Enrico Coiera

Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors

Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

Communication behaviours in a hospital setting: an observational study

Abstract Objective: An exploratory study to identify patterns of communication behaviour among hospital based healthcare workers. Design: Non-participatory, qualitative observational study. Setting: British district general hospital. Subjects: Eight doctors and two nurses. Results: Communication behaviours resulted in an interruptive workplace, which seemed to contribute to inefficiency in work practice. Medical staff generated twice as many interruptions via telephone and paging systems as they received. Hypothesised causes for this level of interruption include a bias by staff to interruptive communication methods, a tendency to seek information from colleagues in preference to printed materials, and poor provision of information in support of contacting individuals in specific roles. Staff were observed to infer the intention of messages based on insufficient information, and clinical teams demonstrated complex communication patterns, which could lead to inefficiency. Conclusion: The results suggest a number of improvements to processes or technologies. Staff may need instruction in appropriate use of communication facilities. Further, excessive emphasis on information technology may be misguided since much may be gained by supporting information exchange through communication technology. Voicemail and email with acknowledgment, mobile communication, improved support for role based contact, and message screening may be beneficial in the hospital environment. Key messages We observed communication behaviour among 10 hospital based healthcare workers Communication behaviours resulted in an interruptive work place, which seemed to contribute to inefficiency in work practice Medical staff generated twice as many interruptions via telephone and paging systems as they received, and possible causes for this included a bias by staff to interruptive communication methods, a tendency to seek information from colleagues in preference to printed materials, and poor provision of information in support of contacting individuals in specific roles Staff were observed to infer the intention of messages based on insufficient information, and clinical teams showed complex communication patterns, which could lead to inefficiency We conclude that hospital staff may need instruction in appropriate use of communication facilities and that some communication technology—voicemail and email with acknowledgment, cellular telephones for mobile communication, improved support for role based contact, and message screening—may be beneficial

When Conversation Is Better Than Computation

While largely ignored in informatics thinking, the clinical communication space accounts for the major part of the information flow in health care. Growing evidence indicates that errors in communication give rise to substantial clinical morbidity and mortality. This paper explores the implications of acknowledging the primacy of the communication space in informatics and explores some solutions to communication difficulties. It also examines whether understanding the dynamics of communication between human beings can also improve the way we design information systems in health care. Using the concept of common ground in conversation, proposals are suggested for modeling the common ground between a system and human users. Such models provide insights into when communication or computational systems are better suited to solving information problems.

Improving clinical communication: a view from psychology.

Recent research has studied the communication behaviors of clinical hospital workers and observed a tendency for these workers to use communication behaviors that were often inefficient. Workers were observed to favor synchronous forms of communication, such as telephone calls and chance face-to-face meetings with colleagues, even when these channels were not effective. Synchronous communication also contributes to a highly interruptive working environment, increasing the potential for clinical errors to be made. This paper reviews these findings from a cognitive psychological perspective, focusing on current understandings of how human memory functions and on the potential consequences of interruptions on the ability to work effectively. It concludes by discussing possible communication technology interventions that could be introduced to improve the clinical communication environment and suggests directions for future research.

Four rules for the reinvention of health care

If health care is to evolve at a pace that will meet the needs of society it will need to embrace this science of sociotechnical design, but ultimately it is our cultures beliefs and values that shape what we will create and what we dream Futurists might like to speculate on what the health services of 2020 look like. The world may be such that as a clinician you work in flexible virtual teams and some of your colleagues are computers. You would of course instinctively mistrust clinicians who always know the answer without consulting the information grid, and patients often choose to be the team leader. Keyboards are banned as harmful and can be found in museums, next to punch cards and spittoons. The health record is a direct multimedia history of conversations, and a software agent is its curator. For the still cognitively limited clinician, your earring whispers your patients name when you meet. More importantly, in 2020 the health system in most nations will have to treat proportionately more people, with more illness, using relatively fewer tax dollars and workers.1 Given that commentators today are alarmed at the current strains on the health system, we have to assume that by 2020 the healthcare systems in most nations will therefore either have somehow transformed substantially or will have failed. If health care is to flourish in the coming setting of diminished resources and increased demand, then it will do so because we have explicitly designed and implemented new systems of care that are fundamentally sustainable. Given the likely enormity of that task, it may require nothing less than the reinvention of health care. Many of the innovations needed for this reinvention are still unimagined today, but we can predict some of what must come to pass. In …

CareTrack: Assessing the appropriateness of health care delivery in Australia

Objective: To determine the percentage of health care encounters at which a sample of adult Australians received appropriate care (ie, care in line with evidence‐based or consensus‐based guidelines).

The Internet's challenge to health care provision.

The unprecedented growth of the Internet presents a defining moment at the end of the millennium.1 The information age, long predicted, seems at last to be upon us. Yet the speed of its arrival has left most of the medical profession ill prepared to participate in it and unable to foresee its consequences for clinical practice. Through the Internet, the public has access to a growing supply of information on health and disease, often of variable quality and relevance.2 As a result, providing information on health will no longer be the exclusive remit of health care professionals. The quantity of information on the Internet will continue to grow over the next few years, as will the proportion of people with access to it. Access is already widespread in some populations. In 1994, 46% of patients in one Californian clinic had access to email, 89% of them through their place of work.3 In some areas, proportionately more patients than doctors will have access to the Internet. Health care information on the Internet has potential major benefits for patients. Numerous electronic discussion groups already allow patients to share experiences and some health related Internet sites offer email advice on a fee for service basis. Other organisations, including the BMJ, provide free access …

A Systematic Review of Failures in Handoff Communication During Intrahospital Transfers

BACKGROUND Handoffs serve a critical function in ensuring patient care continuity during transitions of care. Studies to date have predominantly focused on intershift handoffs, with relatively little attention given to intrahospital transfers. A systematic literature review was conducted to characterize the nature of handoff failures during intrahospital transfers and to examine factors affecting handoff communication and the effectiveness of current interventions. METHODS Primary studies investigating handoff communication between care providers during intrahospital transfers were sought in the English-language literature between 1980 and February 2011. Data for study design, population characteristics, sample size, setting, intervention specifics, and relevant outcome measures were extracted. DATA SYNTHESIS Study results were summarized by the impact of communication breakdown during intrahospital transfer of patients, and the current deficiencies in the process. Results of interventions were summarized by their effect on the quality of handoff communication and patient safety. FINDINGS The initial search identified 516 individual articles, 24 of which satisfied the inclusion criteria. Some 19 were primary studies on handoff practices and deficiencies, and the remaining 5 were interventional studies. The studies were categorized according to the clinical settings involved in the intrahospital patient transfers. CONCLUSIONS There is consistent evidence on the perceived impact of communication breakdown on patient safety during intrahospital transfers. Exposure of handoffs at patient transfers presents challenges that are not experienced in intershift handoffs. The distinct needs of the specific clinical settings involved in the intrahospital patient transfer must be considered when deciding on suitable interventions.

A systematic review of the psychological literature on interruption and its patient safety implications.

OBJECTIVE To understand the complex effects of interruption in healthcare. MATERIALS AND METHODS As interruptions have been well studied in other domains, the authors undertook a systematic review of experimental studies in psychology and human-computer interaction to identify the task types and variables influencing interruption effects. RESULTS 63 studies were identified from 812 articles retrieved by systematic searches. On the basis of interruption profiles for generic tasks, it was found that clinical tasks can be distinguished into three broad types: procedural, problem-solving, and decision-making. Twelve experimental variables that influence interruption effects were identified. Of these, six are the most important, based on the number of studies and because of their centrality to interruption effects, including working memory load, interruption position, similarity, modality, handling strategies, and practice effect. The variables are explained by three main theoretical frameworks: the activation-based goal memory model, prospective memory, and multiple resource theory. DISCUSSION This review provides a useful starting point for a more comprehensive examination of interruptions potentially leading to an improved understanding about the impact of this phenomenon on patient safety and task efficiency. The authors provide some recommendations to counter interruption effects. CONCLUSION The effects of interruption are the outcome of a complex set of variables and should not be considered as uniformly predictable or bad. The task types, variables, and theories should help us better to identify which clinical tasks and contexts are most susceptible and assist in the design of information systems and processes that are resilient to interruption.

Building a National Health IT System from the Middle Out

The top-down approach of many national programs for healthcare information technology (IT) may be at the heart of their current problems. The medical-industrial complex loves a big procurement, and the contracts do not get much bigger than for building nation-scale health information systems (NHIS). But do we really need government embedded in the process of IT implementation, something it so clearly and routinely struggles with? Or is it better for government to simply set the policy rules of the game, given that it is policy in which they are expert? As the new United States Administration has recently signalled a massive injection of funds into building a National Health Information infrastructure via the American Recovery and Reinvestment Act (ARRA), what lessons can be learned from the past, and what strategic shape should the Federal intervention take? The English National Health System (NHS) National Program for IT (NPfIT) in many ways serves as an international beacon for healthcare reform, because of its clear message that major restructuring of health services is not possible without a pervasive information infrastructure. The NPfIT is rolling out working systems and delivering tangible benefits to patients and caregivers. Yet no one could deny that there have been plenty of setbacks, misgivings, clinical unrest, delays, cost overruns, and paring back of promised functionality, culminating in demands from some political quarters to shut down the program.1 The NPfIT was bound to experience some difficulties purely on the basis of its scale and complexity.2 However, it is becoming apparent that there may be another, more foundational, cause of NPfITs problems. The NHS remains one of the few nation-scale, single-payer health systems in the world. It thus has nation-scale management and governance structures to match, and these inevitably encourage a top-down system architecture, standards compliance, and procurement process. …