1. VA HSR&D Salt Lake Informatics Decision Enhancement And Surveillance Center Information Integration to support Medication Management Jonathan R. Nebeker MS MD VA Salt Lake City GRECC University of Utah

2. Acknowledgements Charlene R. Weir, PhD Frank Drews, PhD Molly Leecaster, PhD Rand Rupper, MPH MD Kenneth Boockvar, MD Kevin Meldrum Sandi Geary Mike Lincoln, MD Chris Nielson, MD PhD Brittany Mallin, MS MPH AHRQ R18 HS017186 VA Salt Lake City GRECC VA Salt Lake City IDEAS Center 2

3. Overview The Electronic Health Record context Current Future How theory gets us to future Theoretical Framework Demonstration 3

4. 4 Current CPRS VistA Emphasis on access Information siloed in tabs Physician centric Patient excluded No interface for control

5. 5 Future CPRS VistA Emphasis on control Information integrated Supports all healthcare professionals and the patient

6. Progress The Electronic Health Record context Theoretical Framework Joint Cognitive Systems or Cognitive Systems Engineering Contextual Control Model Demonstration 6

7. Cognitive System Engineering Contextual Control Model (CoCoM) Understanding/Sense making Goal reconciliation Feedback/Feed Forward Control Sharp-end efficiency, resiliency Assistive decision support 7

8. Decision Support v. Sense Making Computerized decision support is typically normative and targets the right decision. The CPRS of the future will emphasize an information-rich environment that targets sense making to support higher quality decisions in the highly variable context of patient care. 8

9. Contextual Control Model (CoCoM) Performance in context Different types of behaviors predict better outcomes Functional not structural approach Not about information processing models: Memory, programs, etc. Used in engineered systems ABS at Saab Nuclear Power Plants 9

10. Control Cycle in Healthcare 10 What is going on.

11. Control Modes Scrambled Lack of purposeful activity Opportunistic Addressing salient characteristics Tactical Following procedure, limited scope Strategic Broader scope and higher-level goals 11

12. Preliminary Conclusions CoCoM translates well to chronic disease care. High-mode characteristics have face validity for predicting better outcomes. Implications for software design: Need to support efficient, rich reconstruction of mental model of patient Need to highlight interaction of goals and therapies Need to increase time horizon including feed forward 12

13. Demonstration 13

14. 14 Example of Integrated Control

15. Building up to Understanding 15

16. Snapshot of condition 16

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22. 22 Advantages of Contextual Control Simplification of current systems Medication reconciliation Alerts Allows for shared mental model of care plan by all professions and the patient Provides natural coordination of care Reduces errors? Facilitate the relevance of nursing documentation

23. 23 Summary Theory-driven design (human factors) Reintegrates patient and system Patient-centric outcomes Assistive decision support Facilitates geriatric-style care