Human Factors in Prescription Medication Management

Slide Presentation from the AHRQ 2008 Annual Conference

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On September 8, 2008, Jonathan R. Nebeker, MS, MD, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.2 MB).

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Slide 1

Human Factors in Prescription Medication Management

Jonathan R. Nebeker, MS, MD
VA Salt Lake City GRECC

Slide 2

Acknowledgements

• Charlene R. Weir, PhD
• Frank Drews, PhD
• Molly Leecaster, PhD
• Rand Rupper, MPH MD
• Kenneth Boockvar, MD
• Brittany Mallin, MS MPH
• AHRQ R18 HS017186
• VA Salt Lake City GRECC
• VA Salt Lake City IDEAS Center

Slide 3

Overview

• The Electronic Health Record (EHR) context:
  • Current
  • Future
  • How theory gets us to future
• Theoretical Framework
• Study design
• Preliminary Findings

Slide 4

Current Computerized Patient Record System (CPRS) Veterans Health Information Systems & Technology Architecture (VistA)

The diagram shows:

• Access, presentation, and inputs:
  • Tables, charts, lists, graphs, text fields
• Logical relationships:
  • Reminders
• Storage of basic clinical information:
  • Lab, pharmacy, vitals, reports/notes, demographics
• Emphasis on access
• Information siloed in tabs

Slide 5

Future CPRS VistA

The diagram shows:

• Access, presentation, and inputs:
  • Integrated tables, charts, lists, graphs, controls, text fields
• Logical relationships:
  • Diagnoses and supporting evidence; treatments, conditions, and goals; prescriptive decision support
• Storage of basic clinical information:
  • Ontologies of lab, pharmacy, vitals, reports/notes, demographics
• Emphasis on control
• Information integrated

Slide 6

Goal: EHR of future

The colored photograph shows Star Trek characters Capt. Kirk, Dr. McCoy, and Spock watching over a sleeping Vulcan character in the medical wing.

Slide 7

Decision Support v. Sense Making

• Computerized decision support is typically normative and targets the right decision.
• The CPRS of the future will emphasize an information-rich environment that targets sense making to support higher quality decisions in the highly variable context of patient care.

Slide 8

Progress

• The Electronic Health Record context
• Theoretical Framework:
  • (The pathway to the future)
  • Joint Cognitive Systems or Cognitive Systems Engineering
  • Contextual Control Model
• Study Design
• Preliminary Findings

Slide 9

Towards the Future

• Apply Cognitive Systems Engineering
• Human Factors in this talk:
  • Not about usability
  • About the human-computer system

Slide 10

Joint Cognitive Systems

• Erik Hollnagel and David Woods
• System of artifact(s) + human(s) that accomplishes work.
  • Not what do human and computer do best
• Control is a measure of the work's quality.
• Examples of JCS:
  • Scissors
  • Fighter jets
  • Combat robots

Slide 11

Contextual Control Model (CoCoM)

• Performance in context
• Different types of behaviors predict better outcomes
• Functional not structural approach
• Not about information processing models: Memory, programs, etc.
• Used in engineered systems:
  • ABS at Saab
  • Nuclear Power Plants

Slide 12

CoCoM Main Concepts

• Competencies: possible actions in context
• Constructs: assumptions about situation
• Control modes: characteristics of performance that govern quality of performance
• Feed forward and feedback: anticipatory versus reactive control

Slide 13

Control Cycle in Healthcare

The diagram shows a circle comprised of arrows rotating in a counter clockwise rotation which presents:

• Physician, Patient, Nurse, Pharmacist, Social Worker, etc. asking "What is going on?"
• Healthcare of Patient
• Construct/Shared understanding of patient health:
  • Determines
  • Action/Care Plan
  • Produces
  • Events/Feedback:
    • Disturbances
  • Modifies
• An inner red arrow suggests that the cycle repeats.

Slide 14

Control Modes

• Scrambled:
  • Lack of purposeful activity
• Opportunistic:
  • Addressing salient characteristics
• Tactical:
  • Following procedure, limited scope
• Strategic:
  • Broader scope and higher-level goals

Slide 15

Control Characteristics

• Goal Complexity (Number and Interaction)
• Perceived Time Pressure
• Evaluation of Outcome
• Selection of Action
• Expertise
• Motivation
• Familiarity

Slide 16

Progress

• The Electronic Health Record context
• Joint Cognitive Systems Contextual Control Model
• Study Design
• Preliminary Findings:
  • Control characteristics

Slide 17

Study Goals

• Immediate Aim:
  • Translate CoCoM to medication management for chronic diseases
  • Explore associations between control characteristics and surrogate outcomes
• Next Aim:
  • Establish validity of adapted CoCoM control characteristics as predictor of higher quality outcomes through simulation

Notes:

• Need to do formative work
• Some work done in medicine by Cook, Woods, and Cuschieri.

Slide 18

Study Design

• Subjects: 40-50 physicians, mid-levels, residents, nurses, pharmacists in 5 outpatient clinics/4 States. Focus on hypertension (HTN).
• Think-aloud protocol + Interview.
• Saturation coding for control characteristics.
• Content analysis.
• Multi-dimensional scaling.

Slide 19

Preliminary Findings

• Semi-Qualitative
• Stories of control modes:
  • Scrambled
  • Opportunistic
  • Tactical
  • Strategic

Slide 20

Scrambled Mode

• Type: Trial and error performance.
• Case of the new intern and forgetful patient.
• Low information quality and availability plus.
• Low experience.

Slide 21

Opportunistic Mode

• Type: Reaction to salient characteristics
• Have not seen yet for HTN:
  • Reaction to systolic blood pressure (SBP) only
• Pain syndromes even among experienced:
  • Poor construct of problem
  • Low information quality
  • Vague goals: difficult to resolve competition
  • Vague evaluation of outcome: not mentioned, then OK.

Slide 22

Tactical

• Type: Following procedure
• Dominant mode for HTN
• Use of protocol
• Focus on procedure* (forget clinical goal)
• Minimal consideration of interacting goals
• Low use of feed-forward control
• Problem with information quality-clinical inertia
• Less common in highly experienced MDs

Slide 23

Strategic

• Type: Broad consideration of context
• Almost exclusively with experienced MDs
• Awareness of protocols but deviation to accomplish conflicting patient goals
• Familiarity with past therapy a key factor
• Feed forward strategies account for physiologic and organizational factors
• Still, incomplete use of explicit control limits

Slide 24

Conclusions

• CoCoM reveals interesting characteristics of system performance.
• High-mode characteristics have face validity for predicting better outcomes.
• Implications for software design:
  • Need to support efficient, rich reconstruction of mental model of patient
  • Need to highlight interaction of goals and therapies
  • Need to increase time horizon including feed forward

Slide 25

The screen shot of medical software first shows Interventions, Conditions, and Goals for Spironolactone 25 mg po qday and Hydrochlorothiazide 25 mg po qday for Hypertension and then the line graphs for both Systolic and Diastolic blood pressure and K+ for Goals, and the line graphs for Lisinopril, Spironolactone, and Hydrochlorothiazide for Interventions.

Current as of January 2009

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Internet Citation:

Human Factors in Prescription Medication Management. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090808slides/Nebeker.htm

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