©2003 Sowerby Centre for Health Informatics at Newcastle The PC, the Patient and the Practitioner...

transcript

The PC, the Patient and the Practitioner

Paul RobinsonInformatics seminar

12-14. 11. 3

What am I doing here??

What am I doing here?

• Presentation• Talking about the iiCR project• Thinking about perception, attention and

consciousness • Looking at the background to computer use

at the point of care

• Teaching the skill set• Communication skills

What effect have computers had?

• Information superhighway

• Convergence of older technologies• Printing press• Telegraph• Typewriter• Radio/ TV

Context

(At the point of care…..)

COMPUTERS CHANGE

EVERYTHING

Computers change everything

• Records

• Knowledge flows

• The medium

Records

• Paper: Filing cabinet

• EHR: Broadcast/ publishing

Knowledge flows (old)

Expert-client: traditional. The expert dispenses knowledge that has been acquired elsewhere

Expert Client

Initial

training

colleagues

Knowledge flows (new)

Expert-client: triadic. The same information source is potentially available to expert and client at the same time. The question is how much of this can the client make use of.

Expert Client

The medium

Computer screens are more engaging than sheets of paper.

Interactive programmes are seductive of attention.

Working with a computer is active, not passive

Neural Monism

• “Mind stuff” and “physical stuff” are the same stuff

• Mind emerges from the network• Brain• Body • Social

• This takes time (.03 to .05 second)

• Most human behaviour is automated

• This includes the consultation

Research and Development

Information in the consulting room(iiCR)

iiCR team

Nick BoothJudy KohannejadPaul Robinson

(PRODIGY evaluation team)(Durham and Darlington EHR project

iiCR: aims

1. Identify the skills that help the GP to maintain rapport with patient and use the computer during the consultation.

2. Develop and pilot a teaching package that supports the training of GPs and the development of these skills.

(Calgary-Cambridge Guide)

Research Questions

• Can these skills be identified?

• What are they?

• Can they be taught?

• Can people divide their attention?

iiCR: phases of the project

• Phase 1: video-tapes of GP consultations (grounded theory)

• Phase 2: simulated patient consultations with immediate facilitated review of tape (IPR, Calgary Cambridge)

• Phase 3: iterative development of teaching package (action research)

iiCR Phase 1: sample

• GP Trainers (purposive sample)

• Self selected

• Familiar with using computer in the consultation

iiCR Phase 1: method

• GPs taped a surgery • Looked at all consultations on tape• One or two consultations selected

and transcribed by JK (CA transcription)

• 2 columns (Dr – Pt interaction: interpretation) added to transcript (PJR)

iiCR phase 1: what we saw

• A lot of use of paper!

• Most GPs do the minimum of typing/ data entry while the patient is present

3 types of behaviour:• Controlling (the flow of

consultation)

• Responsive/ Opportunistic

• Ignoring

3 strategies:

• Signpost

• Blather

• Respond (every time)

Variation in sharing of:

• Screen

• Knowledge sources

iiCR (phase 1): what we saw

Failures to respond to speech-act•When in prescribing or template filling modes

•Were they deliberate??

Multi-tasking

• Can GPs do it?

• Can researchers do it?

iiCR Phase 2: method

• GP’s own surgery• Trained simulator, loosely defined

scenario: demands computer use• Video of consultation and video

feed from screen• Immediate facilitated review of

iiCR phase 2: consultation 2

Patient has asthma, inhaler use increasing: (is anxious and has started smoking again)

Computer glitch was major distraction to GP

In discussion:GP’s skillsInterpretation issueUndivided attention (on the screen) for 105 seconds

iiCR Phase 2: findings

F my impression is that you explained very well what you were doing. (to Patient) did you understand what he was doing?

P Yes from my point of view, computers are

part of the culture: F so did you know what he doing? P I just guessed that he was like writing

things down.

F It looks to me Alison like you were looking at the computer when you came in

P It’s like I said before when someone else is

focussed on something you are drawn to it. F if I was just looking at this tape, I’d think that

you were reading the screen P no

F now what I’ve seen in the last 10-15 seconds is Alison, moving around in her seat, looking up, looking away: did any of that impinge on you?

D No D No she was off limits, completely off

P It’s difficult to say with all the distractions going on. You were distracted for quite a long time. So it’s difficult to say.

D the chunk… was long, much longer

than I thought it was. … it just goes to show how you can lose track of time when you are busy with something else.

iiCR: phases of the project

• Phase 1: video-tapes of GP consultations (grounded theory)

• Phase 2: simulated patient consultations with immediate facilitated review of tape (IPR, Calgary Cambridge)

• Phase 3: iterative development of teaching package (action research)

Competencies: Rapport• Adapts behaviour to take into account relative

position of doctor, patient and computer• Maintains open posture when using computer• Uses verbal and non-verbal behaviour to indicate

when attention is being paid to the computer screen

• Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctor’s attention is on the computer

• Responds to patient cues when attending to the computer

Competencies: Involving the Patient

• Explains to patient why computer is being used

• If the computer is to be used as an information source, negotiates the use of such information with the patient

• Lets the patient read information from the screen when appropriate

Competencies: Explanation and planning

If using screen-based information (shared screen, PIL etc)

• Checks that patient can see the screen clearly

• Remains quiet, and gives the patient time to read the text

• Checks that patient has understood the text• Gives patient opportunity to ask questions• On a busy screen indicates (points etc)

relevant information

Phase 3: the training package

• Iterative development• Used with over 200 GPs, community

nurses and pharmacists• Workshop style

• Role plays, scenario consultations• Works best in facilitated small groups• Can be adapted to larger numbers

Phase 3: the training package

More details available on:http://www.schin.ncl.ac.uk/iiCR/

(final report tab)Or from p.j.robinson@ncl.ac.uk

©2003 Sowerby Centre for Health Informatics at Newcastle The PC, the Patient and the Practitioner...

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