Assessing the information environment in intensive care units

This paper describes the development and application of a methodology for evaluating how physicians and nurses view the usefulness of various sources of patient information available within a hospital intensive care unit (ICU). The methodology encompasses semi-structured interviews, task analysis, a simulated case study of a critically ill patient, verbal protocol analysis, questionnaire responses based on both past experiences in the ICU and performance on the simulated task, and a post-task interview. Eleven nurses and six physicians participated in the study. Analysis of the questionnaires revealed significant differences in the rankings of the information sources by both the nurses and the physicians on each of seven evaluation criteria. Significant differences were also found among both the physicians and the nurses in rankings of the relative importance of the individual information sources for meeting task requirements. A framework for describing information gathering applicable to critical care environments was proposed as a means for better understanding how information sources are used. Overall, the methodology was found to be useful in terms of providing valuable data regarding the utility and usability of information sources. The importance of using a systematic approach for assessing the usefulness of information sources, particularly from the perspectives of performing design interventions and predicting the effectiveness of new information technologies, as well as the limitations in adopting this type of approach, are also discussed.     

Revising ranked probabilities: a Bayesian approach to incomplete knowledge

Incomplete knowledge refers to situations in which a decision maker can rank the probabilities of occurrence for events of interest, but cannot specify these probabilities exactly. In this paper a Monte Carlo approach is used to investigate how physicians can arrive at revised or posterior rankings of disease probability given only rank order information about both the patient's prior probabilities of disease and the conditional probabilities of specific clinical findings for each disease. Computer-generated estimates of the expected frequencies of the posterior rankings are presented for the cases of 2, 3, and 4 disease states. The application of probability revision under conditions of incomplete knowledge to therapeutic decision making is discussed.     

Macroergonomics and patient safety: The impact of levels on theory, measurement, analysis and intervention in patient safety research

The study and practice of patient safety has seen a surge over the last 10 years. New resident training and staffing policies, health information technologies, error reporting systems, team models of care, training methods, patient involvement, information handoff strategies, just cultures, and many other interventions have been mandated or attempted to improve the safety of patient care. While some of these interventions focus on individual providers and others focus on organization-level changes, little, if any, patient safety research has purposefully sought to understand how variables at different levels, such as the provider level or organization level, interact to impact patient safety outcomes such as errors, adverse drug events, or patient harm. Looking at relationships across levels is important because adverse events might be related to variables at different levels; consider that adverse events may be nested within patients, patients nested within nurses and physicians, nurses and physicians nested within shifts, shifts nested within hospital units, and so forth. Because these nested levels exist, they may exert as yet untested influence on the levels below. In this paper the impact of levels on theory, measurement, analysis and intervention in patient safety research is discussed.     

Streamlining patient consultations for sleep disorders with a knowledge-based CDSS

ObjectivesThis paper examines the workflow of sleep physicians during a patient consultation and how an innovative clinical decision support system (CDSS) provides efficiency and effectiveness gains.MethodsThe CDSS tools consisted of two input applications for patient data, with a knowledge based decision support system developed participatively with physicians and an international panel. An argument tree approach was used to produce diagnostic explanations and an evidence-based report for the physician using medically correct and shared terminology. A usability evaluation using a qualitative approach was carried out to ensure that the CDSS met the physicians׳ information needs, as well as the wider needs of a Sleep Investigation Unit.ResultsThe physicians found the CDSS both useful and usable with clear applications in triage and diagnostic decision-making, and in patient education.ConclusionThe CDSS both reduces the time and number of visits needed for consultations, and helps focus consultation on better individual patient care through informed explanation of diagnostic and treatment decisions.     

Exploring performance obstacles of intensive care nurses

High nursing workload, poor patient safety, and poor nursing quality of working life (QWL) are major issues in intensive care units (ICUs). Characteristics of the ICU and performance obstacles may contribute to these issues. The goal of this study was to comprehensively identify the performance obstacles perceived by ICU nurses. We used a qualitative research design and conducted semi-structured interviews with 15 ICU nurses of a medical-surgical ICU. Based on this qualitative study and a previously reported quantitative study, we identified seven main types of performance obstacles experienced by ICU nurses. Obstacles related to the physical environment (e.g., noise, amount of space), family relations (e.g., distractions caused by family, lack of time to spend with family), and equipment (e.g., unavailability, misplacement) were the most frequently experienced performance obstacles. The qualitative interview data provided rich information regarding the factors contributing to the performance obstacles. Overall, ICU nurses experience a variety of performance obstacles in their work on a daily basis. Future research is needed to understand the impact of performance obstacles on nursing workload, nursing QWL, and quality and safety of care.     

Learning medical alarms whilst performing other tasks

Two studies are reported which first observe, and then attempt to replicate, the cognitive demands of intensive care unit (ICU) activity whilst concurrently learning audible alarms. The first study, an observational study in an ICU ward, showed that the alarms are very frequent and co-occur with some activities more than others. The three most frequently observed activities observed in the ICU were drugs (calculation, preparation and administration), patient observation and talking. The cognitive demands of these activities were simulated in a second, laboratory-based experiment in which alarms were learned. The results showed that performance in the alarm task generally improved as participants were exposed to more repetitions of those alarms, but that performance decrements were observed in the secondary tasks, particularly when there were two or three of them. Some confusions between the alarms persisted to the end of the study despite prolonged exposure to the alarms, confusions which were likely caused by both acoustic and verbal labelling similarities.

Practitioner Summary: The cognitive demands of working in an ICU were observed and simulated whilst alarms were learned. Alarms should generally avoid sharing similar rhythmic (and other) characteristics. The simulation task described here could be used for testing alarm learning without requiring a clinical environment.     

Using tablets in medical consultations: Single loop and double loop learning processes

ObjectiveThis paper investigates the influence of using tablet in waiting rooms and medical examinations on how physicians give information and how patients learn. It further assesses the factors that impact patient satisfaction.MethodsPatients and physicians in a primary care clinic were given a tablet device to search for health information in the waiting room, and when interacting with the physician, while physicians used the tablet device to share information with patients during the medical consultation. 82 patients completed a ‘pre’ survey on using tablets to search for health related information and a ‘post’ survey after their visit. Structural equation modeling was employed to analyze patient's perceptions.ResultsTablet use during consultation has a negative effect on patients' perceptions of physician information giving, but using the tablet in the waiting room has a positive impact on patient learning, perceptions of physicians' information giving and patient satisfaction.ConclusionsThis study indicates the importance of tablet use in ensuring information giving and patient learning. It further highlights the potential for tablets to promote single-loop learning in the medical encounter by better preparing patients for the physician's information giving. Tablets also enable double-loop learning, which leads to greater patient satisfaction.     

Boundary-Object Trimming: On the Invisibility of Medical Secretaries’ Care of Records in Healthcare Infrastructures

As health care IT gradually develops from being stand-alone systems towards integrated infrastructures, the work of various groups, occupations and units is likely to become more tightly integrated and dependent upon each other. Hitherto, the focus within health care has been upon the two most prominent professions, physicians and nurses, but most likely other non-clinical occupations will become relevant for the design and implementation of health care IT. In this paper, we describe the cooperative work of medical secretaries at two hospital departments, based on a study evaluating a comprehensive electronic health record (EHR) shortly after implementation. The subset of data on medical secretaries includes observation (11 hours), interviews (three individual and one group) and survey data (31 of 250 respondents were medical secretaries). We depict medical secretaries’ core task as to take care of patient records by ensuring that information is complete, up to date, and correctly coded, while they also carry out information gatekeeping and articulation work. The importance of these tasks to the departments’ work arrangements was highlighted by the EHR implementation, which also coupled the work of medical secretaries more tightly to that of other staff, and led to task drift among professions. Medical secretaries have been relatively invisible to health informatics and CSCW, and we propose the term ‘boundary-object trimming’ to foreground and conceptualize one core characteristic of their work: maintenance and optimization of the EHR as a boundary object. Finally, we reflect upon the hitherto relative invisibility of medical secretaries which may be related to issues of gender and power.     

That's nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care

Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses’ perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses’ perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA.

Relevance to industry

By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.     

Describing nurses' work: combining quantitative and qualitative analysis

OBJECTIVE: To better understand nursing activities and working conditions. BACKGROUND: Nursing practice involves astute clinical decision making and the competent delivery of nursing care procedures. To complete nursing procedures, nurses must simultaneously organize and reorganize priorities and manage changing clinical information for multiple patients. Few researchers have examined the specific nature of nurses' activities and the effect of the environment on their work. METHODS: Quantitative and qualitative methods were used to collect data on 7 nurses engaged in nursing activities. Examples of methods include link analysis, subject matter expert, task analysis, cognitive pathway, and "stacking." Data collection focused on how nurses managed priorities, changing clinical information, and interruptions. RESULTS: The "cognitive pathway" graphically depicts the nature of nurses' work. Specifically, it reveals the shifting of the nurse's attention from patient to patient and the occurrence of interruptions. "Stacking" shows the number of tasks a nurse must balance at any one time. On average, nurses had 10 or more activities waiting to be performed and experienced 3.4 interruptions/hr. CONCLUSION: These methods provide unique insight into the dynamic nature of patient care and nursing work. APPLICATION: Extension of the methods demonstrated here may be useful in guiding efforts to change the work of nursing to better provide quality care and less stressful work environments.     

Analysis of diabetic patients through their examination history

The analysis of medical data is a challenging task for health care systems since a huge amount of interesting knowledge can be automatically mined to effectively support both physicians and health care organizations. This paper proposes a data analysis framework based on a multiple-level clustering technique to identify the examination pathways commonly followed by patients with a given disease. This knowledge can support health care organizations in evaluating the medical treatments usually adopted, and thus the incurred costs. The proposed multiple-level strategy allows clustering patient examination datasets with a variable distribution. To measure the relevance of specific examinations for a given disease complication, patient examination data has been represented in the Vector Space Model using the TF-IDF method. As a case study, the proposed approach has been applied to the diabetic care scenario. The experimental validation, performed on a real collection of diabetic patients, demonstrates the effectiveness of the approach in identifying groups of patients with a similar examination history and increasing severity in diabetes complications.     

Learning social behavior

This paper discusses the challenges of learning to behave socially in the dynamic, noisy, situated and embodied mobile multi-robot domain. Using the methodology for synthesizing basis behaviors as a substrate for generating a large repertoire of higher-level group interactions, in this paper we describe how, given the substrate, greedy agents can learn social rules that benefit the group as a whole. We describe three sources of reinforcement and show their effectiveness in learning non-greedy social rules. We then demonstrate the learning approach on a group of four mobile robots learning to yield and share information in a foraging task.     

Rendering ground truth data sets to detect shadows cast by static objects in outdoors

In our work, we are particularly interested in studying the shadows cast by static objects in outdoor environments, during daytime. To assess the accuracy of a shadow detection algorithm, we need ground truth information. The collection of such information is a very tedious task because it is a process that requires manual annotation. To overcome this severe limitation, we propose in this paper a methodology to automatically render ground truth using a virtual environment. To increase the degree of realism and usefulness of the simulated environment, we incorporate in the scenario the precise longitude, latitude and elevation of the actual location of the object, as well as the sun’s position for a given time and day. To evaluate our method, we consider a qualitative and a quantitative comparison. In the quantitative one, we analyze the shadow cast by a real object in a particular geographical location and its corresponding rendered model. To evaluate qualitatively the methodology, we use some ground truth images obtained both manually and automatically.     

Computerized management of patient care in a complex, controlled clinical trial in the intensive care unit

Acute respiratory distress syndrome (ARDS) is often not responsive to conventional supportive therapy and the mortality rate may exceed 90%. A new form of supportive care, extracorporeal carbon dioxide removal (ECCO2R), has shown a dramatic increase in survival (48%). A controlled clinical trial of the new ECCO2R therapy versus conventional continuous positive pressure ventilation (CPPV) is being initiated. Detailed care protocols have been developed by 'expert' critical care physicians for the management of patients. Using a blackboard control architecture, the protocols have been implemented on an existing hospital information system and will direct patient care and help manage the controlled clinical trial. Therapeutic instructions are automatically generated by the computer from data input by physicians, nurses, respiratory therapists, and the laboratory. Preliminary results show that the computerized protocol system can direct therapy for acutely ill patients.     

Evaluating Bar Coding‐Aided Medication Administration through Identification of Nursing Work Deficiencies

Health care information technology (IT) systems manage administrative and clinical processes more accurately and efficiently. However, their effects on clinical work flow are still not fully understood. In this article, we investigate the bar‐coded medication administration (BCMA) system for its effect on nurses working in inpatient departments. Evaluation is applied by examining work deficiencies before and after the IT system implementation based on a proposed nursing work model. A list of nurse‐perceived risks of work deficiencies related to the current BCMA system has been identified. Results show five main deficiencies that are mainly related to aspects of the IT environment and work schedule/process, including increased workload, IT systems downtime, unclear orders/task schedules, reduced time for patient‐care tasks, and redundant documentation. This study emphasizes the importance of understanding the reciprocal relationship between IT implementation and health care work system. © 2012 Wiley Periodicals, Inc.     

Measuring task-specific perceptions of the world wide web

This paper describes the development of multi-item scales for measuring user perceptions of the ease-of-use and usefulness of the Web (hereafter web), incorporating a system task focus into the scales dimensional structure (e.g. how easy or useful the web is for information search, communication and or purchasing). The items are tested on 2077 web users recruited using a web survey, revealing four factors for each scale. Perceived ease-of-web use consists of learning, search and find, transaction and communication ease, and perceived web usefulness consists of communication, purchase, information search and acquisition, and access to quality products and information. A regression analysis on web usage frequency shows how easy users find it to learn how to use the web and how useful the web is for purchasing are the best predictors of how frequently they will use the web. These results highlight the importance of training users how to effectively use hypermedia-based systems like the web, and the design of systems that are easy to navigate and that provide advanced functionality for transactional activity.     

Measuring task-specific perceptions of the world wide web

This paper describes the development of multi-item scales for measuring user perceptions of the ease-of-use and usefulness of the Web (hereafter web), incorporating a system task focus into the scales dimensional structure (e.g. how easy or useful the web is for information search, communication and or purchasing). The items are tested on 2077 web users recruited using a web survey, revealing four factors for each scale. Perceived ease-of-web use consists of learning, search and find, transaction and communication ease, and perceived web usefulness consists of communication, purchase, information search and acquisition, and access to quality products and information. A regression analysis on web usage frequency shows how easy users find it to learn how to use the web and how useful the web is for purchasing are the best predictors of how frequently they will use the web. These results highlight the importance of training users how to effectively use hypermedia-based systems like the web, and the design of systems that are easy to navigate and that provide advanced functionality for transactional activity.     

Virtual Nursing Using Deep Belief Networks for Elderly People (DBN-EP)

The demand for better health services has resulted in the advancement of remote monitoring health, i.e., virtual nursing systems, to watch and support the elderly with innovative concepts such as being patient-centric, easier to use, and having smarter interactions and more accurate conclusions. While virtual nursing services attempt to provide consumers and medical practitioners with continuous medical and health monitoring services, access to allied healthcare experts such as nurses remains a challenge. In this research, we present Virtual Nursing Using Deep Belief Networks for Elderly People (DBN-EP), a new framework that provides a virtual nurse agent deployed on a senior citizen’s home, workplace, or care centre to help manage their health condition on a continuous basis. Using this method, healthcare providers can assign various jobs to nurses by utilizing a general task definition mechanism, in which a task is defined as a combination of medical workflow, operational guidelines, and data gathered from a remotely monitored virtual nursing system. Practitioners are in charge of DBN-EP and make treatment decisions for patients. This allows a DBN-EP to act as a personalized full-time nurse for a client by carrying out practitioner support activities based on information gathered about the client’s health. An electronic Personal Health Record (ePHR) system, such as a specialized web portal and mobile apps, could provide such patient information to elderly person family members and care centres. We created a prototype system using a DBN-EP system that allows traditional client applications and healthcare provider systems to collaborate. Finally, we demonstrate how this system may benefit the elderly through a result and debate.     

A health information network for managing innercity tuberculosis: bridging clinical care, public health, and home care.

The purpose of this study was to use a health information network and innovative technology to coordinate tuberculosis care. An innercity medical center, a local health department, and a home care nurse service in northern Manhattan were used. The organizations were linked with computer networks. An automated decision support system with a natural language processor was used to detect tuberculosis cases and report them to the health department, and to select patients for respiratory isolation. Educational materials were placed on the World Wide Web and a Web-based kiosk. Home care nurses were outfitted with wireless pen-based computers, and data were relayed to the medical center. Automated tuberculosis case reporting resulted in time savings but not improved accuracy. Automated rules resulted in significant improvements in respiratory isolation. Kiosk educational materials were well-used. Wireless computing led to better access to information for both nurses and physicians, but not to reduction of workload. The key success element was recognition of critical priorities. It is concluded that innovative technology can facilitate the coordination of clinical care, public health, and home care.