Yan Xiao, PhD, Human Factors @ Baylor Health Care System © 20131 Yan Xiao Human Factors & Patient...

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


• Healthcare context

• Task “paradigms”

• Theoretical frameworks

• Practical impact


•Healthcare context

The quality and value imperative

• Task “paradigms”• Theoretical frameworks• Practical impact


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.


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


Preventable Harms during Hospital Care

Landrigan et al, NEJM 2010


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



• Healthcare context

•Task “paradigms”

The Collaborative Work Patterns

• Theoretical frameworks• Practical impact


Example collaborative tasks- Dispatching- Preparation at ED- Medical direction

CSCW examples:- Command & control syst.- Voice and data link- Shared GIS and info space


Example collaborative task- Articulation of surgical activities

CSCW examples:- Shared data displays


Example collaborative tasks- Care planning- Hand-offs- Case management

CSCW examples:- Shared data displays- Mobile devices


Example collaborative tasks- Activity & resource planning- Monitoring - Hand-offs

CSCW examples:- Shared data displays- Coordination software


Example collaborative tasks- Team-based care- Activity articulation- Management of orders

CSCW examples:- Electronic Health Record- Order entry- Med Admin Records- “Flowsheet”



• Healthcare context• Task “paradigms”

•Theoretical frameworks

Understanding Socio-Technical Systems

• Practical impact


“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


- 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


Xiao Y, Seagull FJ.. Intl J Med Inform. 76(S):261-266. 2007


"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


We built, but they don’t use. Why?


“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


Information Hub Design

23

Separate areas Overlapping areas


“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).


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


“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


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

29457921

Akerman, Olivia

37549263

Kang, Katherine

89468383

Lessingger, Jonathan

12341234

Paxton, Amy

32341627

Zimmerman, Ashley

26950293

Barton, Caleb

43945732


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


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


“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.


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)


Director

Matcher


Director

Matcher Overhearer


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


Back-Stage

Front-Stage

1

2

4

3

The front-stage back-stage model of information processes during group discussions.


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



• Healthcare context• Task “paradigms”• Theoretical frameworks

•Practical impactImproving Quality and Value


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


Ann. Emerg Med 2007



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



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


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)



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, PhDHuman Factors & Patient Safety Research Baylor Health Care SystemDallas, Texas

Adjunct Professor, University of Texas at Arlington

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