Author Archives: Kathleen Begonia

Systems… from a nurse’s perspective

Before diving into edtech, I want to share a healthcare perspective on systems. In my work as a nursing informatics specialist, I observe and analyze nursing workflow, identify gaps, speak with vendors or our internal IT team for solutions, propose, implement, and maintain solutions with the help of an interdisciplinary team of information systems analysts and clinical folks. Some clinicians are not satisfied with the systems they use to document care because not all systems were built with clinician input.

To provide some background, the American Reinvestment & Recovery Act (ARRA) enacted in 2009 included many measures to modernize our nation’s infrastructure. One particular measure, the “Health Information Technology for Economic and Clinical Health (HITECH) Act” included the concept of electronic health records – meaningful use [EHR-MU], an effort led by Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT (ONC).

Under Meaningful Use, hospitals needed to implement certain electronic services and technology by government established timelines in order to receive monetary incentives from CMS and avoid financial penalties. For example, Meaningful Use stage 1 established base requirements for capturing clinical data, which means hospitals needed to implement an electronic health record.

As a result of the EHR Incentive Programs and the temptation of EHR incentive payments for EHR adoption, many healthcare organizations rushed to implement technology that became obstacles for efficient clinical workflows.  As Broussard mentions, computers really are proxies for the people who made them! Vendors without clinical staff perspectives jumped at this opportunity and hospitals made deals quickly to meet Meaningful Use standards and get incentive pay. A decade later, we have EHRs that are barely usable and we keep layering on APIs (application programming interfaces) to make the systems we have slightly more usable. Depending on the development and implementation, sometimes I feel like it’s a house of cards waiting for the next upgrade or API to break it all down. But, I love being in the middle of it because I have a say when I test systems. I can advocate for my clinicians.

It’s interesting how government incentive payments have the power to drive implementation. Money speaks!

A perspective on Electronic Medical Record systems

and back to EdTech…

Learning management systems, adaptive learning systems, centralized computer systems, mobile applications, and algorithms built into systems that reinforce oppression. This week’s readings covered various systems that produce educational technology.

I appreciate Broussard and Noble’s respective pieces about how people can significantly impact the system experience. Broussard highlights how systems can fail students if not used to their full potential. Students at poor schools are at a severe disadvantage without the textbook resources they need. But, how would the administrators know what they needed if they didn’t keep accurate tabs of the textbooks in the system they already had?  Even the educators’ haphazard method of keeping track of textbooks was a failure of the school system.  It’s kind of insane to me that the projector method of viewing textbook stock was acceptable…I wouldn’t guestimate my patient’s stock of IV fluids or medications and just deny them these resources if I ran out. But, then again I haven’t been an educator in an underprivileged school, so I don’t really know the other factors that come into play.

The centralized computer system did not have accurate records about each district’s textbook quantity and many students did not have a textbook to use, hindering their education and ability to score well on standardized tests. This touches upon the golden triangle of people, processes, and technology, which is a framework often discussed in systems development and process improvement. Without enough people to maintain the system, the process of textbook tracking, and technology in the form of the centralized computer system fail.  There has to be an equal balance among the three concepts otherwise stakeholders of the system suffer. In this case, the students suffer.

I’ve felt this frustration when shopping for an item and driving far to retrieve it, only to have the store associate tell me that the stock is not accurate online and they’re sold out of the product.  So, what’s the point of the system then if the data isn’t accurate?

Noble’s discussion on algorithms of oppression highlight what’s happening today with the coronavirus and xenophobia. I remember seeing images of Chinese food, bat soup with wild animals, and Chinese people while scrolling through Facebook and Google when coronavirus (COVID-19) was extremely new and rampant in Wuhan, China. Today, these images seem to be gone from the feeds and searches, but they still exist in the real world.  Xenophobia and micro-aggressions are trending topics in search engines and real life. If only I could have a dollar for each time I hear “we can’t eat Chinese food….” everywhere I go….

Noble also mentions the significance of the digital divide and how we leave people behind when we implement technology without considering culture, access, or usability. How do I tell my patients who speak Ethiopian to access their discharge instructions on their patient portal when the instructions are only written in 5th grade English and they don’t have Internet or a computer at home? How does an educator tell a student to complete an assignment on a mobile application if they can’t afford a phone?  I liked Liz Kolb’s podcast assignment, but I don’t like how it assumed that every student owned a cell phone. There are students who cannot afford smart phones and may not be able to participate in class activities that suggest cell phone use. Sometimes we also forget about students with special needs who have physical limitations or cognitive delays. How do we incorporate them in learning activities if they do not have a cell phone or cannot use a cell phone?

Cost is always a factor when considering the use of complex edtech tools. As Broussard mentioned, systems are a great responsibility because of 24/7 maintenance. We need a lot of money to pay vendors to upgrade systems, provide help desk support, and account for hardware and data storage.

My new Chief Digital Officer, Claus Jensen, has a phrase he reiterates: “Buy what accelerates, build what differentiates” so we can support our toolmakers and caretakers and keep caring for the people who need help. For some reason, it really stuck with me.

This phrase seems to relate to the private equity deal between Instructure and Thoma Bravo. Thoma Bravo seems to want to “buy what accelerates” since they already own Frontline education, an administrative and HR software solution for educational organizations. Instructure also wants to remain sustainable and “meet the bigger needs of education than just being an LMS” by “exploring strategic alternatives in order to maximize shareholder value.”  Once Instructure’s deal closes (if it does), it will become private and allow it to invest more in its software and potentially make more acquisitions. I’m not sure if Thoma Bravo will decide to merge Frontline and Instructure or what the future holds for them. I’m curious as to what they will build to differentiate. How will their strategy change and do they have the best intentions of the students/faculty? Whenever I see a company take over, I wonder about their intentions.  I looked up Thoma Bravo and I couldn’t tell from their website if an educator sits on the board.

 Instructure’s pending deal rightfully raises worrisome questions about downstream effects. Employees wrote public letters calling for Instructure to make a legally binding public pledge that will protect student data under new ownership after the CEO boasted to investors about having “the most comprehensive database on the educational experience in the globe.”

How are the students and faculty affected? What will happen to their data? Will their data be used for profit without their consent? Will the data be used to create algorithms and predictive models? Will they be charged for modules or specific uses of the system?

It’ll be interesting to see what happens. How will faculty play a role in this? Steven Oxman and William Wong give a thorough overview of adaptive learning systems in their white paper. They cover the three core elements and give examples of these systems in corporate training and different levels of education. I appreciate the overview, but I am left wondering about the role of faculty. I see that the adaptive learning systems are starting to integrate sensor use to integrate the learner’s affect, but something about this doesn’t feel right…it can certainly tell educators how a student is feeling when taking modules or a particular test. This can help the educator make a decision on how to address the learner since other factors in life may affect learning.

What I enjoy most about learning is story telling. Personally, I remember concepts best when faculty find a way to incorporate a personal example. Learning systems can incorporate stories, but there’s a different feel when a professor tells you an emotional story that reinforces the learning concept and you have a live discussion about it. 

I’m curious to know, being of the health profession and as an outsider looking in, do you agree with Phil Hill when he says that the market is much healthier and more focused on educators’ needs than it was a decade ago? Or does it depend where you work (Country wide, internationally, here in NYC)?

If the government decided to revamp the nation’s educational system by providing millions of dollars in funding, what aspects of systems would you incorporate so that it would be fair to all students?

Apologies for the long post. I was a blogger in a past life. Looking forward to our chat Tuesday!

Please remember to stay calm, wash your hands with soap for 20 seconds, don’t touch your face, cover your coughs, drink a LOT of water, and if you feel slightly ill, stay home! I’d also recommend limiting intake of media stories about this virus and navigate straight to the CDC and WHO websites for information.