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Transcript of COMMUNICATION INFORMATICS. Enrico Coiera

  • 1. Communication informaticsE

2. A few problems to focus the mind Modern health systems still struggle toimprove quality and safety despite genuinemotivation and resource allocation While hope springs eternal, Health ICT doeshave a history of repeated large scaleimplementation failure Why after so many years is all this still sohard in health, when other sectors likefinance seem to have moved to fully digitalwork processes? 3. Four levels of system analysisNo se puede mostrar la imagen. Puede que su equipo no tenga suficiente memoriapara abrir la imagen o que sta est daada. Reinicie el equipo y , a continuacin, abrNo se puede mostrar la imagen. Puede que su equipo no tenga suficiente memoria para abrir la imagen o que sta est daada. Reinicie elequipo y , a continuacin, abra el archiv o de nuev o. Si sigue apareciendo la x roja, puede que tenga que borrar la imagen e insertarla denuev o. No se puede mostrar la imagen. Puede que su equipo1. Algorithms 2. Computer 3. Human4. Socio-ProgramsComputertechnicalInteraction systems 4. How many possible conversations can happenin a health service? nurse nurse3doctor patient doctorpatient 10 n! m= GP Labr!(n-r)! 5. Computer interpretation Lab LabNominatedLab clinician Data store3rd partystaffLaboratoryPatientDoctor office Doctors officeCourierofficePractice CourierCourierData storeData store 6. The communication space is large Covell et al. (1985): 50% info requests are tocolleagues, 26% personal notes Tang et al (1996): 60% of clinic is talk Safran et al. (1998): ~50% informationtransactions face to face, EMR ~10%,remainder was e/v-mail and paper 7. What happens in the communicationspace? Wilson et al. (1995): communication errors cause17% of system problems, 84% potentiallypreventable Donchin et al. (1995): doctor nurse communication inICU is 2% of work, but figures in 37% of errors Bhasale et al. (1998): communication contributes to~50% adverse events in primary care 8. The communication space is the largest part of the health systemsinformation space contains a substantial proportion of the healthsystem information pathology is largely ignored in our informatics thinking is where most information is acquired andpresented 9. Consequences of interaction complexity Many tasks, Many teams, task heterogeneity,parallelism, lead to Breakdowns at interfaces: incomplete, inaccurate,delayed or failed message transmission Multitasking: Concurrent execution of two or moredifferent tasks. Individual has control of sequencingetc Interruption: Forced multitasking. Individual suspendscurrent task with variable warning. 10. Communication breakdowns at interfacesof care 11. Transitions at the boundaries of care Communication breakdowns often occur at theinterfaces or transitions between care E.g.: sign-off, hand-off, handover, shift changes, signout of patient from ED Involve the transfer of rights, duties and obligationsfor care of a patient Inverse relationship between shift length and n timescare is transferred Patients admitted by one resident and transferred toanother next day have more tests and longer stay (J Gen Intern Med 1990;5:501-5) 12. Communication breakdowns 2007 Review of 444 US surgical malpractice claims: 13% involved 81 communication breakdowns 73% breakdowns verbal, and 64% involved just 2 people Commonly associated factors with breakdowns: Status asymmetry (74%) Ambiguity about responsibilities (73%) Most common events: Resident failing to notify attending surgeon of critical events Attending to attending handoffs 43% breakdowns associated with patient handoffs 39% breakdowns associated with transfer in patient location(J Am Coll Surg 2007 204(4);533-40) 13. Managing talk at the boundaries 89.5% of US EDs report no formal policy on patient sign out,50% sign out only verbally, and 43% rarely documentedtransfer of attending responsibility(Acad Emerg Med 2007;14(2):192-6) Strategies: Communication triggers e.g. two challenge rule if unsafesituation not dealt with Read-backs e.g. confirm understanding at handover Standardised sign-out templates, which include critical fieldssuch as resuscitation (code) status Computerised rounding and sign out - can halve n patientsmissed at resident rounds and improve allocation of residenttime to seeing patients pre-round(J Am Coll Surg 2005;200(4):538-45). 14. Multitasking 15. Multitasking in the primary care consultationroom Doctors use of a desktop resulted in: Shorten responses to patient Delayed responses to patient Dr looked less at patient because looking at screen Dr not hearing patient comments Patients tried to judge when to talk based upon Drsinteractions with the computer (Greatbatch et al., 1993; Booth at al., 2001) 16. Impact of task switching Switch costs: responses take longer to initiate cfrepetitive tasks 200 vs 500 ms; higher error rates Preparation costs: advanced knowledge of a switchand time to prepare reduces switch cost Residual costs: Even with preparation (600 ms ormore) cant avoid some baseline switch cost Mixing costs: Performance recovery after switchalways slower for mixed cf single task repetition (Trends Cog Sci 2003:7;134-140) 17. "If a teenager is trying to have a conversation on an e-mailchat line while doing algebra, shell suffer a decrease inefficiency, compared to if she just thought about algebrauntil she was done. People may think otherwise, but its amyth. With such complicated tasks [you] will never, ever beable to overcome the inherent limitations in the brain forprocessing information during multitasking." 18. Interruptions 19. Communication in the EmergencyDepartment Face-to-face conversation 89.6%. 30% of communication events were interruptions,rate of 11.2 per hour 10% of communication time involved two or moreconcurrent conversations (multitasking). 12.7% of all events involved formal informationsources like the medical record.(MJA, 2002;176:415-8) 20. Task and Role effectsED interruption rates vary according to: Task loads measured by shift intensity or time tosee patients (Isr J Emerg Med 2005;5:35-42) Clinical role (and presumably task) 15 interruptions/hr average Registrars - 23.5/hr, 35% time Nurse shift co-ordinators - 24.9/hr Most interruptions f2f and related to patientmanagement (Ann Emerg Med 2004;44:268-273) 21. ICU Ward rounds - conversationinterrupted 75% time in communication Conversation initiating interruptions 14/hr, 37% communication time Turn-taking interruptions 20/hr, 5.3% communication time(IJMI, 2005;74:791-6) 22. Why the Interruptions? Poor asynchronous channels (email, voice mail), andreliance on synchronous ones (face to face, phone)and pager. Synchronous bias amongst staff pressure of work and ticking-off the list need for acknowledgement face to face is high bandwidth selfish local, not global reasoning A multitasking environment (requirement for paralleltask execution)(BMJ, 1998;316:673-677) 23. Communication Policies UK Medical staff generated 2x as many interruptionsas they received (43 vs 23) Policies are tactics to filter and prioritise messages(e.g. secretary). I want to always be available ...but I dont want to be interrupted. Receivers tried to assess urgency, caller, task basedupon poor information Callers had no information about availability and soeither interrupted or failed to contact 24. Interruption and Error WM = those mechanisms involved in control,regulation and active maintenance of task information Interruptions challenge working memory (WM)capacity New tasks given during an interruption may interferewith existing tasks leading to disruption of WMprocesses: forgetting of tasks. believing events have occurred, repeating forgotten events decreased performance of original task 25. Resumption lag Time to restart a task after interruption double for aninterrupted vs initiated task resumption (1.9 vs 3.8 s) Cue availability prior to interrupt reduces resumptionlag Suggests preparatory cognitive processes to mitigateinterruption, similar to multitasking interruption lag - brief period prior to interruptprovides opportunity to prepare to resume andencode retrieval cues to facilitate resumption ofprimary task (Altman, Trafton Cog Sci 2004) 26. The true costs of interruption Time penalty? Experimentally, resumption lag can double when a task switch is externally forced via an interruption. Empirically, clinicians spend 29-55% shorter amount of time on interrupted tasks (Westbrook, Coiera et al., QSHC, 2010 in press) The clinical risk is cutting corners on tasks because of reduced available time Errors? increase risk and severity of medication administration errors (Westbrook, Day et al, Arch Int Med 2010 in press) 27. Reducing interruptions Shift from synchronous to asynchronous Training clinicians to understand impact of interruptions and costs of multitasking More voice and e-mail + acknowledgment eg asynchronous notification of lab results BUT unintended consequence is that if poorly designed, can result in more interruptions How? requests: e-directories - locally maintainable, rapidly updated, clinically oriented, personally annotated Who? Requests: Role-based call forwarding via programmable switch Making work visible - whiteboards, active signs -> reduce memory load, recover from memory disruptions. 28. The Sacred and the ProfaneSacred (classic) making Profane (in the wild) The computer Paper The EMR Communication Terminologies To-do lists System architectures System implementation Intelligent decision System failuressupport technologies Local customisation 29. Design challenges for health services1. Clinicians operate with scarce cognitive resources, multiple team interfaces, multitasking and interrupting, leading to inefficiency and error.2. We need to understand the current cognitive science literature about communication and task handling e.g. multitask