Sociotechnical Aspect of

Health Informatics

Nawanan Theera-Ampornpunt, MD, PhDSeptember 5, 2013

Except where citing other works

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Sociotechnical Systems• Coined in 1960s by Eric Trist, Ken Bamforth &

Fred Emery

• “An approach to complex organizational work design that recognizes the interaction between people and technology in workplaces.” (Wikipedia)

• “Interaction between society's complex infrastructures and human behaviour.” (Wikipedia)

http://en.wikipedia.org/wiki/Sociotechnical_system

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People-Process-Technology

Technology

ProcessPeople

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“People & Organizational Issues” (POI)• POI focuses on interactions between people

and technology, including designing, implementing, and deploying safe and usable health information systems and technology.

• AMIA POIWG addresses issues such as– How systems change us and our social and clinical

environments– How we should change them– What we need to do to take the fullest advantage of

them to improve [...] health and health care. – Our members strive to understand,

evaluate, and improve human-computer and socio-technical interactions.

http://www.amia.org/programs/working-groups/people-and-organizational-issues

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“People & Organizational Issues” (POI)• We bring varied perspectives, methods, and tools

from– Humanities, Social science, Cognitive science– Computer science and informatics– Business disciplines– Patient safety– Workflow– Collaborative work and decision-making– Human-computer interaction & Usability– Human factors– Project and change management– Adoption and diffusion of innovations– Unintended consequences– Policy.

http://www.amia.org/programs/working-groups/people-and-organizational-issues

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Common Themes in Informatics

Produced based on speaker’s personal opinion. Not based on real raw data.

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Health IT Successes & Failures

Kaplan & Harris-Salamone (2009)

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Health IT Successes & FailuresWhat success is• Different ideas and definitions of success• Need more understanding of different stakeholder

views & more longitudinal and qualitative studies of failure

What makes it so hard• Communication, Workflow, & Quality• Difficulties of communicating across different

groups makes it harder to identify requirements and understand workflow

Kaplan & Harris-Salamone (2009)

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Health IT Successes & FailuresWhat We Know—Lessons from Experience• Provide incentives, remove disincentives• Identify and mitigate risks• Allow resources and time for training, exposure,

and learning to input data• Learn from the past and from others

Kaplan & Harris-Salamone (2009)

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Health IT Successes & Failures

Leviss (Editor) (2010)

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Health IT Change Management

Lorenzi & Riley (2000)

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Health IT Change Management

Lorenzi & Riley (2000)

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Health IT Change Management

Lorenzi & Riley (2000)

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Health IT Change Management

Lorenzi & Riley (2000)

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Considerations for a successful implementation of CPOE

Ash et al. (2003)

ConsiderationsMotivation for implementationCPOE vision, leadership, and personnelCostsIntegration: Workflow, health care processesValue to users/Decision support systemsProject management and staging of implementationTechnologyTraining and Support 24 x 7Learning/Evaluation/Improvement

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Minimizing MD’s Change Resistance• Involve physician champions• Create a sense of ownership through

communications & involvement• Understand their values• Be attentive to climate in the organization• Provide adequate training & support

Riley & Lorenzi (1995)

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Reasons for User Involvement• Better understanding of needs & requirements• Leveraging user expertise about their tasks &

how organization functions• Assess importance of specific features for

prioritization

• Users better understand project, develop realistic expectations

• Venues for negotiation, conflict resolution

• Sense of ownership• Pare & Sicotte (2006): Physician ownership

important for clinical information systems

Ives & Olson (1984)

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The Missing Piece in IT Adoption

Theera-Ampornpunt (2011)

Technological Sophistication

Functional Sophistication

Integration Sophistication

Managerial SophisticationProposed Addition

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Critical Success Factors in Health IT Projects

Theera-Ampornpunt (2011)

Communications of plans & progressesPhysician & non-physician user involvementAttention to workflow changesWell-executed project managementAdequate user trainingOrganizational learningOrganizational innovativeness

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Theory of Hospital Adoption of Information Systems (THAIS)

Theera-Ampornpunt (2011)

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The “Special People”

Ash et al. (2003)

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The “Special People”

Ash et al. (2003)

• Administrative Leadership Level– CEO

• Provides top level support and vision

• Holds steadfast• Connects with

the staff• Listens• Champions

– CIO• Selects champions• Gains support• Possesses vision• Maintains a thick skin

– CMIO• Interprets• Possesses vision• Maintains a thick skin• Influences peers• Supports the clinical

support staff• Champions

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The “Special People”

Ash et al. (2003)

• Clinical Leadership Level– Champions

• Necessary• Hold steadfast• Influence peers• Understand other

physicians

– Opinion leaders• Provide a balanced

view• Influence peers

– Curmudgeons• “Skeptic who is

usually quite vocal in his or her disdain of the system”

• Provide feedback• Furnish leadership

– Clinical advisory committees

• Solve problems• Connect units

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The “Special People”

Ash et al. (2003)

• Bridger/Support level– Trainers &

support team• Necessary• Provide help at the

elbow• Make changes• Provide training• Test the systems

– Skills• Possess clinical

backgrounds• Gain skills on the

job• Show patience,

tenacity, and assertiveness

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Unintended Consequences of Health IT

• “Unanticipated and unwanted effect of health IT implementation” (ucguide.org)

• Must-read resources– www.ucguide.org– Ash et al. (2004)– Campbell et al. (2006)– Koppel et al. (2005)

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Unintended Consequences of Health IT

Ash et al. (2004)

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Unintended Consequences of Health IT

• Errors in the process of entering and retrieving information– A human-computer interface that is not suitable

for a highly interruptive use context– Causing cognitive overload by

overemphasizing structured and “complete” information entry or retrieval

• Structure• Fragmentation• Overcompleteness

Ash et al. (2004)

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Unintended Consequences of Health IT

• Errors in the communication and coordination process– Misrepresenting collective, interactive work as

a linear, clearcut, and predictable workflow• Inflexibility• Urgency• Workarounds• Transfers of patients

– Misrepresenting communication as information transfer

• Loss of communication• Loss of feedback• Decision support overload• Catching errors

Ash et al. (2004)

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Unintended Consequences of Health IT

• Errors in the communication and coordination process– Misrepresenting collective, interactive work as

a linear, clearcut, and predictable workflow• Inflexibility• Urgency• Workarounds• Transfers of patients

– Misrepresenting communication as information transfer

• Loss of communication• Loss of feedback• Decision support overload• Catching errors

Ash et al. (2004)

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Unintended Consequences of Health IT

Campbell et al. (2006)

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Unintended Consequences of Health IT

Campbell et al. (2006)

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Unintended Consequences of Health IT

Koppel et al. (2005)

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Unintended Consequences of Health IT

Koppel et al. (2005)

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How do I open the door?

Door #1

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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How do I open the door?

Door #2

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Back to door #1

Door #1

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Back to door #2

Door #2

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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How do I open the door? Door #3

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Door #3

No instructions needed!

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Design Principles

• “Instructions/explanations are a sign of failure!”

• Visibility• Affordances

• Promoting recognition over recall

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Human-Computer Interaction

• “A discipline concerned with the design, evaluation and implementation of interactive computing systems for human use”

• Interdisciplinary– Computer Science; Psychology; Sociology;

Anthropology; Visual and Industrial Design; …

design

implementationevaluation

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Foundations of UI Design (1)

• Human psychology– Short-term & long-term memory– Problem-solving– Attention

• Design principles– Conceptual models; knowledge in the world;

visibility; feedback; mappings; constraints; affordances

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

4343

Foundations of UI Design (2)

• Understanding users and tasks– Tasks, task analysis, scenarios– Contextual inquiry– Personas

• User-centered design– Low, medium, and high-fidelity prototypes– visual design principles

• Evaluating designs– Without users: cognitive walkthroughs; heuristic

evaluation; action analysis– With users: qualitative and quantitative methods

From University of Minnesota CS 5115 User interface design class (2008) by Loren Terveen

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Human Factors

• “The study of designing equipment and devices that fit the human body and its cognitive abilities” (Wikipedia)

• Also known as “Ergonomics”• Specialties

– Physical ergonomics– Cognitive ergonomics (including HCI)– Organizational ergonomics (including

workplace design)– Environmental ergonomics

http://en.wikipedia.org/wiki/Human_factors_and_ergonomics

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Usability

• “Refers to how well users can learn and use a product to achieve their goals and how satisfied they are with that process” (Usability.gov)

• “The ease of use and learnability of a human-made object” (Wikipedia)

• “The extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use (ISO)

• Key methodology: user-centered designhttp://en.wikipedia.org/wiki/Usability

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Usability & Usable Systems

• Usefulness = Usability + Utility (Jakob Nielsen)

• Dimensions of usability– Learnability: How easy it is for users to accomplish

basic tasks the first time?– Efficiency: Once learned, how quickly can users

perform tasks?– Memorability: When returned after a period of non-

use, how easily can users re-establish proficiency?– Errors: Frequency, severity, recoverability– Satisfaction: How pleasant it is to use?

http://en.wikipedia.org/wiki/Usability http://www.useit.com/alertbox/20030825.html

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User Experience

• “The way a person feels about using a product, system or service” (Wikipedia)

• Focuses on the feelings and perceptions of users

• Subjective

http://en.wikipedia.org/wiki/User_experience

48http://www.msn.com/

49http://www.google.com/

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HCI & Usability Resources

• Usability.gov• Useit.com• Edwardtufte.com• National Institute of Standards and

Technology (NIST)– http://www.nist.gov/healthcare/usability/index

.cfm– Technical Evaluation, Testing, and Validation

of the Usability of Electronic Health Records – NIST Guide to the Processes Approach for

Improving the Usability of Electronic Health Records

http://en.wikipedia.org/wiki/User_experience

“Most people make the mistake of thinking design is what it looks like. People think it’s this veneer – that the designers are handed this box and told, ‘Make it look good!’ That’s not what we think design is. It’s not just what it looks like and feels like. Design is how it works.” – Steve Jobs

Image Source: http://en.wikipedia.org/wiki/Steve_Jobs

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References• Ash JS, Berg M, Coiera E. Some unintended consequences of information

technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004 Mar-Apr;11(2):104-12.

• Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: the importance of special people. Int J Med Inform. 2003 Mar; 69(2-3):235-50.

• Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc. 2003 May-Jun;10(3):229-34.

• Campbell, EM, Sittig DF, Ash JS, et al. Types of Unintended Consequences Related to Computerized Provider Order Entry. J Am Med Inform Assoc. 2006 Sep-Oct; 13(5): 547-556.

• Ives B, Olson MH. User involvement and MIS success: a review of research. Manage Sci. 1984 May;30(5):586-603.

• Kaplan B, Harris-Salamone KD. Health IT success and failure: recommendations from the literature and an AMIA workshop. J Am Med Inform Assoc. 2009 May-Jun;16(3):291-9.

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References• Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL.

Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005 Mar 9;293(10):1197-203.

• Lorenzi NM, Riley RT. Managing change: an overview. J Am Med Inform Assoc. 2000 Mar-Apr;7(2):116-24.

• Paré G, Sicotte C, Jacques H. The effects of creating psychological ownership on physicians’ acceptance of clinical information systems. J Am Med Inform Assoc. 2006 Mar-Apr;13(2):197-205.

• Riley RT, Lorenzi NM. Gaining physician acceptance of information technology systems. Med Interface. 1995 Nov;8(11):78-80, 82-3.

• Theera-Ampornpunt N. Thai hospitals' adoption of information technology: a theory development and nationwide survey [dissertation]. Minneapolis (MN): University of Minnesota; 2011 Dec. 376 p.