1. 1 Designing Health Information Technologies: A Socio-Technical Perspective Madhu Reddy College of Information Sciences and Technology Center for Integrated Healthcare Delivery Systems Penn State University mreddy@ist.psu.edu December 11, 2009

2. Talk Outline 2  Introduction  Socio-Technical Perspective  Research Site  Case Study  Summary

3. Who am I? 3  Ph.D. - University of California, Irvine (2003)  Research Interests  Medical Informatics  Computer-Supported Cooperative Work  Research Approach  Qualitative research methods  Technology evaluation INTRODUCTION S-T PERSPECTIVE RESEARCH SITE CASE STUDY SUMMARY

4. Research Projects 4  Current Projects  Collaborative clinical decision-making 1  Collaborative information behavior in dynamic and information-intensive environments 2  Completed Projects  HIT implementation and use 3,4  Information needs of multidisciplinary patient care teams 5  Inter-departmental coordination activities  Patient transfer process 6  Crises response 7 INTRODUCTION S-T PERSPECTIVE RESEARCH SITE CASE STUDY SUMMARY

6. “To Err is Human” 6 INTRODUCTION S-T PERSPECTIVE RESEARCH SITE CASE STUDY SUMMARY

7. Record archive 1935 and 2000

9. 9 IOM “Crossing the Quality Chasm” report, March 2001

10. Health Information Technologies 10 A “silver bullet” that will solve all our problems  Easily implantable  Simple to use  Reduce errors  Improve patient outcomes  Reduce/contain costs BUT…. INTRODUCTION S-T PERSPECTIVE RESEARCH SITE CASE STUDY SUMMARY

11. Reality is… (2006 AHA Survey) 11 INTRODUCTION S-T PERSPECTIVE RESEARCH SITE CASE STUDY EMR Implementation None – 32%; Partial – 57%; Full – 11% Some Issues (Full implementation) Size matters (500+ beds: 23%, <50 beds: 3%) Urban vs. Rural (16% vs. 5%) Teaching vs. Non-Teaching (17% vs. 9%) Major Barriers Initial Cost – 94%Interoperability – 79% On-going Cost – 87% IT Staff – 67% Acceptance - 82%Inability to meet needs - 62% SUMMARY

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13. 13 How can we improve the design of health information technologies (HIT)? INTRODUCTION S-T PERSPECTIVE RESEARCH SITE CASE STUDY SUMMARY

14. Challenges to Designing HIT 14 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Traditional Assumptions  formulated in terms of technical challenges  formalize work as routine  Clinical Healthcare Domain  Highly collaborative  Complex Unpredictable Many exceptions (“routine exceptions”) SUMMARY

15. Challenges to Designing HIT 15 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Mismatch  system focus vs. collaboration in clinical work  work as routine vs. complexity of clinical work What is another approach? SUMMARY

16. Technology Perspective Continuum 16 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION TECHNOLOGICAL DETERMINISM SOCIAL DETERMINISM SOCIO-TECHNICAL PERSPECTIVE SUMMARY

17. Socio-Technical Perspective 17 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Important features  View of social and technical issues as intertwined  Shifts attention away from the technology in the abstract  Expands focus to social/organizational issues  Why is it important in healthcare?  Collaboration implicit in the work  Highly institutionalized social practices  Adoption/acceptance major issues SUMMARY

18. Surgical Intensive Care Unit 18 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION SUMMARY

19. Surgical Intensive Care Unit Team 19 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION ResidentResidentResident Fellow Pharmacist Nurse Attending SUMMARY

20. Primary Working Concerns 20 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION Patient Stabilization Bed Management SUMMARY

21. Case Study 1: Wireless Alert Pager 21 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION SUMMARY

22. Wireless Pager Expectations 22 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Better collaboration  Quicker event notification  Delivery of more accurate information regarding critical events “Proactive” vs. “Reactive” SUMMARY

23. Problem 1: Maintaining Hierarchies vs. Lowering Boundaries 23 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Creates loss of control  Broadcast information to all physicians  Can’t “control” bad information  Affects the context that hierarchy provides  Information moving up the hierarchy SUMMARY

24. SICU Alerting Workflow 24 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION Resident Fellow Attending Nurse SUMMARY

25. Problem 2: Information Overload and Missing Context 25 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Large number of pages/day  16 alerts/day  No prioritization mechanism  Physical size of pager  Provides limited context  Nurse’s role  Is this really a problem? SUMMARY

26. Problem 3: Missing Feedback Mechanisms 26 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Unidirectional  Physician only receives information  Can’t respond via pager  Lack of feedback  Broadcast problem but not who responds  Maintaining the balance between trust and verification SUMMARY

27. Organizational and Technical Issues  Simple technical fixes  Two-way pagers  Pagers with different tones/alerting mechanism  App phones (iphone, droid, etc.)  Harder organizational issues  Changing the role of the nurses  Changing the institutionalized work practices of the house staff S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION SUMMARY

28. Summary 28 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  What am I not arguing for?  NOT arguing that changing how people work is bad or unnecessary  NOT arguing that the technology itself isn’t important  What am I arguing for?  Vital to understand the relationship between the technology, work, and organizational structure SUMMARY

29. Summary 29 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION  Technical expectations vs. organizational activities & roles  Ex: Misunderstanding who the real users of the system are  Tackling these issues requires collaboration between different disciplines (i.e. health sciences, social sciences, information sciences, computer science, others) SUMMARY

31. 31 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION Thank You! SUMMARY

32. 32 S-T PERSPECTIVE RESEARCH SITE CASE STUDY INTRODUCTION References 1. Zhu, S., J. Abraham, S. Paul, M. Reddy, J. Yen, M. Pfaff, and C. DeFlitch. (2007). R-CAST-MED: Applying Intelligent Agents to Support Emergency Medical Decision Making Teams. In Proc. of the 11th Conference on Artificial Intelligence in Medicine (AIME 07). 2. Reddy, M. and B.J. Jansen. (2008) A Model for Understanding Collaborative Information Behavior in Context: A Study of Two Healthcare Teams. Information Processing and Management. 44(1): 256-273. 3. Reddy, M, Pratt, W., Dourish, P., and Shabot, M.M. (2003). Sociotechnical Requirements Analysis for Clinical Systems. Methods of Information in Medicine, 42, 437-444. 4. Reddy, M., McDonald, D., Pratt, W., and Shabot, M. (2005). Technology, Work, and Information Flows: Lessons from the implementation of a wireless alerts pager system. Journal of Biomedical Informatics, 38/3. pp. 229-238. 5. Reddy, M. and P. Spence. (2006). Finding Answers: Information Needs of a Multidisciplinary Patient Care Team in an Emergency Department. In Proc. of American Medical Informatics Association Fall Symposium (AMIA'06). Washington, DC. Nov. 11 –15, 2006. pp. 649-653. 6. Abraham, J. and Reddy, M. (2008). “Moving Patients Around: A Field Study of Coordination between Clinical and Non-Clinical Staff in Hospitals.” In Proceedings of ACM Conf on Computer Supported Cooperative Work (CSCW’08). San Diego, CA. Nov. 8-12, 2008. pp. 225-228. 7. Reddy, M., Paul, S., Abraham, J., McNeese, M., DeFlitch, C., and Yen, J. (2009). Challenges to Effective Crisis Management: Using Information and Communication Technologies to Coordinate Emergency Medical Services and Emergency Department Teams. International Journal of Medical Informatics. 78: 259-269. SUMMARY