Personalized Medicine

What would be considered a ‘clinical best-practice guideline’ in this new personalized healthcare world?  Would they exist?

Personalized medicine is a growing area of healthcare where specific diagnostic tests are carried out to identify biological markers to diagnose, prevent, and treat disease. It moves from a “one size fits all” approach to a personalized approach. For example, in cancer patients, personalized medicine uses specific information about a patients tumor to help diagnose, plan treatment, monitor the treatment progress, or make a prognosis (National cancer institute, 2019). A common theme when researching this question was that the growth of personalized medicine outpaces clinical guideline development. Pritchard, Moeckel, Villa, Housman, McCarty, & McLeod (2017) provide a research article outlining strategies to introduce personalized medicine into healthcare. Clinical guidelines will absolutely have to exist. The issue will be having to update and integrate them into practice. Current clinical guidelines do not reflect current concepts in personalized medicine which discourages its use in healthcare (Pritchard et at., 2017). Strategies suggested by Pritchard et al, 2017 generally revolve around proving personalized medicines worth, educating the healthcare system as well as the patient, ensuring an infrastructure and information management system that can handle this change, and ensuring access to care. Ways suggested include updating current guidelines that focus on the best care for individuals to be updated to include personalized medicine practices and policies, clinical studies, education, patient involvement, develop standards and policies (Pritchard et al., 2017). 

I stumbled upon the Clinical Pharmacogenetics Implementation Consortium (CPIC). They claim a barrier to pharmacological testing was translating genetic lab test results into actionable prescribing decisions for affected drugs (CPIC, 2019). Their goal is to provide gene/drug clinical practice guidelines and show clinicians “how genetic test results should be used to optimize drug therapy, rather than whether tests should be ordered (CPIC, 2019).” On their website, you can find an extensive list of guidelines that correspond to a specific drug/gene. https://cpicpgx.org/  

What research designs would be best to study cause-effect relationships in healthcare?   Would randomized control trials still be the ‘gold-standard’ when clinicians are able to develop treatments and medications specific to an individual’s genomic markers?

Today clinical trials are large, including thousands of people and revolve around finding out if drugs, medical devices, or treatments will work in general with a overall low response rate (Cristol, 2019). But with personalized medicine, its focus is on a particular aspect of the disease (genetic mutation, lifestyle trait) that only some of the people have (Cristol, 2019). By weeding out non-responders you have a better chance of finding something that works. 

How would the profession of nursing look in a world where there is a focus on the genetic composition of an individual in terms of their treatment and recovery?  What would nursing education/practice need to do to support this refocus on client care? What are the potential legal and ethical considerations that nurses will need to reflect upon?

Currently, advanced practice nurses have little knowledge, understanding, and acceptance of personalized medicine and genetics integration into healthcare (Chadwell, 2013). Precipitated by the fact that there is little to no content included in the nursing curriculum (Chadwell, 2013). This is a huge barrier to its success. Efforts have been made over the past 20 years to integrate genetic and genomic knowledge into nursing practice with the creation of the scope and standards in 1998, the curricula guidelines, and outcome indicators in 2005, and the competencies for nurses in 2012 (Chadwell, 2013). According to Chadwell (2013), the implementation of personalized medicine rests on the understanding and appropriate use by healthcare providers, specifically nurses. In the 2012 guidelines mentioned above competencies outlined include genetic testing, education, ethical, legal, and social implications, and professional role (Chadwell, 2013). Advance practice nurses will be involved in the assessment, diagnosis, and treatment of persons so it is vital they have general knowledge and understanding of genetic testing and guidelines. They also have the opportunity to become certified.

As outlined in the Human Genome Research Institute’s Ethical, Legal and Social Implications Research Program, ethical and legal issues may include informed consent, emotional impact on family, the potential for discrimination, reproductive choices/prenatal testing, inappropriate testing of genetics, setting boundaries in applications of genetic testing, forensic DNA database, and patenting of genes, coverage and reimbursement, genome editing, human subject research, health disparities, intellectual property in genomics, privacy of genomics, synthetic biology, and regulation of genetic tests (Chadwell, 2013; Ethical issues…, 2018; National Human…, 2018). https://www.genome.gov/Funded-Programs-Projects/ELSI-Research-Program-ethical-legal-social-implications https://www.genetics.edu.au/publications-and-resources/facts-sheets/fact-sheet-19-ethical-issues-in-human-genetics-and-genomics

Do you think ‘personalized medicine/healthcare’ will ever exist?

I absolutely do. However, with healthcare slow to change I feel it is still a ways away. Once there is more education, awareness, and proof I believe the benefit will be seen and then we can really put into action what has been happening behind the scenes. 

References

Centre for Genetics Education (2019). Fact sheet 19. Ethical Issues in Human Genetics and Genomics. e-book. Retrieved from https://www.genetics.edu.au/publications-and-resources/facts-sheets/fact-sheet-19-ethical-issues-in-human-genetics-and-genomics

Chadwell, K. (2013). Clinical Practice on the Horizon. Clinical Nurse Specialist, 27(1), 36–43. doi: 10.1097/NUR.obo13e318277703c 

CPIC. (2019). Guidelines. Retrieved from https://cpicpgx.org/guidelines/

CPIC. (2019). Home page. Retrieved from https://cpicpgx.org

Cristol, H. (2019). How Will Precision Medicine Change Clinical Trials? Retrieved from https://www.webmc.com/cancer/features/precision-medicine-clinical-trials#1

National Human Genome Research Institute. (2018). Policy Issues in Genomics. Retrieved from https://www.genome.gov/about-genomics/policy-issues

Pritchard, D. E., Moeckel, F., Villa, M. S., Housman, L. T., Mccarty, C. A., & Mcleod, H. L. (2017). Strategies for integrating personalized medicine into healthcare practice. Personalized Medicine, 14(2), 141-152. doi: 10.2217/pme-2016-0064

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Incorporating informatics and Tanners model of clinical judgement

“Clinical judgement in nursing has become synonymous with the nursing process (RNAO, 2012).” Tanner expanded on this theory to reflect the complex decision making process we as nurses face. In Tanner’s model four steps are introduced: noticing, interpreting, responding, and reflecting. ICT (information and communications technology) can be utilized at each step to support nurses clinical decision making. For example, using documentation tools to review and enter assessment parameters (noticing), extracting evidence to formulate a plan (interpreting), determining appropriate interventions (responding), and evaluating expected outcomes (reflection) (RNAO, 2012).

Below is an example of using Tanners model in a clinical situation I encountered last week.

Noticing-increased sleep in patient
-unable to rouse from verbal or physical stimuli
-ashen skin color
-decreased urine output,
concentrated (foley catheter)
-previous nursing experience enables calm, knowledgeable reaction-use of vitals machine
-refer to electronic chart for patient information (history, medications)

Interpreting-possible seizure activity r/t patient history-patient has history of decreased LOC-recent trach removal (6 days prior)-vital signs required
-access to patient records
(patient history, medications)
-LOC assessment (glasgow
coma scale)
-verbal and physical stimuli (sternal rub)
-need to speak with Dr
-speak with POA to verify code status (new admission)
-vitals machine
-electronic chart
-physicians on call list (accessed through steghnet, internal website)
-telephone
Responding-goal to ensure patient
safety. That pt rouses
without deficit
-LOC assessment  
>patient did not rouse,
moved upper limbs slightly  
>performed sternal rub, pt again moved upper limbs,
eyes remained closed and rolled back into head  
>glasgow coma scale score of 5
-Vitals assessment  
>WNL for patient
-sternal rub  
>slight response, moved upper limbs and head
-checked patients chart
-called POA  
>verified code status
-called doctor  
>came to assess
-vitals machine
-electronic chart
-physicians on call list
(accessed through steghnet,
internal website)
-telephone
Reflecting-DR noted possible seizure,
continue to monitor, no
concerns
-updated POA
-patient began to rouse
within 2 hours
-awake and eating by supper time

-vitals machine
-electronic chart-telephone

References

RNAO. (2012). Integrating eHealth into the Undergraduate Nursing Curriculum. Retrieved June 4, 2019, from https://rnao.ca/sites/rnao-ca/files/Nurse_Educator_eHealth_Resource_-_2012_2.pdf

Medication Administration @ STEGH

Medication administration is something we all perform many, many times per shift. It has become so routine that most times we don’t even think about what we are doing. This assignment has given me the opportunity to break down how much thought actually goes into one simple medication administration, and reminds us how important this task really is.

I work at St. Thomas Elgin General Hospital as a full time RPN in continuing care. Here my patients tend to stay a bit longer, and I get to know them more personally. Although this is one of my favourite parts of the job, there is a danger here. There is great risk of medication error because we become so familiar with our patients and what medications they take that sometimes we forget to simply stop and double check. This assignment was a great reminder to me to do simply that.

Below is a word flow chart I created. I found it very useful, and a great reminder of our basic nursing duties.

As you can see, the majority of thought occurs before you even retrieve the medication. There are so many factors involved in this process and I am sure I have forgotten some. So lets all remember to slow down (easier said then done ;)) to ensure patient safety.

Exploring eHealth Systems

Types of data and information captured in the different eHealth systems utilized in healthcare

Health informatics makes the coordination and collaboration of patient data and information possible. It encompasses a wide range of purposes from administrative to healthcare delivery, and is an essential component of healthcare renewal (eHealth, 2010). Within the eHealth umbrella is nursing informatics. The CNA defines nursing informatics “as the practice and science of integrating nursing information and knowledge with technology to manage and integrate health information” (Nursing informatics, 2019). Several technologies have been developed to aid in communication and delivery of healthcare.

EHR – Electronic Health Record. The building block of all these applications. Simply put, the EHR is a lifetime record of your health history. The information in your EHR can be accessed by anyone on your healthcare team in real time. What you can expect to find in your EHR may include: medical history, allergy information, contact information, appointments, results (lab, diagnostic, etc), infection control, consultations, reports from healthcare team, past hospital/emergency visits, treatment plans, diagnoses, etc (What’s an EHR?, 2019). Here at STEGH we use Power Chart. In addition to the above mentioned data, we also use this program to administer medication and enter order sets.

PACS – Picture archiving and communication system. This is a medical imaging storing and transmitting technology. Data utilized here would be images such as x-rays, nuclear medicine images, ultrasound, MRI, CT scans, mammograms etc. May also include non image documents such as results of image test. These images and results can be accessed by anyone authorized on the healthcare team. We would see this type of system in a hospital setting, clinic, or doctors office. The information from these images are used to diagnose and implement treatment plans.

CPOE – computerized physician order entry. An electronic system for entering physician orders. Before this technology was developed nurses would transcribe verbal orders from physicians resulting in a high chance or error. These systems have been proven highly effective in reducing errors due to the built in safety guards, organization of information, and quick access. Order types consists of medications, treatments, communication orders, wound care orders, diet orders etc. Here at STEGH, our CPOE is integrated into our EHR which is all located in Power Chart as mentioned above. I think this program is beneficial because we have access to all our patients information, and the ability to administer medication, enter orders, check test results etc all in one place. For me personally at STEGH, we have a great group of doctors who put a lot of trust in us as nurses, and we are able to enter many of the orders ourselves, with verbal direction of course. The orders are what nurses use to guide patient centered care.

Telehealth – utilizing technology to connect patients with their healthcare team when they are not located in the same area, or able to attend the healthcare facility. Can be done over the telephone, or by video conferencing. This is beneficial to the patient by helping them save on travel costs, greater access to specialists, reduce barriers to access, and shorten wait times. Another part of telehealth is telehealth Ontario. By calling a 1-800 number you are connected with a Registered Nurse to get general health information, or health advice. It is free, completely confidential, and open 24/7. undefined

Patient Portal – secure, online websites that allow patients access to personal health information. Patients can view information such as recent visits, discharge summaries, medications, immunizations, and lab results. Some may allow access to prescription refills, communication with your doctor, schedule non-emergency appointments, make payments, download and complete forms, request referrals, and check benefits (What is a…, 2017).

Handheld – handheld technology such as phone, or iPad/tablet. Mobility is a central feature to healthcare delivery. This technology aides physicians to better communicate and collaborate with the team as their job requires them to move between clinical areas, patients, locations, etc. These devices would also house the same information of the electronic or paper chart, and be accessible to anyone authorized. The benefit of this is ease of access, and time saved. The physician will have immediate access to patient information at the bedside and not have to go in search of a computer or paper chart.

References

EHealth. (2010, August 09). Retrieved May 25, 2019, from https://www.canada.ca/en/health-canada/services/health-care-system/ehealth.html

Nursing Informatics. (2019). Retrieved May 25, 2019, from https://www.cna-aiic.ca/en/nursing-practice/the-practice-of-nursing/nursing-informatics

What’s an EHR? (2019). Retrieved May 25, 2019, from https://www.ehealthontario.on.ca/en/ehrs-explained

What’s an EHR? (2019). Retrieved May 25, 2019, from https://www.ehealthontario.on.ca/en/ehrs-explained

Progression of technology in Healthcare

Despite one video taking place in the past and the other in the “possible” future, they both seem pretty far fetched. Starting with the 1960’s EMR video. Before watching this video and starting this class which prompted reflection on informatics in healthcare, I thought technological development in healthcare was relatively reasonable. But the more I think about it and learn, I don’t think I can say that anymore. Having watched this video and learning that over 50 years ago a goal was set to eliminate nurses and doctors paperwork I have to reconsider. Here in 2019, technology has come so far in so many ways yet seems to be lacking in the healthcare industry. Where I work, luckily we have WOW’s and electronic charting. But we have only had them for 5 years while “everyday” computers have been around since the 80’s and the internet since the 90’s. And even with that resource we still have certain tasks that require paper charting. From my social connections and general knowledge of the healthcare industry, it appears there are many places that do not have this “luxury”. At the end of the video, it states their hope is to eliminate medication errors, some of the paperwork and correlation of diseases. I would say we have made a step in that direction but a leap is needed. They achieved such success in such a short time. Yet over 50 years later we still have a great deal of paperwork, and medication errors. I would expect that after 50 years and with such growth in technology that we would be a lot farther ahead. It seems to take the healthcare industry substantially longer to catch up, and I can only assume that has to do with government funding, as well as difficulty in implementing change in such a delicate industry.

In regards to the “Future Vision” video, I watched it twice. The first time I watched it I thought it was great, and somewhat feasible. I watched it again about an hour later and saw it through a completely different lens. As I sit here at the nurses station at work, watching this video, and having an understanding of the current healthcare system I can only conclude that this “future vision” is mostly too far-fetched and a marketing ploy. At least in my lifetime or my children’s’ lifetime. If it took 50 years to barley get electronic charting started in such a technology driven world, I can’t imagine this “vision” coming to fruition any time soon. Aspects of the video I think could be possible was the use of the digital wallet and the prescription refill “kiosk”, the doctors use of ipad’s at the bedside, and the devices they used to either communicate with each other, store data, track progress, and set reminders (aka phones/computers). We can already see these ideas in use in today’s world and I believe development of these ideas will only continue to grow. Aspects of the video that seem far fetched include using the iPad to locate a medical device in a room like it can see through a wall or being used as a map, and the medication reminder table where the patient is responsible for administering their meds. Not only do these ideas seem ludacris, I don’t see the purpose of them. I don’t believe we need technology to locate a device or patients room for us, we should be more than capable of doing that ourselves. In reference to patients administering their own medications, I don’t see that ever working. How would you control this? Where are the regulations in regards to narcotics? Who is accountable if an error is made? When the hospital is responsible for the life of a patient I don’t believe allowing them to essentially “perform” their own procedures is a step in the right direction. We wouldn’t allow them to perform their own surgery would we? I just don’t see how that would be possible. Although this video has some interesting ideas, in the end it plays out as a marketing ploy.

Technology utilized by myself, as an RPN
Employee

WOW – here at STEGH we use a WOW for electronic charting, medical administration

Powerchart/Cerner – software used for electronic charting, EHR, medication administration

Kronos – software used for work scheduling resources

Equipment – ECG machine to perform ECG’s, bladder scanner to assess bladder fullness, fax/phone/copier, vitals machine, IV pump for IV medication administration, vocera (communication device amongst co-workers), ADC (medicine dispensing cabinet), glucometer used to test patients blood glucose, VAC therapy

Student

Simulation lab – computerized mannequin used for patient simulations