1. The PC, the Patient and the Practitioner
Paul Robinson
Informatics seminar

2. What am I doing here?? Establish commonality with the audience!
At this stage in a presentation I’m thinking “help!”, and the audience are probably thinking “what does he know?”

3. What am I doing here? Presentation Teaching the skill set
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

4. What effect have computers had?
Information superhighway
Convergence of older technologies
Printing press
Telegraph
Typewriter
Radio/ TV

5. COMPUTERS CHANGE EVERYTHING
Context
(At the point of care…..)
COMPUTERS CHANGE EVERYTHING

6. Computers change everything
Records
Knowledge flows
The medium

7. Records
Paper: Filing cabinet
EHR: Broadcast/ publishing

8. Knowledge flows (old)

9. Knowledge flows (new)

10. 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

12. 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)

13. And here is a gallant Englishman (born in Canada in fact) bravely losing at Flushing Meadows.
The purpose of showing these pictures is to talk about the fact that a service hit by these guys takes less time to traverse the court than the time taken to assemble the image: i.e. the returner hits the ball before he has consciously “seen” it..
Much ( I think most) of what we do is unconscious in these terms: the mammal in us just gets on with the behaviour and our conscious attention is monitoring this about half a second behind, thinking that it is in control and up to speed.

14. Most human behaviour is automated
This includes the consultation

16. Information in the consulting room (iiCR)
Research and
Development

17. iiCR team Nick Booth Judy Kohannejad Paul Robinson
Nick Booth
Judy Kohannejad
Paul Robinson
(PRODIGY evaluation team)
(Durham and Darlington EHR project team)

18. iiCR: aims
Identify the skills that help the GP to maintain rapport with patient and use the computer during the consultation.
Develop and pilot a teaching package that supports the training of GPs and the development of these skills.
(Calgary-Cambridge Guide)
State where we are

19. Research Questions Can these skills be identified? What are they?
Can they be taught?
Can people divide their attention?

20. 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)

21. iiCR Phase 1: sample GP Trainers (purposive sample) Self selected
Familiar with using computer in the consultation

22. 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)

23. 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

24. iiCR phase 1: what we saw 3 types of behaviour:
Controlling (the flow of consultation)
Responsive/ Opportunistic
Ignoring

25. iiCR phase 1: what we saw 3 strategies: Signpost Blather
Respond (every time)

26. iiCR phase 1: what we saw Variation in sharing of: Screen
Knowledge sources

27. iiCR (phase 1): what we saw
Failures to respond to speech-act
When in prescribing or template filling modes
Were they deliberate??

28. Multi-tasking
Can GPs do it?
Can researchers do it?

30. 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 tapes

31. 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 skills
Interpretation issue
Undivided attention (on the screen) for 105 seconds

32. 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.

33. iiCR Phase 2: findings
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

34. iiCR Phase 2: findings
F now what I’ve seen in the last 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

35. iiCR Phase 2: findings
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.

36. 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)

37. 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

39. Tc,
pc to r
door just in front of chair on left

41. 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

42. 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

43. 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

44. Phase 3: the training package
More details available on:
(final report tab)
Or from