Design Dialogues

Are EHRs (Electronic Health Records) Error Inducing Machines?

Thanks to Brady Anderson on the Design for Care community site who alerted us to Dr. Christine Sinsky’s “eNirvana – Are we There Yet?”

I believe we are “not yet there.”  As long as the Medicare specification known as “meaningful use “criteria ignores design, usability, and the propensity for foreseeable error, we are not even close. The key quote from Sinsky illustrates the problem from the point of care and clinical use:

While Google Desktop Gadgets make access to information as unfettered as possible, HIT systems often sequester individual tidbits of information at the ends of nonintuitive labyrinths, with needless hurdles along the way. Clinicians need clear access to priority information, not an obstacle course. As an EHR user, I have to keep a thought in mind until, five clicks and two screens later, I can find related information. Then, I have to park all of this developing thought for four more clicks, three screens and a slow download until I get to the screen where I can take action. Repeat this process for dozens of tasks per patient and you have an environment that facilitates error and inefficiency.

However, in terms of her design process recommendations, I’d take issue with the Big Box brand names she recommends EHRs should listen to:

So let’s get Google on it, and bring in a Toyota mindset while we are at it. Toyota understands the need for lean, streamlined workflow. Toyota understands that even a minor unnecessary step that causes worker fatigue or extra time is a problem. Many steps in HIT are redundant. They cause worker fatigue and monopolize time.

No, please – Google’s information interfaces are wretched, even if they have the bomb back end. They are engineers with no design sense.  The better example is actually Microsoft, as much as I used to dismiss them. They have done their homework on usability, reliability, and information integration. Google relies on goodwill and monopoly – they are becoming the new Microsoft.

And I’m not sure Toyota’s lean or other processes are representative of the high-reliability processes needed in healthcare.  Redundancy and multiple touchpoints are effective in HRO systems; We need to make sure busy clinical staff don’t miss things. Clinical work requires attention to distributed cognition as much or more than individual.

Attention Overload and the Overabundance of Healthcare Information

The usability gap is not just with EHRs of course. The web does not automatically make things better. Every informatics vendor in healthcare services has a different interface, a different information model, and different applications for their resources. Where a patient can use the Mayo Clinic, Web MD, e-Cleveland Clinic, Everyday Health, and so forth, doctors have dozens of specialized resources available online through the hospital’s library or intranet. But they may be too busy to use the resources available.

These days I actually find fewer and fewer senior physicians (that I speak with) using smartphone for clinical information.  Typically I hear they use “ePocrates” or another drug search tool, but that’s it. Doctors, like most professionals, are overwhelmed with data and with packaged information as well. My current book chapters (the ones I’m writing now) are dealing with these issues. Residents, even senior residents, are in training and will use online resources more. Senior clinicians are not using the plethora – and there is quite a plethora – of resources as much.

Where is all this going?

It will get worse first. The next 3 years will see a shakeout of everything in the professional marketplace. I can already get the clinical handheld version of Medscape as a free app on the iPhone – and maybe residents would use that. But the mere provision of “easy to use” clinical information on the web and phones is not the problem. I would not be surprised to see a revolt of some sort, a lockdown of apps in the institution so that a small number of preferred resources are used.

The VA medical centers have done this for some time on their CPRS menu for CDSS (Clinical Decision Support). Clinicians need only focus on a few supported resources, although new ones can be requested and installed at different centers (or regional VISNs).

The medical literature is even worse to navigate. Senior medical experts and clinical researchers have an increasingly difficult time getting to the articles that matter. Publication inflation and the proliferation of less-than-citable journals have allowed for a huge growth of mediocre research that clutters attention and bandwidth.

For two years or so I’ve been working on a process with U of Toronto’s Dr. Peter Pennefather to address this problem. We call this system the Interpretive Collaborative Review, which is currently a rough prototype. The ICR process is designed to guide collaborative profiling, scoring, and recording of jointly perceived significance associated with online publications. The goal is to make explicit a group’s perspective and understanding of the value of claims presented in these publications.

We address the problem of an overabundance of published and Internet accessible health science research information. The overloaded research ecosystem presents a major challenge for identifying a subset of that information for adequately informing specific healthcare choices. This challenge is further complicated when accounting for varying or multiple perspectives in the governance of those choices.

We consider this a problem best resolved by collaborative sensemaking (for more, see prior post).

February 9th, 2010 | Tags: Collaborative sensemaking, Healthcare informatics | Category: Uncategorized | Leave a comment

Design with Dialogue, our Toronto community of practice, is moving into its 20th month of regular sessions at OCAD’s Strategic Innovation Lab. Our new website shows current and upcoming events, and we’ll update the archives from the old site soon enough.

We are making new connections between dialogic group communication, design problem solving, facilitated consultation, and sensemaking.

Recent posts have perhaps tipped any reader to what I believe to be pressing concerns. While I have opinions and ideas about open innovation, the viability of the iPad in healthcare and educations, creating new ecosystems for local innovation, the marriage of systems thinking with design practices, and so forth, I’m not sure I’m contributing to solutions discussing what’s popular.

I’m more interested in how committed collectives of people – as in organizations and mixed stakeholder groups – might find breakthroughs in problem understanding and collective action. The practices of sensemaking (Dervin, Klein, Weick) are called for to manage these complex situations, but do we know how to make sense together? Technologies of dialogue are necessary to bridge the distance between an individuals’ perspective and collective agreements for wise action.

Can this be done online, people ask. My first response is, why? Are our situations not serious enough to call for taking the time to engage in person? Do any of us really believe that crowdsourcing leads to better sensemaking? To borrow the sorry monkeys on typewriters analogy, will a million people typing answers to questions online (devoid of context or their commitment to act) create a Shakespeare of solutions? Will people online somehow arrive at a better sense of a shared situation than 12 committed stakeholder who are willing to act on their own decisions?

Online, we can facilitate socially-recruited responses to focus questions, we can collect commentary and clarifications, we can publish our synthesis and findings. But can we perform collective sensemaking?  If so, where is the research suggesting this? I think this matters, because if effective collective decision making requires the understanding acquired by sensemaking to result in high-leverage shared action, we might stop fooling ourselves that the efficiency of “everything online, all the time” will achieve our goals.

February 2nd, 2010 | Tags: Collaborative sensemaking, Dialogic Design | Category: Uncategorized | Leave a comment

Part II.   Human-Scale Tools for Change

While many authors recently warned of the consequences of an ideology of unfettered growth, including Ronald Wright, Jared Diamond, George Monbiot, and Thomas Homer-Dixon), philosopher/priest Ivan Illich warned us 40 years ago.  He foresaw a collapse of the post-industrial economy, which did not happen then. Illich proposed that autonomous, creative citizens take responsibility for creating the tools that might regenerate a civilization for real human needs and purposes. Perhaps both, breakdown and a creative civilization, are happening now.

As with the Club of Rome (1969) and their Limits to Growth (1972), Ivan Illich was right – but at the wrong time.  Those who remember the 1970’s may recall that alternative publications at the time (I have all the old Co-Evolution Quarterlies) treated the mid-70’s as if the apocalypse was happening then. Perhaps it always seems that way. As Dayton’s (now Austin’s) Troy Campbell sang on 2004’s American Breakdown, The World Keeps on Ending – every generation reinvents their desire the end the problems they inherited before the problems end the generation. Yet this time there is something different, something truly timely in Illich’s Convivial Tools notion.

I can only conjecture on how the breakdown of industrial society will ultimately become a critical issue. But I can make rather firm statements about the qualifications for providing guidance within the coming crisis. I believe that growth will grind to a halt. The total collapse of the industrial monopoly on production will be the result of synergy in the failure of the multiple systems that fed its expansion. This expansion is maintained by the illusion that careful systems engineering can stabilize and harmonize present growth, while in fact it pushes all institutions simultaneously toward their second watershed. Almost overnight people will lose confidence not only in the major institutions but also in the miracle prescriptions of the would-be crisis managers. The ability of present institutions to define values such as education, health, welfare, transportation, or news will suddenly be extinguished because it will be recognized as an illusion.

Ivan Illich  (1973)  Tools for Conviviality

John Thackara revived a conversation for Tools with brio at the CHI 2004 conference in Vienna. With Bill Buxton, they presented an unscheduled dialogue they called “A Convivial Conversation” to intrigued conference participants. As I recall they debated their fairly polar perspectives on the possibilities and consequences of ubiquitous, cheap flat screen display panels in the public sphere. They both made convincing cases. Thackara’s is the case that would be expensive to ignore, if he and Illich turned out to be “more right.”

What Happened

Even if you cannot recall (and I can’t), it is clear that in 1973 few – if any – individuals were prepared to make the call that IT would become the great engine for new growth in the next decade. Society was not even yet mourning the loss of manufacturing and the blue-collar middle class the declined with it, because that had not happened yet. Even if Illich did not foresee the forestalling of the American breakdown granted us by 25 years of IT-fueled growth, what Ivan got right was that constant, increasing growth largely serving a managing elite was unsustainable. Crashable, and in a big way.

What economists, sociologists, and visionary editors (like Stewart Brand) also missed was the possibility that long waves of growth and destruction have their own cycles. Although both Kondratieff (1925) and Strauss and Howe’s Fourth Turning called the collapse for soon after the millennium, and not in the 70’s, most people missed those memos, as they were making other plans. Although long wave patterns are not provable hypotheses, they are empirically supported by the evidence they refer to in their models. While all models are biased, the biases that you accept make a difference in the real world.

The 1970’s saw the creative destruction of the first industrial economy. But it was a preview of the larger economic changes that could occur when the IT revolution completed its cycle of automating efficiencies, first by replacing rote work and then destroying administrative employment. Take a look at the figure on the Kondratieff page. We are living in that end phase of the growth cycle right now. We don’t know what’s next, and you’re living in happy times if you believe the Kurzweil post-human Singularity will somehow save us. You should really disbelieve anyone who says they know what happens next.

What’s Happening Now

You also don’t have to believe James Howard Kunstler’s take, that we should learn to live off the land again. Along with systems theory, back-to-the-earth was a major theme in Brand’s old Co-Evolution Quarterlies.  Stewart Brand himself shrugged off the possibility of re-ruralization for the new millennium in a recent NPR interview, and he appears to now be on the side of the “bright greens,” if not the Singularity movement. You don’t have to believe President Obama either, that recovery is imminent. (What are we recovering to?) Just observe for yourself, the evidence is available.

We may be in a services economy that generates value from IT-enabled constellations. But services have not yet generated the sustainable employment necessary to create and hold quality of life and cultural growth. Between these historical shifts, the leisure class we were promised 100 years ago never really got off the ground. The smartest among us today are also the hardest working people I know. Leisure and culture are hard won, perhaps.

Why a Convivial Response?

What does a convivial world even look like?  Do we have any good examples? Copenhagen? Willits, California? Toronto?

Let’s return to what Illich called the tools for conviviality,http://redesignresearch.com/dialogues/wp-admin/post.php?action=edit&post=572&message=1 a process of human-scale cultural design. This means for us to “invert the present deep structure of tools” in order to “give people tools that guarantee their right to work with independent efficiency.”

I choose the term “conviviality” to designate the opposite of industrial productivity. …  I believe that, in any society, as conviviality is reduced below a certain level, no amount of industrial productivity can effectively satisfy the needs it creates among society’s members.

Liz Sanders of Make Tools (former Sonic Rim, Fitch) represented Illichian design thinking to an IDSA conference in Cincinnati (also around 2004). She founded the new design firm on a convivial concept: that users in any service have the autonomy and desire to create their own concepts to express needs and desires for their world. She calls this generative design, a radically co-creative participatory design approach. Make Tools has people “making tools: or expressive projections of their wants, as a means for producers to create new tools in turn.

As designers and innovators, we are social tool producers. What Illich points to is that, while we may find our tools liberating or enhancing of our own autonomy, we  may not foresee whether we serve any long-term social goals. When we serve our clients, are we contributing to more of the same? Where do we, as design “thinkers” grasp the reigns of ethical vision sufficient to effect, not abstract “change,” but just the conversations that change people’s minds? Do we even have the convivial tools of deliberative communication?

A convivial society should be designed to allow all its members the most autonomous action by means of tools least controlled by others. People feel joy, as opposed to mere pleasure, to the extent that their activities are creative; while the growth of tools beyond a certain point increases regimentation, dependence, exploitation, and impotence. I use the term “tool” broadly enough to include not only simple hardware such as drills, pots, syringes, brooms, building elements, or motors, and not just large machines like cars or power stations; I also include among tools productive institutions such as factories that produce tangible commodities like corn flakes or electric current, and productive systems for intangible http://redesignresearch.com/dialogues/wp-admin/post.php?action=edit&post=572&message=1commodities such as those which produce “education,” “health,” “knowledge,” or “decisions.”  School curricula or marriage laws are no less purposely shaped social devices than road networks.

What are tools for scaling conviviality? We need tools for dialogue and making sense together. We need tools that create a culture conducive to communication and dialogue. We need tools we can share – literally, like Philadelphia’s Tool Library.

Let’s look at America. How do we save our neighborhoods from decline, enhance local transportation, bring local farming and food into small towns and cities? How do we use online tools effectively to promote real democratic change? How do we recover election integrity? How might we re-envision school systems and universities? Money and banks? Journalism and news? All of these are questions of conviviality. They all require people work together across ideologies and boundaries, intervene, document their work, make serious decisions, and propose alternatives to others in the community.

January 9th, 2010 | Tags: Cultural Design, social values, Transformation | Category: Uncategorized | Comments (1)

The new year often finds blogs and commentators concerned with the memes and themes of the oncoming era hurtling toward us. Participating as I do in the more “abstract” design communities (e.g., experience, anthro, service design, strategic innovation, interaction, information architecture) I observe a lot of unproductive self-definition.  This takes the form of pronouncements about what a certain field is or is becoming, and why we we ought to care. To be charitable, we might view these discussions as a socially-adapted process of guiding disciplinary evolution. To be less charitable, when I compare design’s disciplinary development with the mature fields I work closely with (in my design research), I have to wonder whether we’re up to the job.

Take a strategic view of Design (and I don’t mean business or competitively strategic, or strategic as in winning).  Strategic also means the capacity to imagine the broader unfolding of the consequences of interventions and emergence toward a desired horizon of some, but not all, possibilities. Let’s ask, who do we really desire to be when we grow up? Because grow up we must – reality is different in 2010. It requires informed action.

Taking a step back and viewing the longer-term evolution of cultural and economic practices, most of these disciplinary definition concerns appear trivial and defensive. Scanning the online community responses to the new year/decade, reflective responses show how seriously we treat things that have little impact, and how we likewise may miss things that we (designers and human systems researchers) should be taking seriously. Rather than waxing normative, let me pick on a couple of examples.

Last year’s (2009) New Year’s posts by Business Week commentator Bruce Nussbaum reflected on the shift in design thinking from innovation to Transformation. I responded to this by suggesting innovation was not dead yet. Hundred of other commentators responded online or by linking, and so it had impact, whether or not we agreed with the proposition. (So it has been a year since then – was 2009 the year of Transformation or not?)

Nussbaum’s latest New Year’s posts aimed toward social impact at globalization, the decline of America, and massive social shifts between generations and countries. He took a more serious position than the aforementioned broadside on innovation, yet it found far less commentary from the “glimmerati.” Not that this comment fell flat, but by comparison, far more heat was generated by his taking on Don Norman’s suggestions that design research is a follower, not leader.

We protest too much. Don has a well-regarded perspective on things, and has a serious publishing history to back it up. After you get past the differentiation and definitions among commentaries, Don is mostly right. So what. It is just what’s so, it doesn’t mean design research fails to innovate.

Don Norman’s (by now) infamous piece Technology First – Needs Last (Dec 2009) was taken as provocation, which design “thinkers” rushed in to disagree with. As a scholar, I could take issue with some of the points as well, but the intent of the article was just to express an observation. It was not a peer-reviewed publication.

Don’s laconic response to Bruce Nussbaum’s huffing about the implications of the piece represented the turning point. (“Sorry folks, but I think you miss the point. I too bristled at Norman’s conclusion — and I happen to be Norman.”) The meta-message I’m reading is that we are behaving as insecure representatives of what should be creative, engaging and developing disciplines. We are focusing far too much attention on differentiating and justifying ourselves. If we miss the big picture, we will find design left out of the very meaningful contributions we say we need to make.

We take ourselves and our definitions of design, design research, transformation, impact, and influence way too seriously. I look at it this way – established professions do not find themselves questioning the public understanding of their identity and perceived value at every turn. Designers, especially the newer design disciplines that have grown up online, appear to thrive on inward-facing identity crises. Let’s get over it and start helping people, working cooperatively, and helping each other build credibility and trust toward an authentic and valued profession.

I acknowledge that the diverse disciplines involved in innovation may adopt meaningfully different definitions. For those still wondering what sensemaking really means, it means (at least) a process of resolving situations where gaps occur in understanding that enable meaning to resolve and recover “sense.” Brenda Dervin, who has struggled with transdisciplinary communication breakdown longer than most of us have been in disciplines, recommends a practice of “verbing.” When we transform the nouns we objectify (and then fight over) into verbs that describe activity that we can agree upon, we recover sense and meaning.

So rather than taking sides, we might starting taking cites. We might become more convivial, not in the social sense, but in the sense of caring for more than just our own tribes. In a recent panel session (OCAD Health Summit), with other designers in healthcare, we resolved to  cite each other more often and share the credit. Designers (and artists) are notorious for ignoring influences, unless they are French postmodernists. We will help the larger field grow if we have some confidence and listen more. If we look up and reference those whose work we admire, even if we don’t happen to love the commentator (see references to spat, above).

We gain nothing by pretending, especially to a designerly audience that does not know the literature, that we invented the concepts we favor. We might learn about the deeper currents that inform our work (like Dervin) and give substantive credit to our influences, and not glossing over them. From a cultural point of view, we are all in the same field. We all play in “design and innovation” as opposed to basic science, arts, or engineering. There’s enough leadership to go around. There’s room for everyone, and we gain more by cooperating than by competing with each other.

Who are our real customers? Is it the evolving progressive society and enlightened commerce? Do they understand what we really do and offer? We could start helping our field recover from its self-inflicted pettiness, and offer something of real value to the society we envision bringing forth. This was the perspective of the 2009 Global Forum, Business as Agent of World Benefit.

This is Part I, the problem statement.  Part II will serve up the obligatory New Year’s foresight and requisite design recommendations.

January 4th, 2010 | Tags: Design Thinking, Transformation | Category: Uncategorized | Leave a comment