Health Information Management: Integrating Information Technology ...

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DESIGNING INTERACTIONS 103 the development of the structured clinical interview and problem-oriented medical record. These can be seen as communication innovations as much as information ones. They ensure that messages between clinicians are well formed and maximize the likelihood that critical information is ‘sent’ and ‘received’ via a reliable communication channel we call the medical record. What we do know about clinical communication systems in an organization like a hospital is that they carry a heavy burden of traffic, and create an interruptdriven workplace. Clinical tasks generate many communication requests, and inefficiencies in communication system design, technology and clinical behaviour lead to an apparently much higher level of interaction than is necessary. It is only by delving into the details of the specific conversations that we can start to understand who is responsible for the high level of traffic across communication systems, and what the reasons for it are. In one analysis of a UK hospital, doctors were the highest generator of communication traffic, sending almost twice as many messages as they received (Reitman 1974). Further, doctor —doctor interactions made up over 40 per cent of the calls made by the doctors in the study, denying the truism that medical staff suffer constant interruption because of the actions of other clinical staff in the hospital. Of concern is that the high level of interruption, whatever its source or reason, may lead to errors by clinical staff. There are well known cognitive costs associated with interruption, leading to diversion of attention, forgetfulness and errors. Further, interruption often requires rescheduling of work plans. The interrupt-driven nature of the hospital work environment thus has the potential to generate extra costs in staff time and efficiency. There are many potential reasons for the high level of call traffic in an organization. Many are specific to the systems in place within particular organizations, but others are general characteristics of clinical work or human interaction. Some of the factors that have been identified in one study as potential causes of the high level of call traffic in hospitals include: ■ ■ Synchronous bias: People seem to favour interruptive communication mechanisms such as face-to-face discussion, paging or the telephone, rather than using less interruptive methods that may be available to them. This may be because in busy environments there is a need for tasks to be ‘ticked off the list’ once completed to reduce cognitive load. For example, asking someone directly to complete a task produces immediate acknowledgement that the hand-over has occurred, but asynchronous channels like e-mail, voicemail or notes are usually not designed to deliver the appropriate acknowledgement of message receipt and task acceptance. <strong>Information</strong> seeking from humans: The reliance of clinicians upon discussion to resolve information needs has suggested to some that this is in response to poor printed or computer-based information sources (Markus 1994). Another hypothesis is that communication is actually the preferred mechanism for
104 STARTING POINTS ■ ■ information gathering. Clinical problems are often poorly defined, and clarification can be obtained through conversation. Thus, clinical staff may opportunistically interrupt each other because face-to-face discussion is highly valued but difficult to schedule, and any opportunity is avidly seized. Poor directory information about roles and responsibilities: Up to a quarter of calls in hospital may be associated with identifying the name of an individual occupying a specific role. This suggests that poor support for identifying role occupants contributes significantly to overall call traffic. Failure to reason about the impact of individual behaviour: Most clinicians operate to maximize their personal efficiency in serving their patients, but do not seem to reason about the consequences of their behaviour on the overall operational efficiency of their organization. However, the consequence of interrupting colleagues to satisfy individual needs may be a far more inefficient organization overall. This phenomenon is similar to everyone electing to drive a car rather than take public transport because the car is more convenient personally, but the overall impact is congested roads and slower transport times for all on the road. While it is clear that much more research is needed to understand the nature of clinical communication processes, we can begin to outline the types of intervention that should lead to improved communications. Non-technical interventions While it is tempting to immediately suggest new technical solutions, there are a variety of powerful non-technical interventions that can profoundly alter the communication dynamics of an organization: ■ Alter communication behaviours: Individuals can be encouraged to regard communication behaviours not as a personal style choice but as a professional skill. Educational programmes can emphasize the individual and systemic costs of interruption, and train staff to reason about the costs and benefits of different communication channels and services. ■ Alter communication policies: Beyond educational interventions, organizations have some power to institute mandatory policies that constrain professional behaviour involving poor communication practice. For example, it might be reasonable to prohibit sending e-mail organization-wide unless strict criteria are met. Technical interventions With the merging of information and communication technologies into new classes of communication networks and devices, the opportunity to innovate technically to improve communication is enormous. When faced with a
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Health Information Management In al
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Health Information Management Integ
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Contents List of illustrations vii
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Illustrations FIGURES 3.1 Medicatio
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Contributors Marc Berg is a physici
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Series preface In almost all Wester
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Acknowledgements I would like to th
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Chapter 1 Introduction In all Weste
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INTRODUCTION 3 touch upon the deplo
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INTRODUCTION 5 can draw upon to mai
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INTRODUCTION 7 Physician Order Entr
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Part I Starting points Understandin
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WAITING FOR GODOT 11 KEY TERMS ■
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WAITING FOR GODOT 13 Netherlands an
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WAITING FOR GODOT 15 facts to show
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WAITING FOR GODOT 17 (Lewinski-Corw
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WAITING FOR GODOT 19 In most cases,
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WAITING FOR GODOT 21 (Anonymous 191
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WAITING FOR GODOT 23 Because of the
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WAITING FOR GODOT 25 they simply sa
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WAITING FOR GODOT 27 expected. Stil
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WAITING FOR GODOT 29 organize their
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WAITING FOR GODOT 31 performance in
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WAITING FOR GODOT 33 different HIS
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WAITING FOR GODOT 35 CONCLUSION: TH
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WAITING FOR GODOT 37 assumption tha
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WAITING FOR GODOT 39 Anonymous (191
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WAITING FOR GODOT 41 Berg, M. (1997
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Chapter 3 Health care work and pati
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HEALTH CARE WORK AND INFORMATION SY
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Page 96 and 97: STARTING POINTS 81 ‘gender, race,
Page 98 and 99: STARTING POINTS 83 Now, imagine an
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Page 102 and 103: STARTING POINTS 87 Figure 5.2 Incre
Page 104 and 105: STARTING POINTS 89 already overflow
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Page 108 and 109: STARTING POINTS 93 answer the quest
Page 110 and 111: STARTING POINTS 95 Kohn, L.T., J.M.
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Page 114 and 115: DESIGNING INTERACTIONS 99 the way t
Page 116 and 117: DESIGNING INTERACTIONS 101 1 Identi
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Page 122 and 123: DESIGNING INTERACTIONS 107 Figure 6
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Page 136 and 137: INFORMATION STRATEGY: AN INTRODUCTI
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Page 154 and 155: STRATEGY, IMPLEMENTATION AND EVALUA
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STRATEGY, IMPLEMENTATION AND EVALUA
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Guidelines for information system d
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Chapter 9 Implementing information
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IMPLEMENTING INFORMATION SYSTEMS 16
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Chapter 10 Project management of in
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Index accumulation 53-4, 61, 73-4,
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INDEX 223 contingent and emergent c
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INDEX 225 satisfaction 176 patient
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INDEX 227 support 164 technology de
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