Virtually Priceless Thoughts

I received a package this week. Inside was the textbook:
Human, Social, and Organizational Aspects of Health Information Systems.

Turning to page 23, as I read the title to Chapter 2, I cannot help but grin. “A Bio-Psycho-Social Review of Usbility Methods and their Applications in Healthcare”

My first book chapter.

Very exciting for me to see – I even had the opportunity to draw my own figures. All in all, it came together fairly well for a first chapter. Writing has never been natural for me (as my dear mother – an English professor – will sigh about), but it did come together.

The key to the chapter is that usability has many forms and can work at many levels. Like medicine, a reductionist view is powerful but not sufficient. We do much better today if we understand the biology of a disease, the personal impact of the illness, and the impact it has on the social network around a patient. For healthcare information systems (e.g. Electronic Health Records), it is the same. First we need to understand the bio (mechanical) aspects of systems – where the computers are, how big buttons are, etc. Next, the design impacts how a user (e.g. RN, MD) makes decisions and need to consider and observe the psychological (cognitive) impacts of design. Finally, medicine is a team sport. At the smallest, the team is the patient:provider pair, and increasingly the team is getting larger including people over time and over distance. Information systems need to support the group work – for improved effectiveness. If we design and test at all three levels, our systems will be more usable and more functional. The chapter is a review of some tools and work at each of the three levels.

So that was my contribution. And the rest book has a great collection of authors. I have had the opportunity to learn and work with several of them over the past several years. I am also honoured that I had a chance to help establish an 18-month primary care informatics fellowship a few years through UBC (thank you Peter!) that supported several BC family doctors learn more about informatics, that grew in collaboration with CIHR’s fellowship to include a primary care stream. Several of the fellows are are contributing authors.

Finally a quick thank you to the editors, Drs. Kushniruk and Borycki for inviting me to contribute a chapter to this book and for not making any snide comments on why “psycho” ended up the title of my chapter.

I have been diving more into visual thinking and visual story telling.

I have often used stories in design and evaluation of clinical information systems – I call them storyboards or clinical cases. Clinical stories help to bridge the technical requirements and clinical needs. It also is an excuse to have some fun, add some color to dry requirements and come up with great names (how about Eara Weatherwax – look at the chart summary here – how can you NOT love a name like that?). They work to focus the clinical audience on a common picture, clear needs, and benefits. Clinicians are patient centric and we all have seen cases like the one’s presented. Cases can also highlight workflow and find gaps in design.

If the story is right.

And that is the tricky part — getting the right story (or stories) to highlight the needs without sounding like you have the worst possible patient in history. Doing that makes the story unbelievable. It has to be honest and completely apparent why a requirement needs to be met. It has to be pitched to the audience at the right complexity. If it is too simple, then the story doesn’t engage and it doesn’t test / stress a system. Too complex and you lose people.

So it is a balance and I have found a few things helpful to get that balance:

1. Carefully adding clinical twists to stories is useful, but only to a degree. They need to fit the scenario. They need engage people in the story line and test the system. Avoid “now this time put in a diagnosis of X” type of scenarios.
2. Making the stories longer is very helpful to enhancing understanding. It provides more context, gives the story duration, and stresses the system. Diagnose a patient with a cough in a visit and any EMR can document that. Now have the story continue with the patient going to get an X-ray and having to update the diagnosis to pneumonia. Shows the process and functionality in a whole different light.
3. Sweat the details. Making sure the story is believable is important. Clinicians will be more engaged the more realistic the story is. I had one colleague dream about our “patients” from a testing session because they were vivid. If there are gaps, errors, it is really REALLY hard to get past them. In one example, I had gone to the point of making up a paper discharge summary of a fictitious patient who was discharged from a fictitious hospital. The page was to be used as back up material in a case. On the list of discharge medications I forgot to add a statin. The doctor who runs the lipid clinic could let that go. So details are important.
4. Pick your values and tests carefully. If you want to show that a flag displays when a lab test is abnormal, don’t make it critical. Unless you intend to (in your story) act on that lab quickly. The doctors in testing will want to — that is what we’ve been trained to do. Better to show something that is slightly abnormal that doesn’t need to be acted on (e.g., a slightly low Hb) and try and impress me with a really high INR or really low potassium. I’ll respond clinically to the value, which isn’t necessarily what your want.

The clinical scenarios engage us in ways that tie us back to what we do as clinicians and that locks in more of our brain as we tie in clinical experience, link to previous cases, etc. This is similar to some of the work on visual thinking that activates more of the whole brain than just narrative.

We use teaching cases with students, but we tend not to use them as well for defining how our systems work.

We also need to look at how to better use clinical stories to teach leadership and the technical folk about the requirements. These require some simpler stories, perhaps, as they don’t need to learn all the details about how to work out pediatric dosing for an antibiotic. But they do need to understand the benefits of a system that supports me and calculates that dose quickly and safely. A system that prompts if there is a drug interaction / allergy. A system that allows me to attend to my patient while not having to think about every detail. Something that helps me treat Eara Weatherwax’s otitis media and makes sure she comes back for her immunizations when she’s feeling better.

I love this idea – tying together smoking cessation and social networking. It reminds me of the awe when I saw the marrying of videogames and maintaining good glucose control in glucoboy.

Qwitter, from tobacco free Florida, leverages the existing Twitter network to link people together and to monitor your own progress towards quitting smoking. Check out Qwitter. There is also a quick (qwick?) video on the site (although the connection does seem to be slow) that outlines how it works.

I had the luxury of spending a couple of years as a Visiting Worker for the National Research Council in Canada. I was working in their eHealth Group with Dr. Harrop. These were exciting times where some amazing ground work was done on Personal Health Records and how to use it integrate health behaviour change into people’s lives. Really, Qwitter is a very simple, targeted Personal Health Record that provides two of the key foundations of success for sustained change in behaviour that Dr. Harrop liked to quote:

1. Engagement in a person’s own health information – by using Qwitter, you will log your smoking habits and can watch them change over time. That is a key base to change, is to understand baseline and to receive feedback.
2. Community Support – by posting and inviting friends and family to participate through the Twitter Network, you are sharing your journey with them and they can support you in your process.

As I was writing this post, into my RSS feed came a great post on Zen Habits about health and balance where the guest poster talked about how he used his blog to publicly lose weight. He said it very well:

How am I healthier you ask? It’s simple really. I blogged. I read. People read. I felt accountable for my weight loss and health. We formed a community. I felt inspired. They felt inspired. I lost weight. I got healthier. I blogged some more. Repeat. It’s a no-brainer really.

The whole Qwitter site is public (you can, of course make up a great alias so nobody can figure out who you are, but everything you post is online. This is good to share publicly your thoughts and actions.

The Qwitter site also provides you with feedback in the form of graphs (see right).

Seems like a great idea, but I found it hard to find many people who had logged in and used it for more than a few days. I wonder if it would be more powerful if Qwitter is more integrated with community support locally. Perhaps providers and local programs could leverage a tool like this? I think this might be something to bring up with a couple of my patients.

This past winter I discovered a relatively new little application called Flying Logic. It’s designed – specifically – to represent decision graphs. Gone is the tweaking with placement of boxes and shapes of arrows and you’re left with the ability (requirement) to focus on how to model the logic of your problem / solution / system. It’s based heavily on the Theory of Constraints and there is information on the web site describing how to use the tool using that paradigm. Basically the idea is that systems are finite. Some systems are more finite than they need to be because there are bottlenecks (constraints) that can be worked on and elevated / removed, making the system more efficient and productive.

One built-in model, the Prerequisite Tree, I find particularly useful (see diagram). Basically it provides a simple structure to document your goals and then map out the things you need to overcome to achieve those goals. Finally you document milestones that, if achieved, mean that what needs to be overcome is completed.

If you want to find out more about Flying Logic, it is best to see it in action and there are a couple of good videos on the site that are worth looking at.

Interestingly, the pro version allows you to create your own classes (the other versions can accept templates, but not create new ones). I have found that feature helpful in arranging thoughts, arguments, etc. in relation to my thesis. The diagram below (click for a bigger picture) was a draft to organize my thoughts in framing various potential research questions on diagrammatic reasoning.

I set up some research elements, based on a framework published by Weber and Wand, attached my questions to those elements and then built down my methods. Finally I mapped out phases for the research and “promoted” some questions to key questions as they were summations of several others.

In the end, we are focusing on the question “In what ways do physicians reason differently about EMR requirements when using conceptual diagrams as compared to textual requirements?” thanks, in part, to Flying Logic Pro.

Of course, we have gone through some more iterations since I sketched this out, but it gives people an idea of a more complex map.

One of the things that I seem to do a fair amount is make decisions. Also, I try to engage others in making decisions. Be it deciding on a treatment option with a patient or developing a strategy for an organization or deciding on a research project for my PhD – coming to a collective decision is a key piece for me.

And it is not easy.

I am regularly looking for tools and methods to use to help make a variety of types of decisions.

With patients, I sometimes find showing them graphs works some things. (Note a lot of qualifications) An engaged patient with a chronic disease, for example, can benefit from a graph of their blood work getting better (e.g. A1c in the picture), but it is key to tie the graph to their actions. “Since last December when you started losing that weight – look at how much better you are controlling your diabetes.”

OK, the site looks different, the content is a bit different and (if you are really OCD) the dates of the postings are off by a bit.

That’s because the daft operator of this site performed a content sync in the wrong direction and then couldn’t rebuild from the back up. I am in need of a new operator.

Of course it is hard to get rid of myself… so instead, I have taken this as an “opportunity” and streamlined the blog so I won’t be tempted to fiddle so much.

I’m somewhat optimistic that this might also mean that I might have more content to post. Historically I have spent a very large proportion of my blog time behind the scenes learning about how I can do amazing things on the blog and hadn’t nearly reached a dozen posts…

So a “whole new beginning” and hopefully some useful information sharing coming up.