We discuss two problems in detail: Working on the computer is rarely an isolated task; health care professionals are always communicating with others, including patients in outpatient settings, but primarily with other health care professionals.
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More often than not, different tasks are executed simultaneously, and interruptions by beepers, telephones, and colleagues are endless. This single-task assumption is aggravated by the fact that so many existing screen designs are already suboptimal by current office standards. This mismatch between interface and use context often results in a juxtaposition error, the kind of error that can result when something is close to something else on the screen and the wrong option is too easily clicked in error.
The patient was talking to me, I accidentally put down solution, realized that's not what I wanted …. Likewise, there were many instances of patient or physician confusion when orders were entered for or on behalf of the wrong person. Again, in a context of many co-occurring activities and interruptions, a suboptimal interface becomes rapidly unforgiving: At the fifth screen she saw that the patient was getting tube feeding.
Professionals need fast access to data that are relevant to the case at hand. Simultaneously, they need to be able to record a maximum amount of information in a minimum amount of time and in such a way that it is most useful to other health care professionals involved in the handling of this patient's trajectory.
Psychologic and sociologic studies have shown that in a shared context, concise, unconstrained, free-text communication is most effective for coordinating work around a complex task. Such formats are generally more time-consuming to complete and read. Some PCIS systems require data entry that is so elaborate that the time spent recording patient data is significantly greater than it was with its paper predecessors.
What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician. Having to go to many different fields, often using many different screens to enter many details, physicians reported a loss of overview.
When professionals are working through a case, determining a differential diagnosis, for example, the act of writing the information is integral to the cognitive processing of the case. Rather than helping the physician build a cognitive pattern to understand the complexities of the case, such systems overload the user with details at odds with the cognitive model the user is trying to develop.
Similarly, the need to switch between different screens can result in a loss of overview. Physicians and nurses in an intensive care unit, for example, reported that the large paper day-sheets they used to work with would include an order list, problem list, vital signs graphs, and medication lists, all on a single large sheet of paper. The graphic user interface software they used allowed all of these functions and more, but the user had to switch among multiple windows to get all of the information.
Doing so, several professionals argued, worked against their ability to acquire, maintain, and refine a mental overview of the case. Likewise, records might overly separate the information flows according to work task or responsibility. In everyday practice, doctors can gather information from nurses' notes, or those of other specialists, that relate to the problem.
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Information systems could limit this easy access to other people's notes or other parts of the record, and thereby severely hamper the professional's ability to be optimally informed. On an order entry, results reporting may only get the raw data and not the interpretation, which could affect clinical work. This separation may also lead to clinicians being too specialty focused [and] not seeing what others have written—now [we] have to flick through notes so we see other information.
Results reporting systems can also mistake completeness for efficacy. Many others use the [standard templates] and then you often see a discussion with standard phrases, one or two added phrases, and then more standard phrases. You then have to really search what the considerations were…. In my reports the text is mine, it doesn't come from the computer, I make it up myself….
Everyone should do that. Too many standard phrases, these physicians argued, actually decreased the readability and information value of the reports. The similarity of the phrases, and the impossibility of judging whether a sentence is part of the template or a result of a thoughtful weighing of words, threatens to obscure the transparency that such systems attempt to introduce. Here, of course, ease of use can also lure users into learning new but poor recording practices.
The ability to cut and paste or, more often, copy and paste, affords users the opportunity to exacerbate the data overload problem. As an attending physician stated: In the previous section, we discussed errors related to the processes of entering and retrieving information in PCISs. In this section, we focus on the way computers can undermine communication about and coordination of events and activities.
Here we encounter the truly interactive and contingent nature of health care work and the consequences of not taking these characteristics into account. Although the issues discussed here are highly interrelated, we have subdivided them in two overarching problems: PCIS systems often appear to be imbued with a formal, stepwise notion of health care work: As a chain of independent actions, an order is executed and reported on, or a piece of information is generated, processed, and stored. Support of work processes is one of the main benefits of PCISs, yet it has its problems.
Finding the proper balance between formalizing work activities so that the information technology application can fulfill its promise and respecting this fluid and contingency-driven nature of health care work is no easy task for system designers. Seemingly easy and clearcut on paper, the real-time intricacies of treatment protocols, for example, could baffle the system's preconceptions of these processes.
In one instance, for example, a drug ordered three times a day had been discontinued, but one dose had already been given. The computer system would not allow the nurse to chart the one dose, because the system considered it an incomplete execution of the task [as told by a pharmacist, U. In the case of urgent medication orders, nurses could already give a medication before the physician formally activates the order.
There is a familiar category of errors here that has to do with the informal realities of medication handling in health care. In everyday health care work, experienced nurses often have more practical knowledge about what medications to give when, and what contraindications could be relevant, than many of the junior physicians who populate the wards. There is a rather large gray zone of informal management of these responsibilities and tasks, which can be entirely rational given the everyday organization and exigencies of health care work.
Within this same gray zone, there could lie many practices that would contribute to unsafe medication routines such as doctors actively discouraging nurses to call them for medication requests or nurses taking too many liberties with dosing. All of these practices exist within the current paper medication systems, but many computerized medication systems all too radically cut off such practices.
In the last example, nurses had to bear the consequences of physicians' not wanting to have to enter every medication order before anything could be given or changed. Understandably, both professional groups refused to fulfill these demands. When such systems do remain in practice, workarounds, which are clever alternative approaches, are artfully developed by the users.
Workarounds allow users to live with the system while avoiding some of the demands that are deemed to be unrealistic or harmful. In urgent situations, physicians could enter medication orders after the medication has already been administered, for example. Alternatively, the order might have been entered by the nurse but would have to be activated by the physician post hoc.
Similar problems abound when transferring patients between wards or when admitting new patients. Here again, the real patient flow does not always match the clearcut, formal model of the patient flow in which you start with the completion of the required administrative data after which the clinical content can be accessed and entered. This ensures that the patient record is not accidentally fragmented over different electronic patient identities.
Unexpected Consequences
In real-life health work, however, information can be required or activities will have to be started or planned before the proper administrative details are entered or even known. Problems such as this are familiar to everyone with some clinical experience, yet there are still systems that very poorly support this, as we have witnessed in all three countries. In another example, we were told that once an order had been entered by a physician, that person expected it to be carried out but, if the administrative data had not yet been entered, the physician's orders might never be executed.
This could make sense from a purely administrative perspective, but not from a clinical one. In a work practice such as health care, which is characterized by contingencies and constantly developing definitions of the situation, proper communication among the involved professionals is crucial. The result is reduced direct interaction among physicians, nurses, and pharmacy, and increased overall reliance on the computer system. In this case, the designers had overlooked the fact that in the previous work process, laboratory personnel called doctors when the results were in.
In the new situation, doctors would have to actively log into the system to see whether the results were already available. In the hectic environment of these wards, this is a highly inefficient mode of communication for these professionals. We encountered many variations on this theme; nurses are often alerted to new orders by the printer, but this assumes the nurse is nearby and that the printer functions correctly: Here again, the sender of the information mistakenly assumes that the computer will take care of notifying the receiver, the nurse.
Similarly, a common problem is that physicians cannot tell if an order has been carried out, or that someone else has entered a similar order, without gaining feedback. The latter might be more correct, but it would require yet another separate computer session. Although logical from the nurses' point of view, the system did not make a distinction between an order that was accepted and an order that was executed.
This was problematic, because doctors then often do not know the true status of orders [field notes, observing nurses and physicians, U. As a result of miscommunication, orders or appointments are missed, diagnostic tests are delayed, and medication is not given. Communication involves more than transferring information. Communication is about generating effect —the laboratory personnel wanted to make sure that the doctors would act on their data. Similarly, communication is about testing out assumptions regarding the other person's understanding of the situation and willingness to act on your information.
Decision support systems suffer from the same problem. They could trigger an overdose of reminders, alerts, or warning messages. These messages can be sent to the computer user even if the message is not relevant for that user at that moment, or if the intended recipient of the message is not even the one entering the data. From a communication perspective, it is crucial to realize that it is not just a simple data overload that such messages could generate. As a result, health care professionals disregard the messages, click them away, or turn the warning systems off when they have an opportunity.
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It is common to blame these professionals for such seemingly irresponsible behavior. However, in too many systems, too little attention is paid to ensuring the judicious use of alerts and to working on the problem of contextual relevancy for the alerts the system generates during actual use. When time is a scarce resource, and too many of the warnings or reminders are either irrelevant or overly predictable, irritated physicians who disregard these alerts are quite rational.
Appropriate and well-supported communication is also part and parcel of a safe work practice. In this sense, the systems we describe in this subsection could actually hamper safer working practices rather than stimulate them. In the hierarchies and task divisions of manual ordering, for example, many error prevention mechanisms are built in, often informally. For example, pharmacists routinely correct the medication orders given by physicians. Restructuring the medication ordering process might unwittingly eliminate these important mechanisms.
The redundancy that is built into the system of people and technologies constituting the medication management chain is partly responsible for the fact that of the many prescription mistakes, only a minute fraction results in actual medication administration mistakes. Similarly, in practice, orders often come into being during patient rounds, during discussions among senior and junior physicians and nurses.
A case is discussed, a suggestion is made and elaborated on, and it becomes an order. It can also be transformed, renegotiated, or ignored. In most clinical order-entry systems, however, the entering of orders is the task of the junior resident, who only does ordering after the patient rounds. This is because systems are rarely mobile, so they are not available during rounds.
Alone at a computer, the resident enters a series of orders on a series of patients, copying from the notes made during rounds. In such a setting, outside of the actual context in which the patient was discussed, and away from those who could correct his misinterpretations, order entry can be prone to errors.
We have outlined a number of issues within a framework describing two major kinds of silent errors caused by health care information systems: Because the potential causes of these errors are subtle but insidious, the problems need to be addressed in a variety of ways through improvements in education, systems design, implementation, and research. Health professionals need to be educated with a critical perspective toward what PCISs can do for them.
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Worldwide Europe European Union U. Energy and Natural Resources. Food, Drugs, Healthcare, Life Sciences. Media, Telecoms, IT, Entertainment. With that fresh perspective in mind, Martin is able to suggest remedies that address service failure and just may help prevent future disasters from taking place. James William Martin is the author of several books focused on change management, teamwork, and process improvement. He has coached and counseled thousands of people across Japan, China, Korea, Singapore, Malaysia, Thailand, Australia, and North America to use fact-based methods to achieve goals and improve their lives.
His interests include environmentally friendly design, as well as personal and organizational ethics, productivity, and change management. Try our Search Tips. Topics Libraries Unlimited Librarianship: Available for Course Adoption. Features Over 40 case studies Easy to grasp figures, tables, and templates to help the readers understand the concepts A glossary of relevant terms A bibliography Highlights Presents the technical, cognitive, and organizational factors associated with the design and failure of products and services Introduces new topics related to social psychology, as well as organizational culture and ethics, to explain product and service failures Shows that when failures occur, they are often due to human error rather than unknown technology Provides helpful advice for preventing failures of products and services.