Kay-CGU Symposium 06

Health System Design from the User's Perspective December 2, 2006

Bradford W. Hesse, PhD Chief, Health Communication and Informatics Research National Cancer Institute

Back to the Future: Asking the Right Questions for the Technology to Solve

Source: http://en.wikipedia.org/wiki/Image: Cover_of_Pop_Science_Mar_2006_Cover_1.jpg

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Historical Views of Medical Computing Historical Tensions • Industrial paradigm: “automate” vs. “informate” (Zuboff, 1984) • “Hypodermic model” of information delivery (Johnson, 1997) • “Data Smog” as science meets public (Shenk, 1997) • Web focus on “exploiting value from Transaction” (Zuboff, 2002) Source: Coiera E. Four rules for the reinvention of health care. BMJ 2004;328(7449):1197-9.

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Medical Informatics Results are Mixed JAMA, March 9, 2005 • Two-thirds of studies on clinical decision support systems revealed improvement, but … • Reports are biased, improvements only noted by internal (not external) reviewers. • Some technologies (e.g., computerized ordering) introduce more errors than they resolve. 4

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Solutions Must be Sociotechnical “This science of health service design must be a science of sociotechnical systems (i.e., people, tools, and conversations), and today that science is called informatics.” -Enrico Coiera BMJ (328) 15 May 2004 ;Technical systems have social consequences ; Social systems have technical consequences ; We don’t design technology, we design sociotechnical systems ; Understand how people and technologies interact 5

Ask: What Can People Do? Early computer engineering asked “what can the computer do?”

Question in health care is “what can people do?” “Everyone thought IT was about computers, but we’ve refined that to say that IT is about health care — it’s about the experience we really have.” -David Brailer, 2005

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Improving Healthcare in the 21st Century

Dr. Elias Zerhouni, Director, National Institutes of Health

Healthcare Redesign • Medical injuries account for 44,000 – 98,000 deaths per year in U.S. (More than breast cancer, AIDS, or motor vehicle accidents).* • “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”§ • American healthcare gets it right 54.9% of the time.± * Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370-6. §

Chantler, Cyril. The role and education of doctors in the delivery of health care. Lancet 1999; 353:1178-81. ± McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 8 348(26):2635-45 (June 26).

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Healthcare Redesign Borrowed Lessons From Aviation: • Safety is a system property • Error is natural; systems must compensate

Human Factors Engineering Reduced Fatalities

• Quality improvement is continuous 9

Healthcare Redesign Users within Healthcare*

* Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood) 2002;21(3):80-90.

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Healthcare Redesign Health System Goals* • Safety • Effectiveness • Patient-Centeredness (Equity) • Equity • Timeliness (Efficiency) • Efficiency

* Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood) 2002;21(3):80-90.

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Safety Patient/Family

Ù

Physician/Team

• Usable design on all patient interfaces Consumer’s choice of “teaspoon”*

Design Challenges?

* Parker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing high-quality health care. Health Aff (Millwood) 2003;22(4):147-53. 12

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Safety Patient/Family

Ù

Physician/Team

• Usable design on all patient interfaces • Patient as participant in safety management • Systems accessible 24 X 7

• Human factors engineering to prevent error • Coordinated system of safeguards • Culture of safety

E.g. Redesigned Pill Bottle (Target)

Error Prevention in Electronic Systems 13

Effectiveness Patient/Family

Ù

Physician/Team

• Informed, healthy public

Tell me how much you agree or disagree with the following statements Strongly Agree “There are so many different recommendations about preventing cancer, it’s hard to know which ones to follow.”

36%

Somewhat Somewhat Agree Disagree 41%

15%

Strongly Disagree 9%

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Effectiveness Ù

Patient/Family • Informed, healthy public • “Vital Information” available as needed to guide decision making

Physician/Team • Practice anchored on medical evidence • Displays ensure effective use of data • Health I.T. puts the right information into hands of medical team at the right time

Trusted, Reliable Sources

Research needed on effective displays

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Patient-Centered Patient/Family

Ù

Physician/Team

• Activated, empowered patient*

* Wagner EH, Bennett SM, Austin BT, Greene SM, Schaefer JK, Vonkorff M. Finding common ground: patient-centeredness 16 and evidence-based chronic illness care. J Altern Complement Med 2005;11 Suppl 1:S7-15.

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Patient-Centered Ù

Patient/Family • Activated, empowered patient • Patient has access to, and control over, personal health information • Care is equitable throughout population

Physician/Team • Coordinated systems of care • Personalized health care oriented to needs of patient • Communication centered on improving outcomes, quality of life

Personal Health Record guides decision making

Personalized delivery of health care 17

Timely Ù

Patient/Family • Time as “currency of Century”

Physician/Team

21st “Cancer is a hurry-up-and-wait experience. It is not a patient problem, but a family problem, which training will not solve. Since the patient spends relatively little time in the clinic per week, improving the patient-physician encounter [alone] will not solve the problem. Physicians do not have adequate time to spend with patients. The patient must be helped to learn how to cope when not visiting the physician”

David Gustafson, Ph.D. NCI Principal Investigator

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Timely Patient/Family • Time as “currency of 21st Century” • “Healing Relationships” over time • Efficient balance of inoffice, out-of-office resources

Ù

Physician/Team • Clinical systems support work flow • Reminder systems ensure that all steps are followed in sequence of care • Efficiencies in delivery improve cost-effectiveness

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Final Thoughts

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Looked for Health Information past 12 mo.

2005

2003

Source: Health Information National Trends Survey -- http://cancercontrol.cancer.gov/hints/

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Activities Online Percent Engaging In Online Activities

% Population (Weighted)

70 60 50 40

HINTS 2003

30

HINTS 2005

20 10 0 Looked Self Looked Other

Bought Medicine

Online Support

Message Doctor

Percent Yes

Source: Health Information National Trends Survey -- http://cancercontrol.cancer.gov/hints/

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Trust in Information Sources Trust in Information Sources 80 % Population (Weighted)

70 60 50 HINTS 2003

40

HINTS 2005

30 20 10

TV

In te rn et

Ra di o

i ly Ne ws pa pe r M ag az in e

Fa m

Do ct or

0

Source: Health Information National Trends Survey -- http://cancercontrol.cancer.gov/hints/

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Who Will Guide Today’s Patient?

• Informatics diffusion is happening (18% of US lives touched by E.H.R. in 06, 38% by 08) • Window is open for impact • Results are critical; lives are at stake

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For More Information

Visit us at:

http://cancercontrol.cancer.gov/hcirb 25

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