Perspective of Nurse Practitioners on the Use of EBR Embedded in the Electronic Medical Record

The methods by which U.S. healthcare services are delivered are changing within the healthcare delivery system. The decision-making processes of healthcare providers are being guided by standardized protocols, clinical guidelines, policies, and procedures developed through evidence-based research. These clinical-decision support tools are adopted by healthcare organizations and embedded into electronic medical records to improve and standardize care among healthcare providers. Although these clinical support decision tools are readily available to healthcare providers, it is important to understand how these tools are being perceived among nurse practitioners. It is vital that the healthcare system understand the experiences of nurse practitioners with the use of evidence-based research embedded into electronic medical records to ensure consistent use of these tools in practice. While there is research available that supports the use of evidence-based research in practice, there is a lack of research available that explores nurse practitioners’ perspectives on evidence-based practice embedded within electronic medical records. This qualitative, phenomenological evidence-based project was designed to explore these experiences by conducting a semistructured interview with four nurse practitioners who had access to medical records embedded with EBR

Individualized Glycemic Targets for the Elderly Residing in Long Term Care Facilities

Of people age 65 and older residing in a long-term care facility, 1 in 4 has Type 2 diabetes (Smide & Nygren, 2013). Care and management of this population is a challenge for nurses and other providers. Results of a needs assessment in a local long-term care facility identified deficiencies in the provision of evidence-based Type 2 diabetes care for this target population. American Diabetes Association Guidelines (2017) recommend application of individualized HbA1c targets for the elderly residing in long-term care facilities, especially for those with compromises in clinical and functional status. This two prong quality improvement project strove to educate nurses about these residents’ needs, and incorporate the use of best practice diabetes standards in the nurse practitioner’s practice. Specifically, emphasis was placed on HbA1c and finger stick monitoring, eye exams, and foot care. Results indicated that educational in-services designed for nurses were an effective approach to improving knowledge concerning care of complex Type 2 diabetes patients. Although ophthalmology and podiatry referrals were not ordered routinely because of APRN, staff, and organizational resistance; utilization of standardized orders improved routine Type 2 diabetes care pertaining to ordering HbA1c, renal panel, and urine to albumin creatinine ratio. The APRN now has the awareness to evaluate discrepancies between HbA1c results and finger stick values. QI projects in long-term care facilities may be difficult to implement and sustain related to staff turnover, understaffing, high patient acuity, and organizational and provider opposition. APRNs must advocate for continual utilization of evidence-based practice guidelines for all LTC residents

Patient-centered medicine and patient-oriented research: improving health outcomes for individual patients

BACKGROUND: Patient-centered medicine is developing alongside the concepts of personalized medicine and tailored therapeutics. The main objective of patient-centered medicine is to improve health outcomes of individual patients in everyday clinical practice, taking into account the patient’s objectives, preferences, values as well as the available economic resources. DISCUSSION: Patient-centered medicine implies a paradigm shift in the relationship between doctors and patients, but also requires the development of patient-oriented research. Patient-oriented research should not be based on the evaluation of medical interventions in the average patient, but on the identification of the best intervention for every individual patient, the study of heterogeneity and the assignment of greater value to observations and exceptions. The development of information-based technologies can help to close the gap between clinical research and clinical practice, a fundamental step for any advance in this field. SUMMARY: Evidence-based medicine and patient centered medicine are not contradictory but complementary movements. It is not possible to practice patient-centered medicine that is not based on evidence, nor is it possible to practice evidence-based medicine at a distance from the individual patient

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Engaging Paradox in Situated Practice: A Study of Electronic Case Management in Family Law

This dissertation examines how organizational paradoxes are managed in practice, over time, and under technological change. Paradox theory suggests that technology is a disruptor, intensifying tensions and rendering them salient. Less is known about technology’s role in responding to tensions or the complex and situated experience of managing paradox. I investigate these issues through an ethnography examining the implementation of a new case management system in the Family Law division of a California county court. Employing a suite of theoretical lenses – sociomateriality, microfoundations, and power – I present three studies of organizational paradoxes upended following this change. In the first study, I explore the social and material actors involved in managing the tension between standardization and individualization in the performance of service. I find that different configurations of people, artefacts, and policies create opportunities to reframe the tension. Learning from errors allows each reframing attempt to reduce the space and time required for its performance, facilitating the gradual integration of competing demands. The second study examines how visibility into individuals’ actions is experienced in performance evaluation schemes that emphasize collective goals. I find that system features rendering individual actions visible trigger defensive behaviors focused on protecting individual interests above collective goals. Managers’ use of empowering actions and reassuring discourse reduce anxiety by anchoring individual performance standards and minimizing dissonance. In the third study, I examine shifting power dynamics in the negotiation of belonging across multiple groups. I find three ways in which the new case management system serves as a tool for circulating power among courtroom clerks, managers, and judges: collapsing the spaces of role play, creating opportunities for concessions, and (re)defining expertise and its relative influence. Taken together, this research shows how the transformation in court services under electronic case management echoes a transformation in the meaning of service for those charged with its provision. As performing, organizing, and belonging tensions are upended and repaired under the new technology, new practices shift the focus of service from customer to case file, challenge employees’ shared sense of responsibility to case resolution, and surface new identities and sources of power

Perspectives on Model-Informed Precision Dosing in the Digital Health Era: Challenges, Opportunities, and Recommendations

Drug approval is based on exposure, response, and variability of studied populations, typically excluding comorbidities/medications and very ill patients, thus not representing real‐world populations. This results in wide variability in therapeutic outcome for individual patients. Model‐informed precision dosing (MIPD) can characterize/quantify this variability, support optimal dose selection, and enable individualized therapy. The aim of this perspective is to raise awareness for MIPD, identify challenges hindering its implementation in clinical practice, provide recommendations, and highlight opportunities

An Instructional Unit Utilizing Computer-Assisted Instruction for Teaching the Application of Sociocultural Information to Individualization of Diets

An instructional unit utilizing computer-assisted instruction was developed, implemented, and evaluated for teaching the application of information concerning sociocultural food behaviors to the individualization of diet modifications. The instructional unit was administered to professional level dietetic students in the Coordinated Undergraduate Program in Dietetics at the University of Tennessee, Knoxville. The instructional unit included a pretest for prerequisite knowledge, three simulated dietary counseling sessions, and a dietary counseling session with an actual patient. The simulated dietary counseling sessions were presented via computer-assisted instruction (CAI) and the effectiveness of the instructional unit was assessed by content analysis procedures. Hypothetical medical charts and simulated dietary counseling sessions for three patients with adult-onset, noninsulin dependent diabetes were developed to give students experience in individualizing patient care. Each simulated patient had different sociocultural characteristics. Students completed nutritional care plans and CAI dietary counseling sessions for the simulated patients prior to completing a nutritional care plan and dietary counseling session for an actual patient at a local out-patient clinic. Content analysis procedures were developed for quantifying the content of nutritional care plans and dietary counseling sessions. Seven subject matter categories relevant to sociocultural and physical factors to be considered when planning the nutritional care of individuals were identified. The categories were designated as cultural, economic, psychological, religious, social, miscellaneous, and physical. The average score of six coders was used in determining the content of the nutritional care plans and counseling sessions. Prior to the instructional unit, one-third of the students considered only physical needs of the patient in planning dietary care for that patient. All students identified and utilized both physical and sociocultural factors related to the dietary care of the simulated patients. Following the CAI, all but one student considered both sociocultural and physical factors in planning the dietary care of the actual patient. The greatest transfer from the CAI to the actual situations was in the content under the cultural and economic categories. Data did not indicate any carry over of content in the category concerning religious needs of the patient. The results of the content analysis indicated that the students utilized more sociocultural considerations in developing plans for the dietary care of patients following the computer counseling sessions than were used prior to the computer counseling sessions. The instructional unit was determined to be effective in teaching students to individualize patient dietary care

Latent Print Examination and Human Factors: Improving the Practice Through a Systems Approach: The Report of the Expert Working Group on Human Factors in Latent Print Analysis

Fingerprints have provided a valuable method of personal identification in forensic science and criminal investigations for more than 100 years. Fingerprints left at crime scenes generally are latent prints—unintentional reproductions of the arrangement of ridges on the skin made by the transfer of materials (such as amino acids, proteins, polypeptides, and salts) to a surface. Palms and the soles of feet also have friction ridge skin that can leave latent prints. The examination of a latent print consists of a series of steps involving a comparison of the latent print to a known (or exemplar) print. Courts have accepted latent print evidence for the past century. However, several high-profile cases in the United States and abroad have highlighted the fact that human errors can occur, and litigation and expressions of concern over the evidentiary reliability of latent print examinations and other forensic identification procedures has increased in the last decade. “Human factors” issues can arise in any experience- and judgment-based analytical process such as latent print examination. Inadequate training, extraneous knowledge about the suspects in the case or other matters, poor judgment, health problems, limitations of vision, complex technology, and stress are but a few factors that can contribute to errors. A lack of standards or quality control, poor management, insufficient resources, and substandard working conditions constitute other potentially contributing factors