Ebook: Context Sensitive Health Informatics: Human and Sociotechnical Approaches

This volume presents the papers of the International Conference on “Context Sensitive Health Informatics, Human and Sociotechnical approaches” held at Herlev Hospital in Copenhagen, Denmark in August 2013.

Context Sensitive Health Informatics is about health information technologies and their environments. Environments may be people in different roles such as users, designers, and evaluators, but also non-human constructs such as organizations, work practices, guidelines and protocols, buildings and markets.

This pre-Medinfo conference joins and continues two conference series: HFE-HI – Human Factors/Ergonomics for Health Informatics – previously held in 2006 (Lille, FR), 2007 (Aarhus, DK), 2008 (Amsterdam, NL), 2009 (Sonoma, US) and 2011 (Trondheim, NW) and ITHC – Information Technology in Health Care – Sociotechnical approaches – previously held in 2001 (Rotterdam, NL), 2004 (Portland, USA), 2007 (Sidney, AUS) and 2011 (Aalborg, DK).

The conference is endorsed by IMIA, EFMI and AMIA and organized/supported by the IMIA Working Groups Human Factors Engineering for Healthcare Informatics, Organizational and Social Issues, Health Informatics for Patient Safety and by the EFMI WG on Human and Organizational Factors of Medical Informatics.

The editors want to thank Bernadette Lucas from University Hospital of Lille for the final editing of the proceedings. Anni Møller Brændstrup and Marianne Sørensen, Danish Centre for Health Informatics, Aalborg University did a great job in setting up the conference web site and keeping track of the registration process. We would like to acknowledge Linda W. Peute from Department of Medical Informatics, Academic Medical Center, Amsterdam for designing the logo for the conference. We also want to thank Sanne Jensen, Bithe Hermansen, Karen Marie Lyng, Stine Loft Rasmussen and Niels Reichstein Larsen for making it possible to organize the conference at Herlev Hospital and setting up the tour of the IT Experimentarium. Finally we want to thank the Scientific Program Committee for their great efforts to establish the content of the conference and all the reviewers for providing constructive feedback to the authors. Their excellent work has significantly improved the quality of many papers.

Marie-Catherine Beuscart-Zéphir

Monique Jaspers

Craig Kuziemsky

Christian Nøhr

Jos Aarts

Context is a key consideration when designing and evaluating health information technology (HIT) and cannot be overstated. Unintended consequences are common post HIT implementation and even well designed technology may not achieve desired outcomes because of contextual issues. While context should be considered in the design and evaluation of health information systems (HISs) there is a shortcoming of empirical research on contextual aspects of HIT. This conference integrates the sociotechnical and Human-Centered-Design (HCD) approaches and showcases current research on context sensitive health informatics. The papers and presentations outlines theories and models for studying contextual issues and insights on how we can better design HIT to accommodate different healthcare contexts.

Many of our most pressing societal challenges arise from our inability to move on from present practices and structures and do what is needed. Healthcare struggles to improve safety and quality. It resists adoption of best practices and persists in high levels of unwarranted variation in care delivery, and clings to financially unsustainable models of care. One explanation for this state of affairs is not a lack of will, but that we are experiencing system inertia - a consequence of the increasing complexity of our human systems. In this paper I explore three possible system level interventions that may help design systems that are less likely to approach inertia, as well as help change our current systems so that they again become adaptive, and move to the outcomes we desire. Firstly, I question our religious belief in the power of standards, an intervention designed to minimise adaptation and almost from first principles designed to lead to inertia. Next I explore the power of apoptosis, a process that sees existing structures and practices programmatically removed to free up resource for adaptation. Finally I explore a flexible but controversial approach to system management called market-based control. Whether any of these, together or in tandem, are a way out of inertia is an open question. However, it is time for us to engage with the challenge of system inertia, and find a way out.

The introduction of health information technology (HIT) has been associated with a decrease in medical error and this has been one of the main reasons for international efforts at increasing adoption of systems such as electronic health records, computerized physician order entry and clinical decision support systems. However, in recent years there is growing evidence that if not designed and tested properly such HIT can also lead to new categories of errors that were previously unseen in healthcare. These errors are known as technology-induced errors and they typically manifest themselves in the complex interaction between healthcare providers and HIT during real clinical use. In this paper the author explores the concept of technology-induced error in healthcare and discusses a range of strategies for detecting and mitigating such errors. Strategies include creating new organizations whose focus is to reduce technology-induced errors, develop and deploy new ways to detect such errors before systems are released, as well as approaches to reporting such errors after they occur. Other strategies include the development of regulation and policy to reduce such errors. It is argued that a multi-faceted approach to dealing with technology-induced error is needed.

The paper is dealing with the problematic positioning of the whole health care system towards the concept of standard. There is a constant quest for standards, and a prediction of how everyday language gradually will disappear. It is the assumption and conjecture of this paper that as we outdo everyday language from our communication in the system we lose major part of meaning-construction concerning health and life of the patient/citizen. It is the normative and ethical aim of the discussion to frame how human factors are terminated as standards and bodies as machines replaces everyday language and bodies as carrier of health. Hans Georg Gadamer has led me on the way through inspiring essays on the Enigma of Health.

It is argued that a development of healthcare systems should emerge within a healthcare providing organization and as part of daily practice instead of something implemented by a third party, in order to become successful. This sociotechnical view on system development is shared with new methods developed in the end-user development field. However, is it possible to realize this in practice? This paper explores the obstacles and potentials in the realization, leading to a discussion about sociotechnical systems as innovation systems. We describe two examples of sociotechnical innovation systems, and discuss the results from an end user driven innovation process perspective.

Traditionally health records have a source-oriented structure, as opposed to a clinically logical structure. The aim of the current study is to record and depict the clinically logical information structure built by doctors as part of their contextualisation of clinical information, to compare this structure to that of a given health record, and to assess whether a structural difference may have negative consequences. Eight doctors in a medical department were observed during contextualisation of clinical information. The method of observation included simultaneous interviews and with the technique used it was possible to depict the clinically logical information structure and compare it to the structure of the health record. The doctors' information structure was found to differ widely from the structure of the health record, causing split-attention and stress. It is concluded that the present health record is suboptimal. Further research in information support based on clinically logical structure is recommended.

User-centred approaches in the development and evaluation of health information systems promote the importance of involving users and understanding their social contexts to optimise the quality and safety of these systems for patient care. Simultaneously, the standardisation of clinical practices has also been advocated to improve the quality and safety of patient care. In the context of clinical handover improvement within three different departments in one tertiary teaching hospital, this paper highlights the potential for tensions between these two approaches and explores their implications. Based on a user-centred approach, the paper reports on the unique requirements identified within each of the three departments for an information system to support improved clinical handover. Each department had clinical practices, work cultures and user requirements that needed to be considered and accommodated. This led to the project developing distinct minimum data sets for each of the three departments that posed challenges for efforts to standardise handover practices across the hospital and for building an integrated information system. While on the one hand accommodating unique departmental user requirements was valuable, they revealed the potential for the introduction of quality and safety risks at the organisational level. To resolve these tensions, the project team developed an approach called flexible standardisation that has now been embedded in Australia' s national guidelines on clinical handover improvement.

Increasingly, studies are being published on the potential negative effect of introducing poor designed Health Information Technology (HIT) into clinical settings, relating to technology-induced errors and adverse events. Academic research on HIT design and evaluation is an extremely important source of information in providing new insights into factors contributing to successful system (re)design efforts, system user-friendliness and usability issues and safety critical aspects of HIT design. However, these studies have been inconsistent and incomprehensive in their reporting, complicating the appraisal of outcomes, generalizability of study findings, meta-analysis and harmonization of the available evidence. To improve identification of type of use errors and safety related issues regarding design and implementation of HIT, consensus on issues to be reported on in scientific publications is a necessary step forward. This study presents the first approach to a framework providing a set of principles to follow for comprehensive and unambiguous reporting of HIT design and usability evaluation studies with the objective to reduce variation, improve on the publication reporting quality and proper indexation of these studies. This framework may be helpful in expanding the knowledge base not only concerning the application of Human Factors (HF)/Usability studies of HIT but also improve the knowledge base of how to (re)design and implement effective, efficient and safe HIT.

Recent international guidelines encourage more prominent placement of patient-generated information about medications on the pharmacovigilance information landscape. Online platforms where patients share medication experiences with one another and with healthcare professionals are one possible avenue to accomplishing this goal. Public reports of medication-related events posted on the web, however, are under-utilized in the pharmacovigilance community. Moreover, little is known about who writes such reviews, what information is shared and how this information can be used by authorities. This paper reports the first results of a study of user and comment characteristics on a European-based platform.

Health information technology (IT) can have a profound effect on the temporal flow and organisation of work. Yet research into the context, meaning and significance of temporal factors remains limited, most likely because of its complexity. This study outlines the role of communications in the context of the temporal and organizational landscape of seven Australian residential aged care facilities displaying a range of information exchange practices and health IT capacity. The study used qualitative and observational methods to identify temporal factors associated with internal and external modes of communication across the facilities and to explore the use of artifacts. The study concludes with a depiction of the temporal landscape of residential aged care particularly in regards to the way that work is allocated, prioritized, sequenced and coordinated. We argue that the temporal landscape involves key context-sensitive factors that are critical to understanding the way that humans accommodate to, and deal with health technologies, and which are therefore important for the delivery of safe and effective care.

Technologists are constantly working to improve clinical practice by developing new health information technology (Health IT) tools, yet may not always consider the context of how these tools may be used. Patient preferences can vary widely as a result of demographics, health conditions, physical limitations, and personal inclinations, with healthcare providers having to adapt clinical encounters to better suit patient needs. Health IT tools, too, need to be agile across different healthcare contexts, with each stakeholder's specific needs in mind. In this paper, we discuss the challenges and limitations associated with the design and automation of contextually sensitive devices in the healthcare environment. We target the various contexts in which health information is presented in patient-provider encounters, and discuss contextual constraints that may apply to the aforementioned situations. In addition, we present a number of suggestions for informational constraints and the design of informational tools in these settings so that patient and provider informational needs can be better met in clinical communication contexts.

With the growing population with chronic disease in most developed countries, the amount and variety of interactive medical devices adopted in healthcare and wellbeing management is on the rise. Studies show that people with chronic conditions are facing many barriers to effective self-management, which leads to significant economic losses in many countries. The question as to how we can design personal medical devices that are able to facilitate an effective self-management by tackling these barriers presents a challenging research topic. We offer an overview of a controlled-experiment designed to evaluate an innovative tagging feature and a confidence of measurement feature in chronic disease management. This is a work-in-progress, which will finish by the end of June 2013.

Clinical Systems have become standard partners with clinicians in the care of patients. As these systems become integral parts of the clinical workflow, they have the potential to help improve patient outcomes, however they have also in some cases have led to adverse events and has resulted in patients coming to harm. Often the root cause analysis of these adverse events can be traced back to Usability Errors in the Health Information Technology (HIT) or its interaction with users. Interoperability of the documentation of HIT related Usability Errors in a consistent fashion can improve our ability to do systematic reviews and meta-analyses. In an effort to support improved and more interoperable data capture regarding Usability Errors, we have created the Usability Error Ontology (UEO) as a classification method for representing knowledge regarding Usability Errors. We expect the UEO will grow over time to support an increasing number of HIT system types. In this manuscript, we present this Ontology of Usability Error Types and specifically address Computerized Physician Order Entry (CPOE), Electronic Health Records (EHR) and Revenue Cycle HIT systems.

The availability of health information is rapidly increasing; its expansion and proliferation is inevitable. At the same time, breeding of health information silos is an unstoppable and relentless exercise. Information security and privacy concerns are therefore major barriers in the eHealth socio-eco system. We proposed Information Accountability as a measurable human factor that should eliminate and mitigate security concerns. Information accountability measures would be practicable and feasible if legislative requirements are also embedded. In this context, information accountability constitutes a key component for the development of effective information technology requirements for health information system. Our conceptual approach to measuring human factors related to information accountability in eHealth is presented in this paper. Measuring the human factors associated with information accountability can benefit from extant theories from information systems research and business management. However, the application of such theories must clearly address the specialised nature of the application context coupled with the role of the users within the context.

The distribution of tasks between humans and machines in the design of healthcare systems is an important issue for patient safety. This paper presents a usability test performed to compare a semi-automated unit dose system (UDS) with the usual/manual preparation procedure for preparing and administering drugs. The results show that the UDS prevents the frequent administration errors encountered with the usual cabinets and produces a better performance in terms of time for filling the pill dispensers (6.52 sec ± 1.1 vs. 8.5 sec ± 1.5 (t_{9, 16} = 3.12, p <.007)). But the results also stress that the UDS takes entire control of the preparation and administration tasks, thus leading to a loss of control of the process by nurses (difficulties experienced by them in resuming their actions, difficulties in memorizing drugs, lack of confidence in the UDS while they “blindly” rely on it). The distribution of tasks between the nurses and the UDS should be modified to give back control to the nurses. Design suggestions were provided in this way. For instance, the UDS may guide the nurses for the drugs localization in the cabinet but leaves the validation of the drugs to the nurses.

The emerging computerized system for patient safety event reporting eases the course of learning from medical errors and adverse events for a safer healthcare environment. To a medical event like patient falls, the course usually involves pre, during and post stages for the prediction, reporting and solution of the event. However, the reporting stage often separates from the other two stages for risk assessment and cause analysis. As this iterative flow of actions falls apart and becomes unintelligible or intangible due to information gaps, it is dubious for users to join and complete the task at all three stages in a high quality. Therefore, in this paper, by referencing studies in aspects of Norman' s task action theory and fall management programs, we proposed a gap-bridging model to describe the process of assisting users in proceeding along the stages by user-centered design approaches. Based upon the model, we also developed a series of interface artifacts served as gap-bridging features, which hold promise in improving the quality of reporting and reporter engagement of the system.

Due to the versatile nature of nurses' work, whether contact requests can be initiated or received depends on the situation the nurses find themselves in. Through a qualitative study influenced by the participatory design methodology, we uncover issues with a communication system at a hospital when nurses are situated in different contexts. Based on the findings, we suggest a new system design where nurses can initiate and receive contact requests on a heterogeneous set of devices. Further, we argue that the new system should allow communication of context information to aid nurses to assert whether to engage in a communication request or not.

Information systems in healthcare need to be designed and developed in a collaborative way. However, existing collaborative methodologies for the parallel development of healthcare work and information systems are vague and fragmented. Furthermore, they neither address people-centred healthcare nor limited-resource contexts. In this paper we introduce an emerging holistic approach, based on a unifying theoretical basis, for co-developing the services, work and information systems in healthcare. The approach intends to (a) be collaborative in nature; (b) address the domains of both healthcare professionals and ordinary people / communities; (c) span the main analysis and design tasks of socio-technical information systems development from needs assessment through requirements setting to functional-architectural solutions; (d) be contextually sensitive; and (e) be practicable in “real life” beyond research settings.

While health information technology (HIT) may be designed to support specific tasks the integrated nature of healthcare delivery often requires HIT to play various coordination roles. While studies have shown that coordination issues with HIT can cause adverse impacts there is little research that has looked at the specific types of coordination that HIT need to support. This paper uses a longitudinal study of a perioperative information system to identify and discuss different categories of HIT coordination. The findings can help the design and evaluation of HIT to support the coordination needs of healthcare delivery.