Circle of Care Modelling: Improving Continuity of Care for End of Life Patients.

I have posted some of the findings previously and will post other components and findings in the future. I learned a great deal through this (both about my area of study and about myself) and am pleased to have taken the steps to get my PhD. The future looks exciting!

Today, however, I am going to rest and see my family.

Thank you everyone for your support on my journey. To my committee for being fair, supportive and asking good questions. To Francis, my supervisor, for pushing me that much more along the way.

And to my family.

–Morgan

1. Yes, this is a sad mis-quote from Austin Powers. I know what you are thinking “Oh, behave!”

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For 25 days this summer, I counted my days by the word. I set myself the task of writing 1,000 words per day on my dissertation.

That was the minimum I could write. I could write more, but not less — and no banking of words. And contrary to my earlier post on pictures being worth 1,000 words, they didn’t count.

I had to write at least 1,000 words a day.

Every. Day.

My idea was to set up a chain of accomplishments so that even when I was waning, I would not want to break the chain by missing a day. I had to reach 1,000, then I could stop and rest. Or edit. Or revise a picture. Or re-review my findings. Or do something else. Anything, as long as I wrote my 1,000 words.

25 days later and I was at the end of my 1,000 word days. The body of my dissertation was drafted. 228 pages, over 66,000 words.(1)

This proved to be a successful approach for me to get through my draft and one I will likely use again in future projects.

I think the trick to find the right metric that is an accomplishment that is significant for a day without being overwhelming that cannot be achieved. For me, last month, 1,000 words a day worked.

Since then I have started the editing process. I have shifted metrics to a set of tasks, determined based on a review cycle and laid out over a week. Not as clean as the 1,000 word metric, but that’s the nature of editing.

____________

1. Yes, 66,000 / 25 is more than 1,000 words a day. I was working on my draft prior to July 30th, so I had several chunks completed before I started (that I didn’t count in my 1,000).

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Well I have actually discovered plenty of excuses… that is the nature of writing, isn’t it?

I am moving steadily along and feel like I have a handle on where I need to go. I have done enough of the analysis work before now that this is mostly about writing, instead of doing the conceptualizing / analysis in parallel with the writing. That definitely seems to help.

I have my daily and weekly goals and that’s good.

One of my touch points is volume of words. The target is at least 1,000 words a day. I feel like I have accomplished something if, among the other pieces (e.g. editing, etc) that I have generated 1,000 words. It’s not the only measure, but it is one metric to work against (to quote Monty Python:

Sir Edwin: Ah, well, I don’t want you to get the impression it’s just a question of the number of words… um… I mean, getting them in the right order is just as important. Old Peter Hall used to say to me, “They’re all there already– now we’ve got to get them in the right order.”

But number of words is a good metric. It’s clear and measurable. And I start to create a chain of activity that I don’t want to break — every day, 1000 words. What if I miss a day? Can’t do that, I’ve had 9 1000 word days in a row. Gotta make it ten. That works well.

In a break today I started thinking about ways to keep the chain and slack off (the human mind never ceases to amaze me). “Never fear, I can count my pictures… that’s right. A pictures worth a thousand words, isn’t it? If I miss a day, I’ll count one of those…” My dissertation is full of pictures. Excellent! My brain has found a way around my own self imposed productivity standards… but maybe pictures are really worth a 1,000 words.

So I surfed and – even better – I came across this image:

It appears there was an error in translation – 10,000 words! I can take off the whole week and still make quota! Ah, I love August by the lake… but alas, no matter how I count my actions, I still have to reach “done” as defined by my supervisor and my committee in fairly short order and cannot bask in the warm shade much.

Also, it turns out that there were a couple of errors in the translation of the chinese proverb, actually. As Paul Lester explains:

In fact, the literal translation is: A Picture’s Meaning Can Express Ten Thousand Words.

He goes on to explain that:

With the correct interpretation of the proverb, words and pictures live in harmony as they are both used equally in order to understand the meaning of any work that uses them both.

This is a wonderful interpretation that works well with my dissertation. I’m sure to find a use for it somewhere as much of the work in the study relies on visual communication of findings through pictures and (visual) models.

Until then, however, I am either going to have to change my metrics (1000 words, and 1 picture) or I am going to have to up my daily quota for words, otherwise I am sure I am going to find myself slacking off, counting pictures as 10,000 words each.

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I was invited to spend the day there and was able to present on my current research for my first time to a surprisingly large audience (thank you all for attending). I also spent time with some great people learning and getting feedback. They have a productive and energized group there. I think that is what most impressed me. There was play in the rooms as they discussed dreadfully dull (to most people) topics like CDSS taxonomies, thematic coding and findings from months of qualitative analysis review.

Yes, I was thrilled to find some like minded folks on my trip.

I was also excited by the exchanges I was able to have, even in the short period of time. There were several people working on, or had worked on ideas that very much compliment the work I am doing now on Circles of Care and Continuity of Care.

The discussions will, I have no doubt, add to the richness of my evaluation, both from the perspective of adding some new ideas but also from the simple energizing from this visit. Thank you for that.

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The side benefit is that I do not have access to my email, calendar, task list, etc. I have tailored the environment for only the applications I need to do my analysis and so I can focus deeply. I have thought I have been quite good keeping focus and being productive and on task when i have work to do. This does take my focus to the next level. I didn’t realize quite how often my eyes look down at the little badges on my dock (when they are not at zero). Now, when I am focusing on my analysis work, there is nothing there to distract me in the dock, not even the mail icon (or accounts set up).

With fast user switching, it is easy enough to make a change and come back to the rest of my world, but it is just hard enough that I am not doing it unconsciously.

I wouldn’t recommend setting up separate accounts for every project, but for something as substantial as this research, it is proving to be a good choice.

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Right now for me, it’s starting “the big one” – my dissertation. I want to get started on the background sections in parallel to the research, so I have a large portion done when the results are coming in. I have moments of being daunted. There are these images of this grand document, hundreds of pages in length, gold edged paper, culmination of years of work, etc. etc.

It’s not unusual to feel that about one’s dissertation, I’m told. It hampers the ability to start.

Anyway, I ended up “playing” in Scrivener. Using the index card metaphor — you know titling index cards for sections, a few notes on the index cards about what sections would say, etc – nothing fancy, just pushing some pixels around to let the ideas percolate. Certainly not writing anything. That would be too daunting. Just outlining, some notes, play.

So this morning, with about 50 virtual index cards, I realized I hadn’t written over one thousand words already.

Now with the psychological hurdle of starting out of the way I get to just keep writing, which is far easier.

Thanks Keith.

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Now, several months later, I have successfully defended my PhD Proposal. I am developing a model to analyze and improve Continuity of Care. Care Continuity is not a new interest (I posted about it in June) and is a topic that keeps me grounded in the clinical aspects of health information science.

It has been a busy ride since I have made the decision – I have had to re-develop knowledge in several new theoretical foundations and methods, but I am excited about the study that I have developed and think that it will have a positive impact in the communities that I will be working with. Stay tuned for more details on my approach in the future.

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Perhaps that is my new slogan. Hopefully not. I am ready to get to my research.

I haven’t posted for a while about my PhD research as I have done a lot of soul searching over the summer and decided that even though I had a proposal drafted, the study was not for me. It was too far removed from the clinical coal face. So I made a change.

At the end of September, I changed topics and put my old proposal on hold.

My new proposal, just submitted in draft to my committee, focuses on exploring Continuity of Care for end of life patients. I will be looking at Continuity of Care first through interviews with providers. By leveraging work in Genre Theory and Soft Systems Methodology, I will develop some accessible models that describe communication activities of members in a patient’s Circle of Care. Using these models to structure group discussions, I should be able to guide study participants (both providers and IM/IT staff) to develop feasible recommendations to improve Continuity of Care.

This study is focused on generating the recommendations. Work after the study will be on implementing the recommendations within the communities I am working with.

It is an accomplishment, to have gotten to this point and I am looking forward to the next steps.

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That’s a 6:40 presentation run, no exceptions.

It is an interesting constraint to a presentation and one that would be very interesting for academic talks. We already present under time limits, but don’t have the slide restrictions.

I think having a restriction on slides to precisely 20 images, makes you become more explicitly aware of what you are going to do with each one rather than just stringing together a bunch of slides. 20 seems a reasonable number to get students or faculty to start experimenting with.

Some groups are apparently trying this. I might try and suggest this for our department. It is definitely something I would like to try. There is a group not far away – but my topics of medicine / informatics might not quite fit what they want…

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After spending some time coding a set of EMR requirements to see what format might make sense, it was clear that activity diagrams were a good choice. My reasons include:

• Content mapping confirmed that the published functional requirements covered most “processes” or “things,” which is as expected for functional requirements.
• The “things” were not well defined. That is it would be difficult to create a data model from the content within the functional requirements (some groups have defined data elements separately, which is a good start for interoperability).
• In my research, physicians will be reviewing activity diagrams. They are somewhat familiar with activity diagrams as they are similar enough to care flow decision trees. They won’t require a weekend course on how to read the diagrams to be able to interpret them.
• They are commonly used and part of the UML standard, so many requirements engineers will be familiar with them (good for future application)
• My learning curve is not as great and I can focus on content development.

Interestingly, how the requirements are written (see Saskatchewan Ministry of Government Services website – Competition Number 2462), have made swim lanes difficult to create the requirements do not typically specify which user can do what — see the example below from Saskatchewan.

The Solution should provide standard clinical tools that support clinical documentation and decision making and can be accessed when doing clinical notes.

e.g. Framingham risk calculator, BMI calculator automatically placed next to height and weight fields.

Other than the swim-lane issue; however, the development of activity diagrams is proving to be achievable. In fact, I think not having the swim-lanes will likely make it easier for doctors to review them as they are more like the flow diagrams we are used to in clinical practice diagrams. As you can see from this BC Asthma Guideline (pic below)

Once the diagrams are complete they will be validated and compared to a set of published text requirements to ensure that they contain equivalent information. Then the experiments begin!

We are going to compare physician comprehension and reasoning using requirements in diagram form with the published requirements in text form. We’ll be asking the physicians to validate the requirements and describe any gaps.

What we are hoping to find is that one method proves to be a clearly better way of getting feedback from physicians for requirements than the other. Which method does not matter as much as discovering if one way is more impactful than the other.

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