Blankets and DNR . . .

INDIVIDUAL

|

     INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

Initially not person-centred, I -	Blankets
- recall several 'conversations' with junior doctors. The situation was 'recovered'.	"Blanket use of forms"

22:00-22:30 BBC News at Ten. DNR - Do Not Resuscitate 

DNR is a critical aspect of health care that will not go away. It can't as part of the interface (to put it mechanistically) between life, death, and quality of life and death. Ever since and even prior to the Liverpool Care Pathway, the issues raised in medical care, humanity, dignity and respect, ethics, professionalism, integrity and governance are challenging to reconcile.

Hodges' model can play a part in critical thinking about not just a troublesome concept, but the interaction of several and making sense of them and the situation to hand - and heart. 

As such Hodges' model isn't going away either.

Knights D, Wood D, Barclay S. The Liverpool Care Pathway for the dying: what went wrong? Br J Gen Pract. 2013 Oct;63(615):509-10. doi: 10.3399/bjgp13X673559. PMID: 24152449; PMCID: PMC3782767.

Survey: Dissertation on Artificial Intelligence and Record-keeping

My source:
records-management-uk AT jiscmail.ac.uk

Mon, 27 Jul at 14:10

 

Hi Everyone,

I hope everyone is doing well.

Thank you to everyone who has filled out my survey so far, the response has been fantastic. This is just a reminder that the closing date for the survey below is 3rd of August 2020.

As part of my Masters, I am writing a dissertation on the challenges faced by record-keepers in the digital age and how Artificial intelligence might be used to rectify these challenges.  I am currently conducting a survey to collect as many perspectives and opinions as possible from professionals working within the sector, where the data collected will form the basis of my dissertation research.

I would greatly appreciate you taking the time to complete my survey. There are 25 questions in total and it should not take more than 10-15 minutes to complete. All responses will be kept anonymous.

Please click the following link to start the survey: https://opinio.ucl.ac.uk/s?s=68574

Also, if you or your institution have implemented Artificial Intelligence and you have information that will help me in my dissertation please contact me via email: mohamed.tahayekt.19 AT ucl.ac.uk.

If you have any questions about this survey, or my research, please contact me at mohamedbentahayekt AT gmail.com or mohamed.tahayekt.19 AT ucl.ac.uk

Kind regards,

Mohamed Ben Tahayekt

To view the list archives go to: https://www.jiscmail.ac.uk/cgi-bin/webadmin?A0=RECORDS-MANAGEMENT-UK

'Desk-topping' i [ c/o BBC Radio 4 today 5 Feb. ]

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

'desktop' Definition #1 below is as obvious as it is brief. A desk might be topped with various things, so-called executive toys (still?), personal affects, or company related branding. It may have the proverbial in-tray, out-tray (paper still lingers?). The desk may be clear, or cluttered as a workspace. It will be the home of technology, it's PC - desktop - namesake, that shares the floor nearby, wired the sign of connectedness and energy.

'Desk-topping' To have 'papers' on the desk, might be to denote action of some sort, but how long are those 'papers' held for? The subjects of the issue at hand could be experiencing a protracted delay. The desktop in this case exemplifies not just bureaucracy, but obfuscation.

desk·top (dĕsk′tŏp′)
n.
1. The top of a desk.
2. Computers
a. The area of a display screen where images, windows, icons and other graphical items appear.
b. A computer that is designed to be used at a desk or table and is not easily moved, in contrast to a laptop or other portable device. Also called desktop computer.

https://www.thefreedictionary.com/desktop

My source:
BBC Radio 4 Today 5 February- discussion regarding historical child abuse in the Church.

Desk-topping or desktopping?

The Art & Science of Health: [conceptual scraps iii]

In clinical administration and informatics the question of 'ownership of information' is one of what I've described as legacy problems. Here's a stab at a definition:

A legacy problem is characterised by being:

An aspiration that presents as a problem due to its scale, complexity, and the fact that they are passed-on from one generation of professionals to another. As such legacy problems are common across disciplinary and professional groups. They are embedded within professional education, teaching, learning, practice, management and are expressed in successive  policy developments and within public and media discourse. In scale legacy problems are inherited by new learners and governments.

This is admittedly a broad brush treatment - and a work in progress (I focus upon and list the characteristics). Here, I'm not concerned with the whys and wherefores, or the minutiae. (Perhaps this post is a result of not burn-out(!?) but professional and organisational exposure otherwise known as experience?)

Clinically then legacy problems include:

• integrated care;

- across physical, mental health and social care
- between disciplines (location, co-working - teams)
- as experienced by the patient, carer (as proxy)
- financially

• holistic care;
• person centred care;
• reflective practice;
• critical thinking;

To these we can add:

• the electronic health record
• and as mentioned above 'ownership' of the record (as a whole and the data within).

The question is - are the above being miscategorised? Are they problems or features of healthcare that no matter how much you might wish you cannot dodge them?

Records are critical to the definitions of being a professional and professionalism - public safety, care planning and delivery, accountability, responsibility, research... Perhaps though the existence and consequent longevity of the above are bound to give rise to their analogues and not just their solution, but how they are framed?

Comprehensive record anyone and is that a computer before me...?

What are your thoughts - h2cmng@yahoo.co.uk I'd be pleased to hear from you. Can you add to the list?

To be continued ... [ and there's the legacy conundrum that is the National Health Service? ]

See also:

Daniel Bayley: The problem with Patient Online and the NHS App
Related posts i & ii:

The Art & Science of Health: [conceptual scraps i]

The Art & Science of Health: [conceptual scraps ii]

Data, Information, Knowledge defined c/o McGonigle & Mastrian

Graves and Corcoran (1989) drew from Blum (1986) to define the three concepts as follows: (1) data are discrete entities described objectively without interpretation; (2) information is data that are interpreted, organised, or structured; and (3) knowledge is information that is synthesized so that relationships are identified and formalized. Drawing on this work, Nelson (1982, 2002) defined wisdom as the appropriate application of knowledge to the management and solution of human problems.  

Data, which are processed to create information and then knowledge, may be obtained from individuals, familes, communities, and populations and the environment in which they exist. Data, information, knowledge, and wisdom are of concern to nurses in all areas of practice. For example, data derived from direct care of an individual may then be compiled across persons and aggregated for decision making by nurses, nurse administrators, or other health professionals. Further aggregation may address communities and populations. Nurse educators may create case studies using these data, and nurse researchers may access aggregated data for systematic study. pp.97-98.

McGonigle, D., Mastrian, K.G. (2012) Nursing Informatics and the Foundation of Knowledge, Second Edition. Jones & Bartlett Learning, Burlington, MA.

Fourth edition: http://www.jblearning.com/catalog/9781284121247/

See also:
Jones, P. (1996) Humans, Information, and Science, Journal of Advanced Nursing, 24(3),591-598.

Reflecting on Nortin Hadler's "Missing the Forest For the Granularity"

I read Nortin Hadler's Missing the Forest For the Granularity (July, 2014) on The Health Care Blog with great interest. The article draws attention yet again to the risks and preoccupation with processes and systems. This provides me with another opportunity to highlight the 4P's within Hodges' model: Process, Policy, Practice and Purpose and add some of the points that Dr Hadler addresses.

The 4Ps by themselves might have meaning but they can't do work. For that we need a context and several perspectives. As Dr Hadler points out big data intrudes on the clinical encounter determining not just what is collected, but how it is captured and structured.

There are frequently two datasets at the practitioner level: one is administrative and managerial in form and purpose; the other is clinical - patient, person centered. Effective communication already presents a challenge. On top of that then how relevant are the IT systems. The holy grail of IT systems still seems to be benefits for clinicians and patients - the public. Until then will the IT continue to push the patient-clinical relationship as if it is some wobbly toy? You bet it will!

Where exactly should the “Physician’s Dashboard” reside? Is it a case of "the ayes have it" but only on the right?

Nortin also refers to the United States postponing ICD-10. From Wigan Pier I clearly do not understand the issue, but this seems from here more like a very prolonged delay. A delay that perhaps says more; not just about the healthcare 'system(s)', but the many interfaces to be found there.

Many thanks to Dr - Prof. Hadler for his article:
https://thehealthcareblog.com/blog/2014/07/11/missing-the-forest-for-the-granularity/

individual
INTERPERSONAL : SCIENCES

humanistic ------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

group

“cognitive” specialists, the care of the patient revolves around the “granularity” of the narrative. PURPOSE individual attention and focus ability to share purposes  Using individual differences and idiosyncrasies	patients as widgets (here)? Can you see the dashboard here? PROCESS  data gathering big data, ICD-10 Electronic Medical Record -  templates and “smart sets”
PRACTICE Patient - BIG DATA - Doctor relationship  empathy 'NOISE' empathy life-course (“social”) epidemiology	POLICY Europe, health care systems, United States, health economists, hospital administrators, patients as “units of care”, physicians as “providers”, clinical demand = “throughput.” common denominators invoicing

Drupal musings 4: Modules and the nursing masquerade

Periodically I go through the list of available modules for Drupal both the current version and that in development - at present that is versions 6 and 7.

Reading the descriptions and reflecting on a module's functionality it is surprising where they can take you. Some of the modules stand out, prompting thoughts of potential applications. This is not just a case of descriptions fulfilling their role. Some of them shout out just by virtue of their name.

'Organic groups' will change to 'Group' in Drupal 7. If there is one thing about groups in nursing they are organic - whether that's disciplinary groups, groups held by nurses. Groups are a basic part of the structure and content of Hodges' model, and so it may be well worth factoring in the Group module from the outset.

As I read about the Masquerade module:

The masquerade module is designed as a tool for site designers and site administrators. It allows a user with the right permissions to switch users. While masquerading, a field is set on the $user object, and a menu item appears allowing the user to switch back. Watchdog entries are made any time a user masquerades or stops masquerading.

I thought of the tribes and camps within nursing and health care in general. Have we moved on? Well OK, let's see how holistic, integrated, multidisciplinary nursing is these days: picture then the nurse in medicine, surgical, operating theatre acting as a mental health nurse, learning disability nurse and vice versa?

Can we spot the imposter? One suspects (surely) that given a technical case study, care scenario then the game would be up very quickly. As to basic nursing care situations, there might be an interesting party there?

Original image source: http://www.mchooksinc.com/catalog/index.php

More SF (speculations on person-centred care...?)

I've been reading a bit more SF - this time Joe Haldeman's, The Forever War here's a fascinating excerpt:

I went to the phone in the kitchen and with some difficulty managed to get through to the hospital. A plain girl in her twenties formed in the cube. "Nurse Donalson, general services." She had a fixed smile, professional sincerity. But then everybody smiled.
"My mother needs to be looked at by a doctor. She has a --"
"Name and number, please."
"Beth Mandella." I spelled it.
"What number?"
"Medical services number, of course," she smiled.
I called into Mom and asked her what her number was.
"She says she can't remember."
"That's alright, sir, I'm sure I can find her records."
She turned her smile to a keyboard beside her and punched out a code.
"Beth Mandella?" she said, her smile turning quizzical.
"You're her son? She must be in her eighties."
"Please. It's a long story. She really has to see a doctor."
"Is this some kind of joke?"
"What do you mean?" Strangled coughing from the other room, the worse yet. "Really -- this might be very serious, you've got to--"
"But sir, Mrs. Mandella got a zero priority rating way back in 2010. "
"What the hell is that supposed to mean?"
"S-i-r . . ." The smile was hardening in place.
"Look. Pretend I come from another planet. What is a 'zero priority rating'?"
"Another -- oh I know you!" She looked off to the left.
"Sonya -- come over here a second. You'd never guess who .." Another face crowded the cube, a vapid blonde girl who smile was twin to the other nurse's. "Remember? On the stat this morning?"
"Oh, yeah," she said. "One of the soldiers -- hey, that's really max, really max." The head withdrew.
"Oh, Mr Mandella," she said, effusive. "No wonder you're confused. It's really very simple."
"Well?"
"It's part of the Universal Medical Security System. Everybody gets a rating on their seventieth birthday. It comes in automatically from Geneva."
"What does it rate? What does it mean?" But the ugly truth was obvious.
"Well, it tells how important a person is and what level of treatment he's allowed. Class three is the same as anybody else's; class two is the same except for certain life-extending--"
"And class zero is no treatment at all."
"That's correct, Mr Mandella." And in her smile was not a glimmer of pity or understanding.
"Thank you." I disconnected. Marygay was standing behind me, crying soundlessly with her mouth wide open. ...

Joe Haldeman, The Forever War, Gollancz, SF Masterworks, pp.148-149.

Link:
http://en.wikipedia.org/wiki/The_Forever_War

Ticks in boxes and triplicate thinking

Having things in triplicate may be reassuring from an admin perspective. ...

That said, 1st year learners on wards can relax to focus on learning, not having to worry (too much) about the administration - the running of the ward 24/7.

Very soon though years 2... 3 come knocking and they must consider due process, they have to question and get to grips with the established routine that sets and keeps several plates spinning.

Of course IT has by and large (?!) removed the need for paper carbon copies (although those three copies should have three distinct purposes).

Despite that an obsession with ticks in just three boxes may not be enough when it comes to high quality multidisciplinary, holistic and integrated care - it's ticks in the mind and attitude that count.

Additional links:
Records Management Society

The Productive Ward

Image source:
Triplicate Girl - http://upload.wikimedia.org/wikipedia/en/6/63/Triplicate_Girl_LSH3.jpg

The domain once removed ...

When we reflect or physically interact with the world it is easiest to effect those things nearest to us. From an early age - stationary - we learn to look and reach.

Sometimes however it is those things that are remote, inaccessible that may be significant and deserving of our attention.

Imagine yourself placed in any of Hodges' knowledge domains as if in a prison cell.

The knocks on two walls clearly come to our attention. There - is another domain that remains off-limits.

This domain is the cognitive blind-spot: which will be yours today?

Image source: Fallingpixel.com

The 'Health Career' - records and symmetry breaking: Admin vs Clinical needs?

In my nursing career to date and over the past 18 months I've been involved in some complex clinical cases involving profound physical, mental and social aspects of care.

Such complexity given the rise of long-term chronic medical conditions, multiple diagnoses and an ageing population is not uncommon. What is more remarkable is simultaneously reading on the records management and other informatics mail lists questions regarding the retention of specific types records within health care, social care, schools and the human resource departments of other organisational settings.

From the perspective of Hodges' model and the notion of a health career you wonder about the efficiency of administration - and legislation - versus the potential future utility of 'archived' clinical records. Clinical records from 20 years ago and less have frequently been destroyed and you are left to consider the possible relevance of that information to the care delivered in the here and now? This is particularly acute for reasons of the following:

• the increase in dementia and an individual's capacity to account for their past care;
• the increase in fractured family histories;
• the likelihood of significant past care episodes and medical events relevant to future episodes: 1) cancers; 2) psychological problems; 3) negative life experiences;
• the use of the medical record (health career) to inform someone's life story (and not just as a 'therapeutic intervention').

Is there an argument for a re-appraisal of retention schedules? Factors to consider might include:

• the shift to digital collection, storage, archiving and ever improving retrieval technologies;
• the use of semantic search - and intelligent (context - discipline-based) applications;
• the ability of the individual to decide on the longevity of their records;
• the advice of specific patient groups - Alzheimer's; Multiple Sclerosis; HIV / Aids...;
• the transition of an individual record to an item of historical interest;
• the ongoing emphasis upon collaborative care, self-care and personal health records;
• Archiving - shift from paper-centric to inclusion of digital media?

What do you think?

Additional links:

DoH Records Management - Information Policy

DoH (2006) Records management: NHS code of practice

Personal Health Record

Holistic care: What is 'holistic bandwidth'?

The old website with its pages is static. In thinking about how to mix the old and create new dynamic content for a Drupal based site, I came across a possible way to define and explore our notions of holistic care. Here are some very initial musings....

First to focus on quantity. In completing an assessment whichever care domain I start in (let's say the intrapersonal domain) then as that domain is populated can it be argued that within the other domains the same number of placeholders for our assessment data are created? If my patient has eight problems (and two strengths) then according to one definition of holistic bandwidth the remaining domains should have the same number of problems (and strengths). Balance in all things - including holistic care?

One thing that the ADLs teach us is that (holistic) care as represented in Hodges' model is asymmetrical.

This does not mean that the ideal of holistic care is lost.

It might mean that strident efforts to assure holistic bandwidth can interfere with our attaining person-centred, integrated and multidisciplinary care.

It is essential that we recognise holistic care as an ideal, as a constraint and the primacy of functional considerations in:

• assessment;
• planning;
• care interventions;
• evaluation;
• and governance.

It comes as no surprise then that there are several versions of holistic bandwidth:

1. If we want to be inclusive then version #1 is epistemological. This anticipates the total number of semantically associated concepts that can potentially arise in a given care episode. This is what might be termed the 'semantic web of care'.
2. The sum total of concepts across all the care domains (inc. spiritual) that are actually activated in the course of a care episode.
3. The concepts that are deemed relevant by the patient, carer, family and guardians.... These add holistic value to and may well (must!) overlap with the care concepts recorded by the clinical team and reflected in the health record(s).
4. The degree of expressiveness of the care recording system - its capacity to represent holistic care and capture (measure) holistic bandwidth pre- or post- care episode completion.
5. The (idealised and learner generated) collections of care concepts identified and enacted within education.
6. The idealised and actual collections of holistic arrays applied and recorded by the combined clinical and social care disciplines* involved (there are two sets in practise and theory). As per #3 these (should) overlap with the patient and carer's....
7. The final combined lexis of written, electronic and other record(ed) media that constitutes the final:
• personal health record;
• summary health record;
• historical health record;
• clinical record;
• ....
• all the above combined;
• an individual and group's (family) health career!
8. In addition there are the anonymised and aggregated data items that form part of clinical / management reports, local, central government statistics and returns that inform national health and social care policy and global health intelligence at the WHO.
9. Throughout 1-8 holistic bandwidth must also incorporate education, engagement and informatics.

It is reasonable to speak of personal and impersonal forms of holistic bandwidth.

Students - if this is helpful or confusing please let me know h2cmuk @ yahoo.co.uk

Hygiene: Hand wringing and Hand washing

Personally at the moment - and for some months to come - I’ve a lot of hand wringing to do. Ever future facing, while I get on with that - I’m reminded of the ongoing crusade for hygiene in hospitals and other clinical and care environments.

While 'hygiene' does not always seem to have the desired reach that health protection / infection control managers and Trust Boards would like - there are other examples. In mental health - after Clifford Beers - we speak of mental hygiene. In community nursing we commonly speak of sleep hygiene. So (grab the Horlicks) let’s check the sheets for unnecessary creases and see if we can’t improve things as heads are laid on pillows.


There is another form of hygiene which people* in many countries are having to practice at present: economic hygiene. A stock take of income and outcome. Of course, organisations do this when budgets are tight. In health and social care managers quickly identify the soft belly of savings that can be made.

Take the hygiene too far though and obsessive hand-washing becomes a problem.

(Could Hodges' model encourage a tendency for over-thinking? Does it provide evidence for those who characterise  reflection as navel-gazing and prevarication?)
For health care providers given the priority of nursing (the front-line!) administration is an easy target for savings.

There are new dependencies now though. The balance between admin and nursing duties has become blurred, with the arrival of IT AND paper systems.

So clearly - wash your hands according to the policy and latest evidence-based advice, but do take care that admin does not get washed away in the process.

*Me too!

Care Architects in an Era of Care Ecology

Not everyone is an Architect. And yet we are all architects at certain times when a proposal with its accompanying design, construction and commissioning challenges comes along. The difference is formality (the law) and scale: ultimately we the 'architect' may defer to the professional.

Similarly, we are not all Doctors, Nurses, Social Worker, or Occupational Therapists... although we may have played these roles in imagination and in taking on day-to-day diagnosis and problem solving: Do I(we) need to consult? Like a bandage there is a twist here -

You see, we are all Care Architects.

The duty of care is quite an extensive concept. The call to reach for the T-square and drawing desk will hopefully be infrequent, rare even, when we do the starting point is the problem at hand, whether that hand is injured, tonsils are swollen, belly aches or our mood is low.

There are set points in our lives where personal administration is a necessity. The tax return, dental checks, the renewal of insurance policies, eye-sight check-up. It is nice when these things look after themselves, these days we even have e-prompts to jog us into action.

Looking at Care Architecture as a whole - as a Care Ecology - this ecology has another starting point; one to which the individual / patient does not usually have ready access. The medical record. If this is not our starting point, it is for the health and social care workers (although there are many constraints that operate for these Care Architects). More and more is being expected of us as individuals and members of groups - be that as 'patients' or 'citizens'. A primary example is Health Space:

HealthSpace is a secure online personal health organiser. Anyone over the age of 16 and living in England can open a HealthSpace account.

HealthSpace is an initiative that is designed to acknowledge how we are all Care Architects at heart and part of a much wider care ecology.

As of Feb 2008 - once subscribed and depending on geography HealthSpace may provide the account holder with access to their Summary Care Record.

It would be very interesting to see the (h2cm) profiles of HealthSpace subscribers thus far. There's a marvellous MSc. - Ph.d dissertation there for someone. People with long term medical conditions or extended acute episodes may recognise the benefits of being actively engaged in contributing - writing to and viewing - their (own) medical record.

This engagement must be
a vital perspective
not a vanishing
point
.

What about the rest of us? How can we get over the personal admin-hump?

How can people be engaged in their health record? Health is the operative word here.

Bottom line: The parts informatics does not reach

I really must get on board the bus: there are many assumptions that people make, what a nurse does, the role of a social worker and such like. I'd assumed that the private health sector - in this case a provider of residential nursing care would automatically invest in administration and clinical information systems. Silly me.

I don't know if the home I visited is an exception or typical of this particular group, but the staff are not only struggling to provide the best quality care for their residents, they are struggling with paper. Where's the I.T.?

2007 heading fast towards 2008 why I.T.'s in plastic folders, pinned on the office walls, on the office desks, semi-scrunched into pockets.

There is nothing wrong with paper and after all these staff are expert in handling several types.

What I was told, is that when a home (or two) is acquired and there are examples of good practices in documentation these will be adopted by the new parent. That is good; nothing wrong with that, surely this is a key part of what acquisition is all about.

The problem is that amid these additions the whole documentation system is not reviewed and rationalised; so the paper-burden grows literally with the organisation. Conclusions:

1. There is a records management consultancy opportunity there for someone (race you!).
2. I did not have to wait to see and discuss my client. There were no clinical information system vendors cueing up to demonstrate their wares. So good news for clinical informatics suppliers: you have of course not yet covered the (w)hole market!
3. If this particular organisation is successful financially, how much more successful could it be if it embraced clinical and organisational informatics?
4. Does the Commission for Social Care Inspection (and other regulatory agencies) take informatics capability into account in their assessments? If the benefits of effective informatics are real then they must be represented in inspection reports: shouldn't they?
5. 'Success' what does this mean in a nursing home? Well, let's try marks out of ten -

• the bottom line in the Financial Times;
• the bottom line in the nursing home main office;
• the bottom line on that top floor with its residents, staff and relatives/visitors.

So, what is the real bottom line?

Out of sight....

Invitation to post to the QUAD & human ecology

I've sent out some invites to people I've either worked with, or had contact with over the years since starting the website in 1997. Invitees will be able to contribute directly to this blog.

It would be great to have other authors on board, but of course I realise everyone is busy so I'm open minded. This move is long overdue and does me good in terms of 'letting go' and releasing H2CM into the wild.

Switching to the latest Blogger I lost haloscan. I've added it again to manage comments: purely in response to a sense of anticipation than demand. In doing so it appears I've lost earlier comments; although the correspondence is saved the loss is still a pain.

Job-wise things are a bit up in the air at present. Clinical - Informatics: both...?

There are plans for another group meeting on human ecology to possibly establish a NW England group. Possible dates are:

• Sat 9th or Sun 10th June
• Sat 30th or Sun 1st July
• Sun 8th July

The venue could be Sedburgh (lots of bookshops apparently!) or Manchester where we met in March. Let me know if you would like more information.

With the Serres-Hodges chapter now out the door (what a relief!) it would be good to write something collaboratively using some of the available e-tools.

More soon...