Virtually Priceless Thoughts

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.

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