Slide Presentation from the AHRQ 2008 Annual Conference
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).
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:
- 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:
- 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:
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
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