Four rules for the reinvention of health care.
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Delivery of Health Care↗
Biomedical subjects
Enrico Coiera
Publications and source records attributed to Enrico Coiera.
Variation in communication loads on clinical staff in the emergency department.
STUDY OBJECTIVE: We determine whether there are differences in role-related communication patterns in the emergency department (ED). METHODS: This was an observational study of a metropolitan ED. Four medical officers and 4 nurses were observed for 19 hours and 52 minutes. Communication load was measured by proportion of observed time in communication, proportion of concurrent communication events, and proportion of interruptions. RESULTS: Eight hundred thirty-one communication events were identified, an average of 42 events per person per hour. Eighty-nine percent of clinicians' time was spent in communication. Synchronous communication channels, involving face-to-face or telephone conversations, were used in 84% of events. One third of communication events were classified as interruptions, averaging 15 interruptions per person per hour. Senior medical and nursing staff experienced higher rates of interruption than junior medical staff and registered nurses with an allocated patient load. CONCLUSION: There was considerable variation in communication loads on clinical staff occupying different roles in the ED. Medical registrars had a high proportion of interruptions and spent the most time dealing with interruptions. These new data suggest some clinical roles may be at higher risk of communication overload than those of the general clinical population.
Communication↗
Use of on-line evidence databases by Australian public health practitioners.
OBJECTIVE: To investigate use of a web-based portal, known as the Clinical Information Access Program (CIAP), and evidence databases in an Australian population health workforce. METHODS: Self-administered postal survey of 104 staff in a regional Division of Population Health in Sydney, Australia. The main outcome measures were CIAP use and organization support for CIAP use. Two thirds of the respondents agreed that using CIAP was a legitimate part of their practice. However, half agreed that staff were encouraged to use it. One in five respondents (21%) used CIAP weekly. CIAP use was significantly associated with medical qualification or, among non-medical staff, with having at least a Masters qualification. CIAP use was not associated with occupational category, gender, age, employment status nor years of experience. Use of specific evidence databases such as Cochrane also differed significantly by respondents' characteristics. CONCLUSIONS: There has been only partial uptake of on-line databases among this population health workforce, particularly according to attainment of relevant postgraduate qualifications. As CIAP is a resource for evidence-based practice, greater effort to increase its use is recommended to ensure population health does not fall behind hospital-based clinicians.
Adult↗
Do clinicians use online evidence to support patient care? A study of 55,000 clinicians.
OBJECTIVES: To determine clinicians' (doctors', nurses', and allied health professionals') "actual" and "reported" use of a point-of-care online information retrieval system; and to make an assessment of the extent to which use is related to direct patient care by testing two hypotheses: hypothesis 1: clinicians use online evidence primarily to support clinical decisions relating to direct patient care; and hypothesis 2: clinicians use online evidence predominantly for research and continuing education. DESIGN: Web-log analysis of the Clinical Information Access Program (CIAP), an online, 24-hour, point-of-care information retrieval system available to 55,000 clinicians in public hospitals in New South Wales, Australia. A statewide mail survey of 5,511 clinicians. MEASUREMENTS: Rates of online evidence searching per 100 clinicians for the state and for the 81 individual hospitals studied; reported use of CIAP by clinicians through a self-administered questionnaire; and correlations between evidence searches and patient admissions. RESULTS: Monthly rates of 48.5 "search sessions" per 100 clinicians and 231.6 text hits to single-source databases per 100 clinicians (n = 619,545); 63% of clinicians reported that they were aware of CIAP and 75% of those had used it. Eighty-eight percent of users reported CIAP had the potential to improve patient care and 41% reported direct experience of this. Clinicians' use of CIAP on each day of the week was highly positively correlated with patient admissions (r = 0.99, p < 0.001). This was also true for all ten randomly selected hospitals. CONCLUSION: Clinicians' online evidence use increases with patient admissions, supporting the hypothesis that clinicians' use of evidence is related to direct patient care. Patterns of evidence use and clinicians' self-reports also support this hypothesis.
Attitude to Computers↗
e-Consent: The design and implementation of consumer consent mechanisms in an electronic environment.
The effective coordination of health care relies on communication of confidential information about consumers between different health and community care services. However, consumers must be able to give or withhold "e-Consent" to those who wish to access their electronic health information. There are several possible forms for e-Consent. In the general consent model, a patient provides blanket consent for access to his or her information by an organization for all future information requests. Conversely, general denial explicitly denies consent for information to be used in future circumstances, and in each new episode of care, a new consent would be needed to obtain information. In the general consent with specific denial model, a patient attaches specific exclusion conditions to his or her general approval to future accesses. In contrast, in the general denial with explicit consent model, a patient issues a blanket block on all future accesses but allows the inclusion of future use under specified conditions. There also are several alternative functions for an e-Consent system. Consent could be captured as a matter of legal record. E-Consent systems could be more active by prompting clinicians to indicate that they have noted consent conditions before they access a record. Finally, the record of patient consent could be fully active and used as a gatekeeper in a distributed information environment. There probably will need to be some form of data object that is associated with patient information. This e-Consent object (or e-Co) will contain the specific conditions under which the data to which it is attached can be retrieved. Given the complexity of clinical work and the substantial variation we can expect in an individual's desire to make his or her personal medical details available, it is unlikely a "one size fits all" approach to e-Consent will work. Consequently, with a well-chosen consent design, it should be possible to balance the specific need for privacy of some of the population against the desire by others to err on the side of clinical safety, and clinicians desire to minimize the burden that an electronic consent mechanism would impose.
Access to Information↗
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↗
Comparative impact of guidelines, clinical data, and decision support on prescribing decisions: an interactive web experiment with simulated cases.
OBJECTIVE: The aim of this study was to compare the clinical impact of computerized decision support with and without electronic access to clinical guidelines and laboratory data on antibiotic prescribing decisions. DESIGN: A crossover trial was conducted of four levels of computerized decision support-no support, antibiotic guidelines, laboratory reports, and laboratory reports plus a decision support system (DSS), randomly allocated to eight simulated clinical cases accessed by the Web. MEASUREMENTS: Rate of intervention adoption was measured by frequency of accessing information support, cost of use was measured by time taken to complete each case, and effectiveness of decision was measured by correctness of and self-reported confidence in individual prescribing decisions. Clinical impact score was measured by adoption rate and decision effectiveness. RESULTS: Thirty-one intensive care and infectious disease specialist physicians (ICPs and IDPs) participated in the study. Ventilator-associated pneumonia treatment guidelines were used in 24 (39%) of the 62 case scenarios for which they were available, microbiology reports in 36 (58%), and the DSS in 37 (60%). The use of all forms of information support did not affect clinicians' confidence in their decisions. Their use of the DSS plus microbiology report improved the agreement of decisions with those of an expert panel from 65% to 97% (p=0.0002), or to 67% (p=0.002) when antibiotic guidelines only were accessed. Significantly fewer IDPs than ICPs accessed information support in making treatment decisions. On average, it took 245 seconds to make a decision using the DSS compared with 113 seconds for unaided prescribing (p<0.001). The DSS plus microbiology reports had the highest clinical impact score (0.58), greater than that of electronic guidelines (0.26) and electronic laboratory reports (0.45). CONCLUSION: When used, computer-based decision support significantly improved decision quality. In measuring the impact of decision support systems, both their effectiveness in improving decisions and their likely rate of adoption in the clinical environment need to be considered. Clinicians chose to use antibiotic guidelines for one third and microbiology reports or the DSS for about two thirds of cases when they were available to assist their prescribing decisions.
Anti-Bacterial Agents↗
Interaction design theory.
OBJECTIVE: This paper presents a framework for the design of interactions between human and computational agents working in organisations, mediation by technological systems. DESIGN: The design of interactions within an organisation is viewed from the point of view, not of the technology mediating the new interaction, but of the human and computational agents who interact with each other. RESULTS: Understanding the limits to individual agent resources permits an analysis of the impact that a new interaction will have in a given setting. When we look beyond simple interaction settings, we can use the notion of interaction equilibria to predict the impact of new information and communication technologies within an organisation. Economic supply and demand curves, for example, may allow us to make both qualitative and quantitative predictions about technological adoption of communication systems. CONCLUSION: Rather than focusing solely on characteristics of individual technologies, or psychological and social issues, these can be combined to explain the overall decisions that individuals make when using technologies. Without necessarily understanding all the local decision criteria used by any individual, we can make robust predictions about how a group as a whole will interact.
Humans↗
Which clinical decisions benefit from automation? A task complexity approach.
This paper describes a model for analysing medical decision making tasks and evaluation of their suitability for automation. The overall approach focuses on the assessment of decision complexity and possible reduction of human effort by automated decision support. The approach consists of five subsequent steps: (1) selection of the domain and relevant tasks; (2) evaluation of the knowledge complexity for tasks selected; (3) selection of potentially most cognitively demanding task; (4) assessment of unaided and aided effort requirements for this task accomplishment; and (5) selection of computational tools to achieve this complexity reduction. The model described allows for task automation without lowering of decision quality.
Anti-Bacterial Agents↗