Embracing Technology is DUMB' Embracing WellDesigned Technology is Smart

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Embracing Technology is DUMB.Embracing
Well-Designed Technology is Smart

• Dr. Ben-Tzion (Bentzi) Karsh
• Associate Professor
• Industrial and Systems Engineering Department
• Systems Engineering Initiative for Patient Safety
• University of Wisconsin-Madison
• (AHRQ R01 HS013610 (PI-Karsh))
• (NIH 1R01LM008923-01A1 (PI-Karsh))

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Take Away Messages

• We know that patient safety problems are the
  result of the interaction between people, the
  technology they use, and the system in which they
  workSO LEARN HOW TO UNDERSTAND YOUR SYSTEM
  (dont focus on technology)
• There is a science devoted to understanding how
  to design technology to support human performance
  (physical and cognitive). Its called human
  factors engineering (HFE)LEARN ABOUT IT!
• Technology needs to be designed to be a team
  playerANYTHING LESS IN UNACCEPTABLE
• HFE research makes clear that technologies are
  NOT solutions they should be ASSISTIVE DEVICES!

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Main Take Away Message

• THE ROAD TO PATIENT SAFETY AND HIGH QUALITY
  PATIENT CARE RUNS THROUGH THE PERFORMANCE OF YOU
  AND YOUR STAFF
• So if your technology is bad, your performance
  will be bad. If your performance is bad, quality
  and safety suffer

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Is there evidence HIT improves patient safety or
quality?

• CPOE and CDSS?
• Yes (Kaushal Bates, 2001 Kaushal, Shojania,
  Bates, 2003 Mekhjian et al., 2002 King, Paice,
  Rangrej, Forestell, Swartz, 2003 Potts, Barr,
  Gregory, Wright, Patel, 2004)
• Bar coding?
• Yes (Poon et al. 2006 Kaushal, Barker, Bates,
  2001 Puckett, 1995 Wald Shojania, 2001)
• EMRs?
• Yes (Mitchell and Sullivan 2001 Gill et al.
  2001 Legler and Oates 1993, Ornstein and Bearden
  1994, Solomon and Dechter 1995, Mitchell and
  Sullivan 2001, Garrison et al. 2002)

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But something isnt right

• EMR
• Concerns related to cost, a lack of tested
  systems, number of steps to complete tasks,
  problems with data entry, inexperienced vendors,
  confidentiality, and security found (Ornstein and
  Bearden 1994, Wager et al. 2000, Mitchell and
  Sullivan 2001)
• Entire systems have been abandoned because of
  problems with poor reliability, poor credibility,
  poor consistency, and problematic user interface
  design (Lawler et al. 1996)

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But.

• CPOE
• Systems have been abandoned (Prabhu, 2003)
• CPOE can increase the incidence rate of errors,
  adverse events and mortality (Koppel et al. 2005,
  Nebeker et al. 2005, Thompson et al. 2005, Han et
  al. 2005)
• Bar coding
• Nurse dont use it as they are supposed to and
  mistakes can still be made (McDonald 2006
  Patterson et al. 2002, 2006)

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But.

• Smart IV pumps
• We found no measurable impact on the serious
  medication error rate technological and nursing
  behavioral factors must be addressed if these
  pumps are to achieve their potential for
  improving medication safety (Rothschild et al.
  2005)
• CDSS in CPOE
• Physicians override up to 90 of drug alerts
  (Weingart et al., 2003)

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• Oh my

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Confession

• We dont know to what extent technology DESIGN
  has caused patient safety problems.
• In existing studies, it is nearly impossible to
  determine what was related to design, to
  implementation, to new workflow.

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Whats the Problem? The Prevailing Paradigmfor
healthcare technology? (stolen from Matt
Scanlon, MD)
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How do we get beyond this state of technology
will save me and technological determinism?

• A few propositions

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Proposition 1 Stop blaming everything on human
error!
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• Human error?

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If the wrong number is keyed in, is it human
error?

• At the bar code data committee meeting yesterday,
  we discussed the fact that nurses sometimes need
  to scan several times before the bar code
  'takes'. The nurse educator said that she
  teaches nurses that if they don't succeed on the
  first couple scans, to key in the number from the
  med bottle.

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Human Error?
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Proposition 2 Workarounds and violations of
technology protocols are GOOD! When you see
them, you should thank the violator!
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Heroes or Dummies?
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Heroes or villains?

• Maybe workarounds/violations are the right choice
  when the technology is not appropriate for the
  situation?
• Maybe workarounds are responses to poorly
  designed technologies and are therefore symptoms
  of the actual problems?

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Proposition 3 Healthcare professional rejection
of technology is wonderful!
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• Maybe rejection is a sign that smart people dont
  want to be forced to work in ineffective ways
• Maybe the technology is not designed to meet the
  needs, SIMULTANEOUSLY of
• Staff
• Patients
• Other technologies
• Physical layout

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Proposition 4 Only purchase well-designed
technology
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Technology as Assistive Device

• What is the goal of a walking cane?
• What makes a cane well-designed for a
  particular person?

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Technology as Assistive Device?

• What are the goals of bar code scanner?
• What makes an bar code scanner well-designed
  for the users?

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Well-designed technology

• Better feedback to the user
• Better cooperation with the user
• Better visibility and transparency of what the
  technology is doing
• Better matching of designs to mental models of
  the USER, not the designer and not the purchaser

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Example

• an A300 crashed in Nagoya, Japan, after the
  pilots inadvertently engaged the autopilots
  go-around mode. The pilots countered the
  unexpected pitch-up by making manual inputs,
  which turned out to be ineffective. Essentially,
  the pilot attempted to continue the approach by
  manually deflecting the control column, which in
  all other aircraftand in this aircraft in all
  modes except the approach modewould normally
  disconnect the autopilot. However, in this
  particular aircraft and in this particular mode,
  the autopilot had to be manually deselected and
  could not be overridden by control column inputs.
  Consequently, a power struggle developed between
  the pilot and the autopilot, with the pilot
  attempting to push the nose down through elevator
  control and the autopilot attempting to lift the
  nose up through trim control. This caused the
  aircraft to become so far out of trim that it
  could no longer be controlled.

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Proposition 5 Use Human Factors Engineering
Expertise
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Use Human Factors Engineering Design
Thinking(modified from Sanders and McCormick
1993)

• Technologies need to be designed for and to work
  with people
• Systems must be designed to accommodate the range
  of users
• How systems are designed will influence human
  behavior and therefore system performance
• Design needs to be evidence-based, not common
  sense or designer driven
• All design must take into account the system of
  use

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For more information

• Karsh, B. and Scanlon, M. (2007). When is a
  defibrillator not a defibrillator? When it is
  like a clock radio. The challenge of usability
  and patient safety in the real world. Annals of
  Emergency Medicine, 50, 433-435.
• Holden, R. J. and Karsh, B. (2007). A theoretical
  model of health information technology behavior.
  Behaviour and Information Technology, 1-17. DOI
  10.1080/01449290601138245. URL
  http//dx.doi.org/10.1080/01449290601138245
• Karsh, B., Holden, R. J., Alper, S. J., and Or,
  K. L. (2006). A human factors engineering
  paradigm for patient safety designing to
  support the performance of the health care
  professional. Quality and Safety in Healthcare,
  15(Suppl I), i59-i65.

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For more information

• Carayon, P. (Ed.) (2007) Handbook of Human
  Factors in Health Care and Patient Safety.
  Lawrence Erlbaum Associates Mahwah, New Jersey.
• Nielsen, J. Usability Engineering. New York AP
  Professional, 1993.
• Norman, DA. The Design of Everyday Things. New
  York Doubleday. 1998.
• Salvendy (Ed.), (2006) Handbook of Human Factors
  and Ergonomics (3rd ed). John Wiley and Sons.
• Sanders, M. S., McCormick, E. J. (1993). Human
  Factors in Engineering and Design (7th ed).
  McGraw-Hill, Inc.
• Spath (2000). Error Reduction in Health Care A
  Systems Approach to Improving Patient Safety.
  Jossey Bass Wiley.
• Wickens, C. D., Lee, J. D., Liu, Y., Becker, S.
  E. G. (2004). An Introduction to Human Factors
  Engineering (2nd ed.). Prentice Hall.
• Woods and Hollnagel (2006). Joint Cognitive
  Systems. CRC Press.

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THANK YOU! QUESTIONS???

• Ben-Tzion Karsh, Ph.D.
• Associate Professor
• Department of Industrial Engineering
• UW-Madison
• Contact InformationIndustrial EngineeringUnivers
  ity of Wisconsin-Madison1513 University Avenue,
  Room 3218Madison, WI 53706Tel
  608-262-3002Fax [phone]E-mail
  bkarsh_at_engr.wisc.edu
• www.engr.wisc.edu/mesh