EDST 1002 Chapter 2: Viewing Learning as Dependent on Sequencing and Readiness

General guidelines for completing the Assignment-1

1. You are required to work independently on one of the two cases listed for the assignment.

2. You may choose to search for the information online or in standard text books, research journals, online resources of biomedical research, pharmacogenomics knowledge base, etc.

3. You are required to list items of literature referred to at the end of the narrative under the subheading ‘References’. You are encouraged to refer to the original research publications where applicable and cite in the text. Citations in the narrative should be numeric as per the list of references.

4. Please Be Independently Dependent on the resources.

5. Expectations in regards to the required key points of information, are provided for individual cases.

6. Limit the entire narrative to not more than two pages including references.

Timo is a healthy high school student with good dietary habits. He lives with his family in the suburbs of Lexington, KY. He started working part-time to save some money for an international travel that he is hoping to do after high school graduation. Timo has been experiencing lots of fatigue during his regular sport ever since he started working part-time that involves lots of physical activity. He has been very cautious about his diet; he has never missed multivitamins and five servings of veggies/fruits. Timo met with the family care physician. Following the checkup and lab tests, he was suggested to take an OTC product containing L-methyl folate regularly and was scheduled for followup. Timo felt better after taking the OTC product for two weeks however he wanted to see the provider to better understand his situation. He was suggested to continue taking the L-methyl folate especially when he feels fatigued. Furthermore he was given an option of genetic tests for a particular gene so that his condition could be better-explained with a long-term plan for self-care. Timo’s family could not support the genetic testing however he was strongly interested in knowing about his condition and how genes matter.

Investigate and synthesize pharmacogenomics of this case? Your narrative should contain but not limited to the following information:

1. What is the most relevant gene to be tested for variants in this individual? How many genetic variants for this particular gene are reported? What are the major variants? 2 points

2. What is the prevalence of major variants in different ethnic groups? 2 points

3. Describe the molecular and phenotypic characteristics of the mutations (nucleotide or amino acid switch) in the major variants? 2 points

4. What happens if this individual is given folic acid continuously instead of L-methyl folate? (list and discuss in context not more than two clinical conditions excluding fatigue) 2 points

5. The individual has good dietary habits. Would the folate derived from diet be not sufficient to overcome the condition of the individual? Yes or No, explain. 2 points.

For many of us, smartphones have become indispensable, but they have also come under fire
for their impact on the way we think and behave, especially among children. Two of the largest
investors in Apple Inc. are urging the iPhone maker to take action against smartphone addiction
among children over growing concerns about the negative effects of technology. An open letter
to Apple on January 6, 2018 from New York-based JANA Partners and the California State
Teachers’ Retirement System (CalSTRS) stated that the firm must do more to help children
fight smartphone addiction. These two shareholders together control about $2 billion in Apple
stock. The investors’ letter urged Apple to offer tools to prevent smartphone addiction and to
provide more parental options for monitoring children’s smartphone usage. The iOS operating
system for Apple smartphones and tablets already has limited parental controls for restricting
Examiners: Dr. Emmanuel Awuni and Dr. Acheampong Owusu Page 2 of 4
apps, features such as location sharing, and access to certain types of content. The investors
felt Apple needs to do more—for example, enable parents to specify the age of the user of the
phone during setup, establish limits on screen time, select hours of the day the phone can be
used, and block social media services.
The average American teenager who uses a smartphone receives his or her first phone at age
10 and spends over 4.5 hours a day on it (excluding texting and talking). Seventy-eight percent
of teens check their phones at least hourly and 50 percent report feeling “addicted” to their
phones. The investors’ letter cited a number of studies on the negative effects of heavy
smartphone and social media use on the mental and physical health of children whose brains
are still developing. These range from distractions in the classroom to a higher risk of suicide
and depression. A recent survey of over 2,300 teachers by them Center on Media and Child
Health and the University of Alberta found that 67 percent of the teachers reported that the
number of students who are negatively distracted by digital technologies in the classroom is
growing. Seventy-five percent of these teachers think students’ ability to focus on educational
tasks has decreased. Research by psychology professor Jean Twenge of San Diego State
University found that U.S. teenagers who spend 3 hours a day or more on electronic devices
are 35 percent more likely, and those who spend 5 hours, or more are 71 percent more likely,
to have a risk factor for suicide than those who spend less than 1 hour. This research also
showed that eighth-graders who are heavy users of social media have a 27 percent higher risk
of depression. Those who spend more than the average time playing sports, hanging out with
friends in person, or doing homework have a significantly lower risk. Additionally, teens who
spend 5 or more hours a day on electronic devices are 51 percent more likely to get less than 7
hours of sleep per night (versus the recommended 9).
Nicholas Carr, who has studied the impact of technology on business and culture, shares these
concerns. He has been highly critical of the Internet’s effect on cognition, and these cognitive
effects extend to smartphone use. Carr worries that excessive use of mobile devices diminishes
the capacity for concentration and contemplation. Carr recognizes that smartphones provide
many useful functions in a very handy form. However, this extraordinary usefulness gives them
too much influence on our attention, thinking, and behaviour. Smartphones shape our thoughts
in deep and complicated ways, and their effects persist even when we aren’t using the devices.
Research suggests that the intellect weakens as the brain grows dependent on the technology.
Carr points to the work of Adrian Ward, a cognitive psychologist and marketing professor at
the University of Texas at Austin, who for a decade has been studying how smartphones and
the Internet affect people’s thoughts and judgment. Ward has observed that using a smartphone,
or even hearing one ring or vibrate, produces distractions that make it harder to concentrate on
a difficult problem or job. Divided attention impedes reasoning and performance.
A study published in Applied Cognitive Psychology in April 2017 examined how smartphones
affected learning in a lecture class with 160 students at the University of Arkansas at
Monticello. It found that students who didn’t bring their phones to the classroom scored a full
letter-grade higher on a test of the material presented than those who brought their phones. It
didn’t matter whether students who brought their phones used them or not. A study of 91 U.K.
secondary schools, published in 2016 in the journal Labour Economics, found that when
schools ban smartphones, students’ examination scores go up substantially, and the weakest 
students benefit the most. Carr also observes that using smartphones extensively can be
detrimental to social skills and relationships. Connecting with “friends” electronically via
smartphones is not a substitute for genuine person-to-person relationships and face-to-face
conversations. 

CASE STUDY 7 **** WHAT DID YOU LEARN FROM THE CASE STUDY? ( ****basically just summarize what the case study is about)

Transforming the Clinical Process at Farmington Endoscopy Center William C. Kinney

Transforming the clinical work process in healthcare is not going to be a simple task, as many of today’s work solutions are rooted in decades-long and even century-old autonomous and hierarchical structures. As mentioned in the chapter, Paul Starr’s The Social Transformation of American Medicine explained how US healthcare evolved into a system that separates the business side and clinical side of care delivery. Separating the two functions ultimately created two diverging approaches, leaving the patient caught in the middle. Regulations from both the insurance industry and federal government are trying to bring the two sides together in the interest of what is best for the healthcare system as a whole.

The IOM’s reports on medical quality highlighted the inefficiencies and mistakes that resulted from the increased complexity of healthcare. Although IT exists to change the system, it has lacked the leadership and skills needed to bring about a redesign that, in turn, could transform existing processes and structures. The IOM reports and subsequent analyses have highlighted IT as a tool to improve quality and efficiency. Clinical decision support system (CDSS), in particular, has been identified as a priority health IT, as it pushes evidence-based health recommendations that lead not only to better clinical processes, quality, and outcomes but also to lower healthcare costs. The challenge in adopting CDSS is determining where and how to apply the evidence.

This case highlights the use of health IT to transform the clinical and business processes. Readers should take note of who the relevant players are, the information needs in care delivery, and the method of leveraging information to make care delivery more efficient and effective.

Farmington Endoscopy Center

Farmington is a Midwest college town with a population of more than 100,000 and a large and productive medical community supported by a local medical school. The medical community serves not only the residents of Farmington but also the residents of the surrounding rural communities, some of whom drive more than two hours to get to their respective clinic or hospital. The limited number of primary care physicians who work in rural settings, lack of supporting facilities, and varying socioeconomic backgrounds all add to the complexities of rural medicine. Rural communities also have few manufacturers and corporations that hire employees and provide employer-sponsored, private health insurance. This leaves many rural patients no choice but to enroll in government- supported healthcare programs. Farmington Endoscopy Center (FEC) is a freestanding, physician- owned endoscopy facility that serves both adult and pediatric patients. The main procedures—esophagogastroduodenoscopy (EGD) and colonoscopy—are performed by six gastroenterologist (the owners). Last year, it completed almost 5,000 cases, and this year it is anticipating a 5 percent growth in volume by adding a new physician. FEC is owned and managed by the physicians, but a full-time administrator is in charge of day-to-day operations, compliance with state and federal safety/account- ability standards, billing and collections, and staffing. Rounding out the staff are eight nurses, four receptionists, one billing specialist, and one certified registered nurse anesthetist (CRNA).

Patients are referred to FEC for an endoscopy procedure by the six physicians, each of whom runs a separate outpatient clinic, or by independent primary care or specialty physicians. The independent primary or specialty care physician assumes patient-management responsibilities for the results of the endoscopy, so the gastroenterologist who performs the procedure is essentially a technician whose responsibility to the patient ends at the completion of the procedure. Both EGD and colonoscopy are not painful, but they are uncomfortable and thus require sedation. Administered by the CRNA, sedation techniques range from applying topical anesthetic to running an intravenous line of light anesthesia (where the patient stays awake and can communicate) or a heavy dose of anesthesia (where the patient is unconscious and could stop breathing and may need respiratory support). The CRNA is licensed by the state but cannot act as an independent provider and must be under the close supervision of the gastroenterologist. Throughout the procedure, the gastroenterologist is ultimately responsible for the patient’s well being.

Areas of Improvement

Susan Michaels, the FEC administrator, is reviewing last year’s reports to find ways to increase volume. Both private and public insurance have changed their rules, resulting in lower reimbursements. Meanwhile, healthcare costs continue to rise, further cutting into profits. Needless to say, the FEC physician owners are concerned. Susan identifies two problem areas in the reports:

1. The center has a day-of-procedure cancellation rate of 8 to 12 per- cent. These patients show up for their scheduled procedure only to be cancelled by the clinic because of some factors that were not known before their arrival. The top-five factors are blood-thinner usage, unidentified cardiovascular risk, failure to adhere to NPO (latin for “nil per os,” which means no food or drink hours before a procedure), improper guardianship, and lack of bowel prep.

2. Regulations have doubled the amount of required paperwork to be completed for each patient. Explanation of patient rights and privacy policies, medication-reconciliation process, deep venous thrombosis evaluation, and complication reporting are just some of the tasks or forms that must be completed before a case can be closed. The planned addition of another physician to the practice would increase the number of cases, exacerbating the paperwork problem. Susan is considering hiring another nurse to help the existing staff with the workload, a move that would enable the FEC to accommodate more patients and complete the paperwork quicker. Fortunately, Susan just returned

Fortunately, Susan just returned from a health IT workshop that presented a new logic and tools for how to define the dimensions of a problem and derive workable solutions.

Information Needs

Evaluating and managing patient health needs is about acquiring information and making a decision based on that information. A wise physician once stated that 90 percent of the information a physician consults to arrive at a diagnosis is contained in the patient’s medical history. Much of today’s health IT efforts pay attention to the physician’s information needs for two reasons: (1) The doctor is ultimately responsible for health- care evaluation and management, and (2) the doctor gets paid based on a certain level of information she gathers. A careful review of current EMRs shows that information is maintained in vertical silos or “buckets” and based on billing and collection needs. Information is compartmentalized and cannot be shared easily among all players in the care delivery process. Compartmentalization also hinders the use of the information and masks the time-sensitive value of that information. Time, in this case, is chronologic and pertains to information that must be gathered and acted upon before an event.

In the case of scheduled procedures, decisions need to be made days before the encounter. Anticoagulation therapy, for example, is information that must be relayed before a patient’s appointed surgery or intervention. Appropriately managing anticoagulation is not necessarily straightforward, and a new healthcare player (e.g., a cardiologist) may need more information or guidance. CDSS can ensure that relevant patient information, research evidence, and best practice are available at the right time, a system that is infinitely valuable to a freestanding endoscopy center or ambulatory surgery center.

Information Gathering Process for an Integrated IT

Susan decides to use IT to address FEC’s two problems. She identifies the information needs of each player (i.e., physicians, CRNA, and nurses), and then she breaks down the problems into components to better under- stand the clinical processes and find ways to integrate them to improve efficiencies and patient satisfaction. The ultimate goal is to create a sophisticated data-capture and management IT with an integrated CDSS. The steps she takes are as follows:

1. List each team member involved in an endoscopy procedure. Does the team composition change according to who initiated the patient referral? What steps do the physicians follow to refer patients to FEC? The referring physicians’ information needs must be considered so that a better request-for-procedure ordering process can be developed.

2. List the information needs of each team member, including the supporting players who perform billing, collections, and other administrative tasks. Here are a few examples of these needs:

- The gastroenterologist needs to know why the patient is there. Is this a screening colonoscopy because of a family history of colon cancer? Is this a patient with anemia and guaiac-positive stools?

- The nurse needs to know if the patient had surgery in the last 30 days, as this increases the patient’s risk of deep venous thrombosis. The nurse also needs a current list of medications to complete the medication-reconciliation process.

The CRNA needs to know if the patient is taking an angiotensin- converting enzyme inhibitor. Current recommendations are for patients to not take this medication on the morning of a procedure. The CRNA must know the patient’s cardiac history and be able to identify potential risk factors that would affect the patient’s choice of sedation.

The referring physician needs a system for telling the FEC gastroenterologist, nurses, and CRNA information on the patient, including tests, medications, and risk factors, that could affect the patient’s ability to receive the procedure on the day it is scheduled.

Scheduling needs to know which patients are scheduled for what procedure and how long the procedure is estimated to take. Scheduling staff is responsible for reminding the patient of the appointment time, date, and any preparation (such as the NPO).

Registration needs to know the patient’s demographic and social status. Is the patient a minor? Who will be present to sign the consent? If the child is in foster care, does FEC need to obtain a court order to do the procedure? If the patient is an adult, is he of sound mind and body, or does he have a legal guardian?

Procedure room nurses need to know the capability of supplies and equipment to meet the needs of the patient. Is the patient wheelchair bound, and if so, should more time be added to the schedule? Does the patient have an artificial joint, as this will affect where the electrocautery-grounding pad is placed?

Construct a timeline of the information needs across the encounter. Identify overlapping information needs between players.

As a final step, Susan determines the time component of each information need to ensure that it is available at the appropriate time, which could reduce cancellations. Susan considers available consumer technology, such as the Internet, smart phones, and apps, to enhance the IT option. Susan also looks into outsourcing.

A successful health IT solution for FEC results in a significant reduction in cancellation rates and in a faster or same-day completion of the administrative, regulatory, and nursing paperwork. Such improvements enable FEC to schedule more patients and complete more procedures.