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Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 1
Yan XiaoHuman Factors & Patient Safety Research Baylor Health Care SystemDallas, Texas
Adjunct Professor, University of Texas at Arlington
Computer Supported Cooperative Work:
Task paradigms, theoretical frameworks, and practical impact
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 2
• Healthcare context
• Task “paradigms”
• Theoretical frameworks
• Practical impact
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 3
•Healthcare context
The quality and value imperative
• Task “paradigms”• Theoretical frameworks• Practical impact
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 4
The STEEEP® Climb to Quality*
Quality health care should be: Safe Timely Effective Equitable Efficient Patient Centered
*Institute of Medicine. Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001.
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 5
The STEEEP® Climb to Quality
– Safe – avoiding injury to patients from care that is intended to help them
– Timely – reducing waits and harmful delays– Effective - providing services based on scientific knowledge to all
who could benefit and refraining from providing services to those not likely to benefit (avoiding overuse and underuse)
– Equitable - providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographical location, and socioeconomic status
– Efficient – avoiding waste– Patient Centered - providing care that is respectful of and
responsive to individual patient preferences, needs, and values
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 6
Preventable Harms during Hospital Care
Landrigan et al, NEJM 2010
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 7
77
Baylor Health Care System
• Integrated health care system in Dallas-Fort Worth, Texas– 30 owned, leased, ventured, and affiliated hospitals – 27 joint ventured ambulatory surgical centers– 180 HealthTexas ambulatory care
locations: 600 physicians– 4,631 physicians on staff– 72 Satellite outpatient facilities –
imaging, rehabilitation, and pain• 3,534 beds• 20,000 employees• 2.6 million patient encounters/year• 130,000 admissions/year• $4.1 billion net operating revenue• Baylor Research Institute
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 88
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 9
• Healthcare context
•Task “paradigms”
The Collaborative Work Patterns
• Theoretical frameworks• Practical impact
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 10
Example collaborative tasks- Dispatching- Preparation at ED- Medical direction
CSCW examples:- Command & control syst.- Voice and data link- Shared GIS and info space
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 11
Example collaborative task- Articulation of surgical activities
CSCW examples:- Shared data displays
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 12
Example collaborative tasks- Care planning- Hand-offs- Case management
CSCW examples:- Shared data displays- Mobile devices
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 13
Example collaborative tasks- Activity & resource planning- Monitoring - Hand-offs
CSCW examples:- Shared data displays- Coordination software
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 14
Example collaborative tasks- Team-based care- Activity articulation- Management of orders
CSCW examples:- Electronic Health Record- Order entry- Med Admin Records- “Flowsheet”
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 1515
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 16
• Healthcare context• Task “paradigms”
•Theoretical frameworks
Understanding Socio-Technical Systems
• Practical impact
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 17
“Distributed Cognition”
– Axiom: A task is defined by the tools used– What are tools?
– Cognitive resources are distributed between and around “agents”, not just within.– How cockpit remembers speed?– How ICU remember orders?
– Understanding “cognitive properties” of external artifacts can inform design of support systems
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 18
- Collaborative work can be highly dynamic and unpredictable
- patients not ready, surgeons not available, equipment breakdowns, case much longer/shorter
- “Open system”- A number of factors beyond control
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 19
Xiao Y, Seagull FJ.. Intl J Med Inform. 76(S):261-266. 2007
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 20
"Why can't I follow that case" or "move to there."
“I use [the board] to see if I can push”
Collaborative work often requires more than information exchange- Negotiation- “Fairness” and favors
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 21
We built, but they don’t use. Why?
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 22
“Information hubs”(Scupelli 2011)
22
• How architectural designs impact coordination? – Schedule board
• Makes schedule visible• Integrates information • Serves multiple groups
– Control desk area• Charge nurse coordinates• Transport teams• Equipment requests• Online schedule
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 23
Information Hub Design
23
Separate areas Overlapping areas
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 24
“Conversation as Communication”(Coiera, 2000)
– Conversation is more than “acquiring” and “presenting” 60% of clinician time in clinics spent on talking 50% of information requests were to colleagues (not document
sources) 50% of information transactions face-to-face
– Biggest information repository is people; biggest information system is the web of conversations
– Blending of information and communication technology More formalization of process -> more computation potential. Less formalization-> more communication (eg telephone).
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 25
Conversation in intensive care• Nemeth et al 2005. High context
sensitivity, compact reference, gestures, and stylized expressions.
• Kowalsky et al 2005. Clinicians use two forms of conversation to conduct this exchange: variations of soliloquy (monologue) and colloquy (dialogue). Both forms demonstrate the same variable, emotion-laden, dynamic, and complex traits as the work domain that they are used to manage.
Courtesy of Nemeth
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 26
“Trajectory”(Faraj & Xiao, 2006)
– Originally defined as a temporally unfolding sequence of events, actions, and interactions – aimed at ensuring patient medical recovery
– Collaborators often act on, and often share information on, expectation of temporal courses of events.
Admission
Diagnosis (MRI, CT, ETC)
Surgery Stabilization
Assessment+Disposition Discharge
Primary Team Consulting physicians O.T., P.T.
Social workerTransporter
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 272009 © Xiao, UM
Home
Rehab
5 GUD
Homeless
DC summary not done yet
Family does not like facility
Insurance not willing to pay
PT/OT not done
Pt in too much pain
DC Note/Rx not done
Pt waiting
Repeat Test
IV Abx
Pt needs PICCWaiting other
consults to clear pt
Needs facility in another state
Day 506:18
Day 722:18
Patient #3: 19 M MVC Dx: Lt Femur Fx with multiple laceration Tx: ORIF of Lt femur Adm date: Day 1 16:00 DC Date: Day 7 22:18 Total LOS: 6d 6h 18m; 150h 18m
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 282009 © Xiao, UM
Day 1 Day 2
Regular diet ordered
24:00
PACU21:00
OR18:00
Consults: anesthesia& orthopedic
14:00
Tests completed: X-ray, CT, MRI, Lab tests;
13:00
Patient discharges
to home11:00
Physical therapy AssessmentDay 2, 8:00
Admission12:00
Discharge rounds10:00
A 6/1 6N3 L Femur Fx ORIF POD1 6N Pain POPT consult H ?Sta/?Home
32Y MH H 3d oPT recommendation
B 5/18 6S22 R Femur Fx ORIFPOD13 6S-Aspiration Pneum
62Y F H H 13d VENTH 13d possible trach
C 5/31 5N2 Lt Femur Fx IMN POD2 5N oPain PCAPO, H ?STA | Kernan
42Y FH H 3d oPT,oD/C TLC No rehab insurance
A 5/31 STA3-1 R Femur Fx ORIFPOD3 STA H Home|family transport
56Y FH H 2d Pain PO, PT oD/C note & RxH 6h
A 5/31 STA10-2 L Femur Fx oOR
H 2d glass L arm STA Home?
19Y F H H 2d3h IMN POD3waitlistedconsentclearance oPain PCAPO,
A 6/3 TRU2 possible LLE Fx, XrayR
,CTR OR ?
17Y FH 2:05p H 1d o Dx, o Ortho PlanH 6h oconsent oclearance
B 6/3 TRU4 R Femur Fx-Plan:ORIF oOR
H 5h 4th case STA? Home/Kernan??
23Y M H 11:21p H 23h consentclearance
Rowe, Florence
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Akerman, Olivia
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Kang, Katherine
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Lessingger, Jonathan
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Paxton, Amy
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Zimmerman, Ashley
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Barton, Caleb
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Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 292009 © Xiao, UM
Coordination of …Expectations about Trajectories
Day1Day2
day3day4
day5day6
day7day8
day9day10
day11day12
day13day14
day15day16
day17day18
day19
day20day21
day22
day23
0 15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 240
Time in Seconds
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 302009 © Xiao, UM
Coordination of Expectations
Topics Discussed in Patient Discussion Episodes
71.50%66.93%
19.56% 18.40%12%
7.97%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Clinical Dischargereadiness-time/place
OR/procedureplans
Non-clinical NewComplications
Advancement ofcare explored
Topics
Fre
qu
en
cy
pe
rce
nt
in a
ll p
ts
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 31
“Information Arena”
• Assumptions: – Clinical communication is nearly always supported by visual artifacts– Some artifacts are shared, others personal– Preparation of these artifacts can be extensive, often labor intensive
• Research framework: verbal discourse occurs in an “information arena”: informational aspects of workspace
• Hypothesis: computerized tools should and can be used to support communication during rounds, including grounding process.
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 32
Herbert Clark’s Collaborative model of communication
• “we carry around rather detailed models of people we know….It is that model that enables people to make and understand references so quickly and accurately.”
• Speaker-addressee are collaborators to ensure understanding (presentation – acceptance cycle)
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 33
Director
Matcher
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 34
Director
Matcher Overhearer
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 35
Personal Displays
• Personal notes• Prepared patient notes• Checklists• Paper-based• Palm Pilot for Rx
Participants (2 … n)
• Primary Care Nurse• Nurse Practitioners• Resident Physicians• Attending Physicians• Specialty Physicians
Public Displays
• Publicly viewed artifacts• Patient bedside monitors• Bedside vital signs chart• Computers on Wheels
Courtesey of Danny Ho, Univ Waterloo
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 36
Back-Stage
Front-Stage
1
2
4
3
The front-stage back-stage model of information processes during group discussions.
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 37
1:06 2:09
2:20 2:56
Setting the stage. Participants arranged documents and computer displays to allow rapid data access and sharing with minimal disruption to the flow of information
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 3838
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 39
• Healthcare context• Task “paradigms”• Theoretical frameworks
•Practical impactImproving Quality and Value
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 40
Accidental CSCW System:Technological implications
• “If can’t beat them, join them” – co-existing with the physical artifacts
• Modular and embeddable: maximizing user tailoring and “commandeering”
• It is almost inescapable that users will invent new ways of using a collaborative tool
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 41
Ann. Emerg Med 2007
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 42
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 43
Desirable features of a “Rounding Partner”
Physical Requirements
Social / Cognitive Requirements
Supporting Artifacts
RequirementsViewing Angle
and VisibilityLow Tolerance for Delays
and “Glitches”Computerized
Bundles
Size and Spacing
Show Salient and Relevant Data
Data Preparation
Attentional Cues
Multiple and Switchable Screens
Digital Capture and Distribution
General vs. Topic-Specific Data
Integration of Data and Visuals
Flexible Data Visualization Allow Dedicated Media Controller
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 44
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 45
Design principles for coordination
45
• Place information hubs in connected areas• Provide visibility between information hubs• Limit traffic interference with information access • Create staff only information areas
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 46
Acknowledgement
• Supported by National Science Foundation• Acknowledge the guidance and contribution from (partial list)
– Vinay Vaidya, MD (currently Phoenix Childrens)– Marcelo Carderelli, MD (BLNK Medical)– Grant Bochicchio, MD (currently WashU)– Peter Hu, MS, biomedical engineer– Kendall Hall, MD (currently AHRQ)– Danny Ho, PhD (currently Waterloo)– Ayan Sen, MD, research fellow (Henry Ford)– Ayse Gurses, PhD, human factors researcher (JHU)– Brian Hazlehurst, PhD, anthropologist (Kaiser)– Paul Gorman, MD, Medical Informatics Researcher (OHSU)– Sue Fussell (currently Cornell)– Sara Kiesler (CMU)– Peter Scupelli, PhD (currently CMU)– Adam Probst (BHCS)
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 4747
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 48
On-Going Research on Collaborative Work
• Surgeon as leader in the operating room– How can surgeons learn team leadership skills?
• Surgical team consistency– How to improve team consistency?
• Virtual games to learn communication skills– How to support experiential learning via gaming?
• ICU-OR hand-offs– How to structure hand-offs to improve reliability?
Yan Xiao, PhD , Human Factors @ Baylor Health Care System © 2013 49
Yan Xiao, PhDHuman Factors & Patient Safety Research Baylor Health Care SystemDallas, Texas
Adjunct Professor, University of Texas at Arlington