30 years suggests that it does. The analyses of a series of fatal airline crashes in the 1970's led aviation safety experts to understand that human error is causally linked to failures of interpersonal communications, decision making, and leadership. To manage risks associated with human performance, a series of high level communication-oriented behaviors and performance activities, termed Crew Resource Management (CRM), evolved.

Normalizing behaviors within crews has improved the safety of air travel. Malcolm Gladwell tells riveting stories about why and how CRM works in his book Outliers. And a classic scholarly (but easy-to-read) 1999 analysis The Evolution of Crew Resource Management by Helmreich, Merritt, and Wilheim says more and is available online.

Crew resource management is emerging in healthcare with early AHRQ-funded projects now reporting and organizational templates, like TeamSTEPPS now available. The Joint Commission's acknowledgement that disruptive behavior creates breakdowns in the teamwork necessary to deliver safe patient care is an important foundational step in nurturing cultures in which safety is paramount.

Taking on disruptive behavior as the "safety-negative" bully it is, codifies something healthcare providers intuitively know but may have forgotten: If you stab people at the dinner table, they're unlikely to leap to their feet, performing the Heimlich maneuver with efficiency and aplomb when you choke.

Change of Shift: Coming Soon

Flo & Bo will be guest-hosting Change of Shift, nursing's vibrant blog-fest, here on June 11. You can expect a salute to communication, what the voices of front line clinicians, consumers, and other interested (and interesting) people mean to healthcare and healing.


As a new blogger, I've benefited from what you share every day and from the variety of engaging ways seasoned bloggers spread the word! I'm looking forward to "showing your stuff" here next week.

All submissions are welcomed. Please include:

Name of blog
URL to blog
Name of post you're submitting
URL/Permalink to the post
Blogger and/or post author
Twitter link (if you want to include one)
A few words about what you're submitting

Send via the blog carnival portal or directly using blynnolson at gmail. I'll be happy to include all received through 6/10 at 5 pm.

The pay-off for investing in natives

The picture of the oak leaf hydrangeas, now in full bloom in my southern garden, says a lot about what you get when you invest in natives.

The thirsty, showy, flashy things I tote home from the sick-plant outlet I patronize can be counted on to demand time and tax my talent. But the natives pretty much do their thing, reliably and predictably. And they always "wow"!

I use Florence dot com, sometimes as a primer, sometimes as a bully pulpit, advancing the idea that front line healthcare providers are natives in the patient safety garden. We should pay them some attention, invest to give them what they need to get started, then be ready to get out of the way.

Most seasoned healthcare professionals grew up in traditions that emphasized the primacy of individual effort over collaborative processes, traditions that neglected science-based approaches for managing the systems that inform performance. (If we wouldn't expect a fight crew to get from New York to Denver by "heading west, young man" why does anyone tolerate a system that tells nurses to deliver medications without more procedural guidance than "follow the 5 Rights"?)

Building reliability into work processes comes more readily when professionals are schooled in human factors and applied cognitive science. Schooling is part of the reason other industries reap the wisdom of the front line in a way that healthcare, as a whole, isn't yet doing. The tradition of "counseling" the last person to touch a process-gone-wrong is hard to give up (apparently it's akin leaving your roots). And healthcare workers often don't recognize, or can't do anything about, the bad soil they're planted in.

So I was happy to receive a tweet yesterday that led me to a partnership between Auburn University and Baptist Health in Montgomery, AL. Synergistic Management and Resource Team (SMART) training will teach highly reliable communication strategies, like those used in the airline industry, to front line healthcare practitioners and students and promote the use of these modalities at the front lines of care. SMART Training combines the tactics of crew resource management, purpose-based decision making, evidence-based practice and simulation.

It's worth noting that the curriculum was developed using the expertise of Auburn's Aviation and Supply Chain Management faculty in collaboration with professionals from Baptist Health's Institute for Patient Safety and Simulation Training. Applying knowledge that comes from studying the root causes of communication snafus to develop strategies that prevent recurrence is more rewarding, but far more difficult, than focusing on "who-didn't-hear-what-right-this-time." Teaching the science behind measures that are often seen by front line clinicians as "compliance-driven" rather than "safety-essential" may help cultivate healthcare's holy grail, the culture of safety.

Turned out it was in the garden all along. Smart. Or is that SMART?