Health, Technology & Organisation (HTO)

Lecture on Digitalization and our Work Environment

System development work is difficult, and many IT systems do not work satisfactorily despite intensive technology development. My research is about improving the situation and understanding what the problems are. I am working on developing improved working methods in the organizations and projects that develop and introduce IT. The focus here is user-centered methods, gender, sociotechnical perspective and agile development. I have also researched the skills that the people in the projects need to master to be able to work with the development of complex systems that support people in a good way.

If you are curious about my research – listen to the 12 min long lecture in Swedish

On Digitalisation and Fragmentation of Time

Diane Golay and Åsa Cajander did a presentation on Fragmentation of Time and Digitalisation for the Uppsala University Academic Senate this fall. This blog post captures some of what we said in the presentation. Enjoy!

Digitalisation of work sometimes has the unintended side effect that it fragments our time. Fragmentation commonly refers to the separation of activities into many discrete pieces. It is usually calculated based on two different aspects: the length of continuous work episodes, and the number of interruptions. In those terms, fragmented work is characterized by short work tasks and frequent interruptions, as opposed to a work rhythm made of few but long work episodes with no or few interruptions.

Several studies have pointed to the increasing fragmentation of our work. For instance, a 2009 study found that people switched tasks about every 12 minutes. Two years later, another study found that a modern worker’s day comprised an average of 88 work episodes, most of which (90%) lasted for 10 minutes or less. The found average duration for those work episodes was of just under three minutes.

Work fragmentation is related to a perceived increase in work pace and work intensity. It is also detrimental to the actual work taking place. The causes of fragmentation can be both external, such as a phone call or a computer that stops working, or internal, i.e. self-initiated, such as looking up an information on the web while working on a report.

External interruptions have a particularly negative effect on work. A context switch requires cognitive overhead, and context- switching is related to time costs. Concrete negative consequences of external interruptions include errors, stress, work delay, difficulty resuming the interrupted task, and increased user frustration. Interruptions are however not always negative: inquiries, breaks, and adjustments can facilitate the primary task by providing valuable information or creating an environment that encourages increased productivity. Context plays a significant role in determining whether interruptions are considered to be beneficial or detrimental. In general, interruptions that occur outside of one’s current working sphere context are disruptive as they lead one to (sometimes radically) shift their thinking. In contrast, interruptions that concern one’s current working sphere are considered helpful.

However, it should be noted that fragmentation is also a natural part of our work. Work tasks are to a small or high degree woven together and fragmented in complex patterns. Workers seldom work with one task at the time. Interruptions are a to some extent also a natural part of our work. Breaks are for example crucial for collaboration and learning.

So we should not aim for a fully continuous workflow, but might want to try and reduce external and internal interruptions that are not related to the task(s) at hand. Finding an amount of fragmentation that works for us will enable us to boost our work performance, reduce our cognitive workload, and simply make us feel better at and about our work.

***

[1] Jin, J., & Dabbish, L. A. (2009). Self-interruption on the computer. Proceedings of the 27th International Conference on Human Factors in Computing Systems – CHI 09, 1799. https://doi.org/10.1145/1518701.1518979

[2] Wajcman, J., & Rose, E. (2011). Constant connectivity: Rethinking interruptions at work. Organization Studies, 32(7), 941–961. https://doi.org/10.1177/0170840611410829

Dr Grünloh did an Excellent Job Defending her PhD

We all knew that Christiane Grünloh of our team knows how to do great and important research. But we were still amazed by her skills at the defense! Also, the atmosphere was really super nice and the defense was really a discussion among true professionals more than a questioning. The opponent David Hendry did such an excellent job and was really well prepared. If you weren’t there you missed something special!

Minna Salminen Karlsson from the HTO team, who is indeed very experienced, said:

“This was one of the best PhD defences that I’ve been to!”

The title of the PhD thesis is “Harmful or Empowering? Stakeholders’ Expectations and Experiences of Patient Accessible Electronic Health Records”. The research deals with the national eHealth service in Sweden that gives people access to their electronic health records.

You can read more about the PhD thesis in Christiane’s blog found here

Two studies published on the effects of patient accessible electronic health records

Members of the HTO group recently got two journal articles published, on the effects of patients accessible electronic health records (PAEHRs) in Sweden. Both studies were picked up by Swedish media after press releases had been published by Uppsala University.

The first article, “On threats and violence for staff and patient accessible electronic health records” was published September 28 and written by Ulrika Åkerstedt, Åsa Cajander, me and Ture Ålander. The open access article, which you can find here, is based on Ulrika’s masters thesis and presents results from a survey study conducted with healthcare professionals at the emergency and psychiatric departments at Uppsala University Hospital. Among other things, the study showed that the fear of being exposed to threats and violence from patients increased as a consequence of PAEHRs being launched in Region Uppsala. Shortly after the article was published this press release was published by Uppsala University. The news spread from there and Forskning.se, Dagens medicin, SVT Nyheter and Vetenskapsradion all published their own articles based on the press release. Åsa and I were also invited to write a popular science summary on Ciennce.se. The article by Dagens Medicin and the article by SVT Nyheter also took things further by e.g. adding interviews Åsa Cajander and representatives from the psychiatry department in Region Uppsala!

Our second article with a PAEHR theme, “Patients’ Experiences of Accessing Their Electronic Health Records: National Patient Survey in Sweden” was published November 1 and written by me, Åsa Cajander and Christiane Grünloh from the HTO-group as well as several other researchers in the DOME consortium (I introduced all researchers that are involved in the study in this blog post). In this article we focus on patients’ attitudes toward and experiences with PAEHRs in Sweden. It is clear from the results that patients really appreciate the possibilities that the Swedish PAEHR system, Journalen, gives them and that patients want access to new results in their PAEHR within a day after a new examination or visit. You can find many more results, and of course more details about the study, in the open access article published here (please help us share the news!). Even this article was presented in a press release from Uppsala University and the news was once again picked up by Forskning.se and we once again got an invitation to write a popular science version on Ciennce.se. This time around Inera (managing Journalen and several other Swedish eHealth systems), published their own press release about the study. The journal IT-Hälsa also wrote an article based on Inera’s release.

Winding Road to Become Professor of Human Computer Interaction

Next week it is time to celebrate that I have become a new professor of Human Computer Interaction. Up until a couple of years ago I would never had thought that this would happen. The typical professor in my world is odd or excentric, very smart and a man. Well, perhaps I am a bit excentric? Hmm. Especially when it comes to sleeping I do follow a slightly different orbit from the rest of society. I am indeed a proper party pooper and fall asleep early in the evenings :-o. Also my winding background is not very traditional for professors. There was a recent paper about my background in ACM Crossroads found here for those who are curious. But I do not see myself as very smart at all, and I think I am quite an average person generally. Moreover, I am very happy about being a woman.

How did I then end up being a professor of Human Computer Interaction? Well, I think that my best abilities as a researcher is curiosity and being brave. Also I think that Human Computer Interaction is an area that fits well with my interests as it is transdisciplinary. In short: I can fit the areas that I am interested in well into the subject of Human Computer Interaction even though they transcend education, enterprise usability, eHealth, gender and wellbeing. There was a text about my research on the university’s web page found here. Finally, I am convinced that I would not have come this far without the fabulous people I work with both in the HTO group, the UpCERg group and internationally. In a good collaboration everyone is a winner and research becomes so much more fun. A good example of this is that my colleagues Mats Daniels and Arnold Pears are also inaugurated as full professors at the same ceremony as I am, and also the important research that my colleagues and I do.

The inauguration of full professors is a public ceremony with newly appointed professors and this year it takes place on the 16th of November at 15.00. The ceremony has its roots in the medieval times and has been held every year since 1625. Perhaps I’ll see you there?

Philips Future Health Index 2018 released

Last July, I was approached by someone from the Philips team in London that works on the Future Health Index program. Previously they launched the first part of the 2018 Future Health Index, which is the indicator of the value delivered by 16 national health systems from around the world. For the second part, they wanted to produce some tangible guidelines on how things can improve and drive change within the industry.

In order to develop these guidelines, they interviewed 12 key opinion leaders (KOLs) across the Netherlands, US, UK, Australia, Germany, China, Sweden and Estonia – and I was one of them.

The Interview Questions

The interviewer was so kind to send me the transcript of my interview, otherwise I probably would not have remember them. I really enjoyed talking to him, which is not surprising given that people’s experiences with and attitude toward eHealth services is my PhD topic.

We started with my PhD research and I gave a background on the Swedish patient portal through which Swedish citizens can access their electronic health records online. We talked about the initial reaction from healthcare professionals and the conflict between the project and the local medical association (you can read about it in this article), how patients receive it, and what I think about this situation compared to, for example, Germany. Research within the DOME consortium indicates that the initial concerns of physicians might not have become reality and that many patients value direct access to their records, increased their understanding of their medical issues as well as their sense of control. In relation to that, I was asked whether the lesson would be to impose the intended change even if it is against heavy criticism of particular stakeholders. This really is a tricky question, especially in a context like healthcare in which a power-imbalance between clinician and patient still exists. I think, if real change is supposed to happen, sometimes consensus is impossible if the people who are supposed to change are against it. But at the end of the day, all stakeholders (like patients, family, physicians, therapists, nurses, management, insurance etc.) are (or should be) “in the same boat” so to speak and work together.

One of my favorite quotes on this is from Greenhalgh et al. (2012) who called for more effective inter-stakeholder dialogue in relation to telehealth and telecare:

The different interest groups described in this paper are likely to continue to exist in an uncomfortable truce with one another, competing for dominance as they gain more or less public appeal, professional credibility, political power, resource and so on.

and with reference to Checkland & Holwell (1998) they add:

While consensus is not a realistic or even desirable goal, surfacing such things as assumptions and values, and inviting debate on their significance through intersectoral and interdisciplinary dialogue will help achieve what systems thinkers have called ‘accom- modation’ (acknowledgement of, and adaptation towards, other perspectives and practices).

Future Health Index: Key Recommendations

I recommend to read the full report, which you can download here: Part 1, Part 2. According to the Future Health Index research, ‘universal’ electronic health records plays an important role in the future, for example regarding integration of and more effective use of data. They identified five key concrete recommendations to overcome challenges and drive integrated care:

Get regulation right.Clearly defined polices and robust data privacy and security standards at the national level build confidence in all parts of the healthcare continuum and help healthcare institutions develop their own data codes of practice, as well as encouraging healthcare professionals and the general population to collect, share and analyze data with greater confidence.
Modernize education.Healthcare professionals won’t demand EHRs and AI tools at work if they don’t learn to rely on them during medical training. Increasing healthcare professionals’ adoption of these tools must start with their integration into medical school curriculums.
End top-down implementation.Healthcare professionals are unlikely to adopt new tools when they’re presented as a ‘fait accompli’ by technologists. Creating EHRs and AI solutions in collaboration with both healthcare professionals and the general population will have a significant impact on successful integration.
Prove and explain value.Both healthcare professionals and patients need to be able to easily understand how data collection and analytics tools make a difference. Constantly measuring and communicating outcomes will create a body of evidence that will help bridge the understanding gap.
Harmonize data standards.Companies, healthcare professionals and governments in each market must work together to reach a greater degree of consensus on data formats and protocols.

Parts of this post originally appeared in a slightly different form on the my personal blog.

Closed Loop Medication

My name is Iosif Kakalelis and I’m towards the end of my master studies in computer science at Uppsala University. I have finished my four-year bachelor in my hometown Thessaloniki in Greece, where I studied Applied informatics at the University of Macedonia, a business school. My degree combines IT with business, marketing and economics. Here in Sweden, it is more flexible in terms of forming study plans. During my first year l, I experimented with different courses but in the end I realized that I was still more interested at working in real-life projects dealing with needs of society. Hence, I chose to do my master-thesis at Uppsala University Hospital.

Nowadays, technology has been embraced by society in almost every applicable field. Healthcare is no exception. New, innovative technologies are gradually being introduced in different health facilities around the globe in order to make healthcare more effective, less costly and better monitored.

Uppsala University Hospital intends to introduce Closed Loop Medication [1] to its whole workflow. Pre-studies have already been carried out and certain funds are available for this ambitious project. This suggested solution concerns almost everyone involved in healthcare. Most often the end-users are nurses, who first check and then administer the prescribed medicine to patients. Other examples of people affected by this change are doctors who prescribe, pharmacists who control and verify the correct medicine doses but may also include storekeepers who inspect the availability of medical supplies.

The selected medication is prescribed on an unverified prescription order that is then transcribed. Transcribing includes performing multiple crosschecks of the prescription order to real-time patient information, healthcare industry practices, and medication information to generate a verified prescription order. After transcribing, the appropriate dispensing method is determined for the prescription order and dispensed. The dispensed medication is administered after confirmation by the administering clinician of the right patient, right medication, right dosage, right route, and right time. The whole process of medication use described above is monitored continuously in real-time. The monitored information is communicated to the prescribing, transcribing, dispensing and administering parts of the system. [1]

In other words, automation is part of the entire process, starting from the doctors who are prescribing medicine, pharmacists checking and verifying the prescribed medicine, nurses receiving medicine from vending machines and finally the patient being given prescribed meditation in a customized package for him. The reason for automating the process is ultimately to achieve improvement in the accuracy and speed of the medicine distribution chain. Although the hospital today is considered technologically advanced, they are currently using different software, which was developed and often owned by third parties, for each part of the chain. Furthermore, for some specific tasks there is not even an available software solution. The drawback of this approach is that, often, there is limited to no communication and connection between the different software.

Even worse, there is not efficient communication and real time information between the different departments of the same hospital, because, as mentioned above, different databases and software are used, sometimes even for the same functions. Therefore, it is not uncommon for nurses, for example, to manually search for the available medicine on shelves, or doctors to call other departments to ask if a specific medicine is available there. All those factors contribute to making the whole procedure more time consuming and lead to harsher working conditions for employees and generally lead to the diminishment of productivity. Clearly, there is a need for the right medication, in the right place, at the right time, with the least possible effort and risk. Effectiveness could be achieved with closed loop medication through a centralized, interconnected, and interoperable information system which embraces all the functionalities of the current solutions. This system should be closely aligned with the current routines and working habits of the staff. The fact that the end-users are usually nurses or doctors, whose time is always prioritized toward patients, should spend the minimum possible time learning and using a software for their daily tasks.

Implementing a closed-loop system, is a broad and ambitious vision that people at the hospital shares, which involves many different specialists and knowledge from different fields including logistics. The area of my study is going to be the pharmaceutical verification step in close-looped-medication. Here in Sweden, doctors prescribe medicine to patients, but before the latter receive them, the prescription has to be verified and approved by pharmacists for safety reasons. After a meeting I had at the hospital with Dr Anders Westermark and some other medical personnel, I was told that currently there is no software responsible for implementing and monitoring that process. However closed loop medication necessitates a verification solution to be implemented. Thus, this is the part I want to get involved with and below my plan is described.

First, I plan to understand, analyze the workflow of this step from the perspective of all professions involved (i.e. doctors, pharmaceutical employees). A verification system should check if prescribed medicines uphold some predefined standards and/or whether they take into account each patient’s special needs or peculiarities. In case discrepancies are found, relevant warning indicators and messages should be triggered.

Second, I will try proposing solution ideas about this verification system answering questions about how it will look like, and how that would effectively fit inside the workflow, based on feedback I will receive from all the involved actors. This thesis motivates me to study papers regarding eHealth and automation in order to discover how knowledge of the others could give nice ideas for my project. Since the topics is about improving healthcare, potentially I could also make a small literature research about AI and automation in health. The optimal solution would include a verification system that self learns and improves.

It is also important to study the outcome this automation will have to the people. Role of technology is to serve people’s needs and not vice-versa. They should have control and opinion in the whole process and not kept outside the loop, like simple spectators. Therefore, it is my plans to study about potential problems that automation could bring. My final suggestions should take into consideration people’s considerations and concerns.

References

Henderson, D., Richard, L., Marklewicz, E., Tobin,C. (2003). CLOSED LOOP MEDICATION AND METHOD.

NordiCHI’18 – Key Note by Carly Gloge on Moonshot thinking at Google X and Pippi Longstocking Reflections

This week several members of the HTO group attended the NordiCHI 2018 conference in Olso, with the theme “revisiting the life cycle”. Here are some highlights from the first key note that we attended. In this key note Carly Gloge presented some work at company X which is Google’s “moonshot factory”. Their idea is to start with the really big problems first, and trying to solve them with innovation and technology. Some examples of innovations are self driving cars, here presented as reinventing the car driver.

This key note was really also addressing diversity as a success factor for the Moonshot factory, as well as being brave. Google X has really focused on diversity, and Carly Gloge says that this is one of the reasons why Google X has been so successful. A veryinteresting thing that came up related to this in the discussions section was the fact that Google is sued by Caucasian men that feel that they don’t have equal opportunities as other people at Google. They have ended up being accused of discrimination towards Caucasian men!

“If I would have known then what I know now, I would really have focused on diversity on my team in my previous jobs”.

Carly Gloge also presented their finding that psychological safety is at the core of successful teams. This finding is based on a Google investigation on successful teams where they ended up understanding that psychological safety was the only way to create a successful team, and not combining Type A personalities or “alpha males”.

They also very much focus on the growth mindset as a way of thinking, which means that you can always learn new things and that it is not innate to be an expert in something. This mindset is also mentioned as the “YET” mindset – I don’t know this yet and some in our HTO group has done some research on this mindset in computer science. This made us think of one of the famous quotes from Pippi Longstocking:

“I have never tried that before, so I think I should definitely be able to do that.”

― Astrid Lindgren, Pippi Longstocking

Carly Gloge tells us that the importance of diversity is also gaining traction in the asset management community, with large actors such as the US company Blackrock identifying diversity as a success factor that they include when creating their investment strategies.

Google has acquired a lot of companies, small and large, and Carly Gloge’s team is one composed of several such acquisitions. As with any acquisition this has its challenges, especially for a company aiming for radical solutions to the world’s problems. As Carly puts it, they frequently need to ask themselves “are we [our group/team] just a solution looking for a problem, or what are the problems we really would like to tackle?”

A suitable quote from Carly to start off this conference:
“If you obsess over your users, you can’t go wrong”

What is DevOps? Is it a person? A tool? Maybe a culture? Or all of the above?

DevOps illustration by Kharnagy [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons

My name is Mikaela Eriksson and I am studying my last year to become an engineer in IT with a master in HCI. This autumn I will do my master thesis around the subject of DevOps and is fortunate to have Åsa Cajander as my subject reviewer.

The project will be based on interviews held with people that are either working with or have thought about working with DevOps and especially focus on peoples views and feelings on the term.

After just a couple of weeks of research I can say that DevOps is without definition. For some companies it is a person, an engineer that knows how to ”make a process more DevOps”, for others it is about implementing a specific tool that helps the process to be more agile or a culture that is about renewing peoples way of thinking. However, it is still said to bring good results and productivity to a company.

How can a term that is interpreted differently and always evolving be of success where it sets its foot, or is it just that people say that they use this ”so called DevOps” to be cool on the market and that in real life the people within the process does not like it at all? At the end of this project, in January next year sometime, I hope to have the answer to this. To see what the common denominators are between the different organisations and what makes one group more successful than another, and most importantly, how DevOps perceived by the people working with it.

I will show my discoveries and research with you on this blog www.htogroup.org along the way!

Workshop at EPJ, Uppsala University Hospital, about eHealth Benefits Realization

I attended a very interesting workshop last Thursday, arranged by Birgitta Wallgren at EPJ (the department for Electronic Patient Records), with the Advisory Board. The topic was eHealth Benefits Realization: “It doesn’t happen all by itself”.

Advisory Board is a global research, technology, and consulting firm helping hospital and health system leaders improve the quality and efficiency of patient care. At this occasion, the Global eHealth Executive Council’s Senior Research Director Doug Thompson discussed the major activities and purposes of eHealth benefits realisation, common challenges, and tools and solutions that could be of value to the hospital in Uppsala. The audience consisted of specially invited people from the hospital, managers (physicians) from different departments and specializations, project leaders, and IT-developers in different roles. The day included the talk from Doug, supported by a power point presentation, some practical exercises, and it included a break for lunch. In smaller groups, we discussed specific issues relevant for our hospital in Uppsala and then presented our ideas to the bigger group. We got valuable input from Doug on our thoughts and ideas.

The general question was how to realize performance improvements at the hospital with the support of information technology, such as the EPR, or clinical decision support (CDS). The message from the Advisory Board is that we need to work structured, and with an awareness that this is not only a “technology project”. By making use of six best practices, developed by the Advisory Board, it is possible to realize more potentials from EPRs than the “low hanging fruit” that were harvested already. The Advisory Board’s model is to have benefit driven implementation and optimization. By clearly stating the wanted benefits and by identifying what mechanisms are driving each benefit (making it occur) you create a common ground for actors where it is possible to analyze problems and decide on valid routes for action. Else, it may happen that your gut feeling is sending you a false image of what is going on. It is important that you know where you want to be heading, and you need some tools to make sure you are on the right track. This conclusion can certainly be of help in many situations in life!