DISA – Health, Technology & Organisation (HTO)

How to separate the trees from the forest – The workplace as a Swiss army knife

Continuing on the “forests and trees” metaphor from a previous post we will now see what happens when you try to separate the trees from each other. So, let us start with one single tree (or task). One tree does not make a forest, but it can very easily be distinguished as a tree of a certain kind. A Pine tree has long needles; A fir tree has short needles. And a tree without needles is a leafy tree (unless it is a Gingko tree, but that is another story). However, once there are more trees in a lump, the categorisation becomes more difficult.

Transferred to the issue of work and tasks: As long as we are only doing one single task or having one single role, it is also quite simple to see and study it, and also (at least to some extent) to understand how it works, and what the consequences are. This is not to say that this kind of work is simple or uncomplicated, a heart transplant is a complicated task, even though it is a single task and well specified at that. We may also still make design mistakes on this single task design, but these kinds of mistakes are mostly confined to the task environment we work in at the moment.

In a way, as long as we have many instances of the same type of single tasks that we can handle more or less sequentially, we are still proceeding through something, which in the forest metaphor is like a well-managed orchard with the same kind of trees planted spaciously and in neat rows. We can still handle the situation with the same kind of specialised tools, and the tools may also have an easier way to communicate with each other, e.g., using the same terminology, the same data formats etc. since they are designed for the same task.

Now, when we consider the work situation for nurses at a hospital ward explicitly, their situation is completely different. Their work more or less constitutes the very definition of “fragmented work tasks”. First, there is planned fragmentation, where the person has to change tasks or responsibilities according to a schedule. Second, there are interrupting tasks in terms of alarms, visiting relatives, telephone calls and other randomly occurring events that also cause a fragmented work situation. There is a related blog post by Åsa Cajander “On Digitalisation and Fragmentation of Time” about this phenomenon.

The interruptions that occur over a work day can have at least two major effects on the nurse. He or she has to switch context for the work, which in itself is a stressing action for the brain. In the case of sudden intruding tasks, there is also the problem of mentally going back to the interrupted task and continue from where it was discontinued, sometimes after many hours. This situation becomes almost, again in the forest analogy, like looking at a primeval forest or a rainforest. There are trees everywhere and of every kind, and they are all interconnected in some ways. You need both stamina and focus in order to find your way through the forest/work.

This becomes even more problematic when we look at the computer support for work tasks in any workplace. The general computer system is in many cases designed in the same way as a Swiss Army knife. We use the same technical framework for all the tasks that should be performed, using a keyboard, a mouse (or a mousepad) and a screen for the stationary tasks, and mobile apps, in the best case redesigned for the smaller screens of mobile devices, for the tasks that are done on the run. Journal entries, medication dosage calculations, and many planning tasks are therefore performed in the same limited cognitive space, and there is no real support for the switching between those tasks, nor for the fragmentation of the ongoing work.

In some cases, like writing down the notes for the daily ward round, the information is even taken down as hand-written jots on a paper form and has to be transferred manually into the journal later.

A Swiss army knife is not really perfect in any of its functions (even the knife blade leaves a lot to be desired), it still works, and someone who is not a carpenter, mechanic or plumber might even think it is a good and practical tool. But for any professional, if asked, they would definitely prefer to use a specialized tool. Apart from being more efficient, specialized tools also pose a lower risk of accidents and slips. In the same way, non-specialized computer tools may, even though they can perform the desired tasks, still not be the best choice in a complex work situation.

When we design new computer systems for organizations like hospital wards, schools, etc. they are often positioned around one task at a time. We study one tree at a time in the forest. Even though we are much better off than at the beginning of the PC era, when we could only run one program at a time, we are still running several parallel processes that interconnect badly, if at all.

During the study visit at Akademiska in Uppsala last year (the university hospital in Uppsala), I found ten different systems used in one of the wards, all running on the “same computer”. This amounts to having ten tools on the Swiss army knife. Of course, the individual programs are in some way specialized. We don’t use spreadsheets for everything. Each separate task has applications or programs that are explicitly designed for its purpose but not for the whole entangled web of work tasks. Furthermore, the interaction design is often completely different in the different systems, which means that the user has to switch from interaction style to interaction style, and from command structure to command structure.

One example to indicate what I mean: the notes that are made for each patient during the ward rounds are almost always written by hand at the ward where I visited. However, after the ward round they have to be entered manually into the system, which has the double effect that it might be a slow process, taking valuable time from the nurses, and that there is also a high risk of misreading numbers and hastily jotted down notes.

The paper notes are not integrated into the computer system. While we note this, we might realize that we could need a more automated solution (which may still need proof-reading and checking). In this new solution, it would be possible for the doctor on duty to write, still by hand, on a tablet that may offer character recognition. This would reduce the tiring process of transcribing the text, making it much easier and also leave more time for other, more important tasks.

Now, this is, in my opinion, where one of the problems with the systems in the hospital resides. We are so focused on the design of the single system, that we forget all the small details that could make the whole work situation simpler and more manageable. Add to that that we also forget to look at the small details that should incorporate such things as:

specially designed portable devices, that are designed for a single task, such as taking notes for the information rounds.
the development of distinct, but consistent interfaces to all the subsystems.
ncorporating support for the interruptions that occur during a day. Why not a “what did I do last”- kind of function?

The conclusion of this observation is that we need to look at a work situation from a holistic and a reductionistic perspective simultaneously when we are planning and designing the digitised work place, resulting in a well planned and easily manageable rain forest of work tasks.

Digitaliseringen och arbetsmiljön

Idag var det officiellt boksläpp för Digitaliseringen och arbetsmiljön, en bok som professor emeritus Bengt Sandblad författat tillsammans med sina kollegor. Medförfattare är Jan Gulliksen, Ann Lantz, Åke Walldius och Carl Åborg – alla kända namn inom just digitalisering och arbetsmiljö.

Bokens redaktör Jens Fredholm passade på att ställa lite frågor till författarna. Bengt Sandblad slog fast att de flesta problem är onödiga idag, kunskap finns om hur de ska lösas. Åke Walldius fyllde i med att verktygen ska stödja, inte störa men att samverkan mellan alla parter är viktigt. Ann Lantz pekade på ständiga förbättringar som en viktig strategi. Carl Åborg underströk att vi måste sträva mot ett hållbart arbetsliv, det är inte hållbart om en ökande mental belastning ska göra att människor blir sjukskrivna. Jan Guliksen avrundade med att peka på att läget ändå är annorlunda idag, ledningen brukar vilja ta ett ansvar och det finns många fantastiska digitala verktyg vi använder utan problem.

På en fråga från publiken hur man nu ska komma till rätta med alla dessa problem var svaret givet: läs boken.

Shut Up and Write!

Writing is one of our main tasks as researchers: we author papers, books or book chapters, grant applications, blog posts, newspaper articles, etc. for a broad range of different audiences. However, setting time aside for writing is rather challenging, as it is so easy to fill up our schedule with the variety of other assignments we need to accomplish: teaching, supervision, administrative work, data collection, reviewing other researchers’ publications or grants, and more. In the HTO group, we have thus implemented several strategies to help us write more and better.

Following in the footseps of some of our colleagues at Uppsala University (see article above taken from Uppsala University’s magazine, Universen), we are launching afternoon “Shut Up and Write!” sessions every last Tuesday of the month. The idea is simply to sit together and write – each person working in silence on her or his own project – for a few hours at a time. We sit in a meeting room instead of our usual offices to create a change of scenery and atmosphere. The session schedule – the length of each writing slot – is decided beforehand. For example, we might write for an hour to an hour and a half, and then take a break together, possibly with a little fika. Then we move to the next slot. Since it is very focused work, three writing slots in an afternoon can result in significant progress.

Writing retreats, consisting of one or two days of writing in a row, have also become a tradition in our research group. We then gather in Åsa Cajander’s house in the countryside, and sit together the whole day, enjoying fika toghether between writing slots. We wrap up the day with a shared dinner we prepare together, which is a really nice teambuilding activity. Such writing retreats are thus not only an opportunity to be really productive and reach our writing goals, but also to get to know each other in a different context, and to develop friendly working relationships. The discussions that arise throughout the day also give us insights into what others are working on, and can inspire and guide us in our own work. Although writing for several hours is very energy-consuming, I always come back from such writing retreats with renewed motivation and fresh ideas!

Writing sessions and writing retreats can sound over-the-top, but they have definitley been opportunities for very productive work for me. In my experience, getting into the habit of writing often, for a few hours at a time, makes it possible to improve one’s writing and to become a more efficient writer. When are you starting?

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

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?

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.

Kick-off for a series of posts on teaching and learning

In addition to the research that we do, many of the members of HTO are involved in lots of teaching activities at the department of IT in Uppsala. Some of the courses we teach are in the area of health care, and here we have a very good collaboration with Region Uppsala. The setup of this collaboration is to aim for a win-win between students learning and the Region’s goals and visions. We have collaborated with the Region since around 2004, and it has resulted in many new learning opportunities as well as input to innovations in health care both for the Region and for the nation.

We also work with innovation and development of learning opportunities in our teaching. Åsa Cajander is a member of the Uppsala Computing Education Research Group, and this community gives lots of input and ideas for improvements of courses.

This semester we collaborate with Region Uppsala through our course on Medical Informatics and the course IT in Society. We also collaborate through joint master theses on topics of interest to the Region. We have asked a couple of our current students to write blog posts about their experiences during their thesis work, and this fall the HTO blog will contain a series of blog posts on teaching and learning activities related to the HTO group.

Visiting period at the HTO May – June 2018 – Shweta Premanandan

Hello!
I had the opportunity to visit Uppsala University again during May-June 2018. And this time I was welcomed by the warm Swedish summer! I was at the HTO group to work with my co-supervisor Dr. Åsa Cajander on my PhD work. My earlier visit in November 2017 to the group was very successful during which I collected survey and interview data from the Swedish context. My research is to understand the role of culture in the acceptance and use of e-government systems. And hence, data from two contexts is really important for the quality of my work.

During the duration on my visit, I worked on analysing my interview data. I discussed my work with Dr. Marta Larusdottir and Dr. Minna Karlsson, apart from discussions with my supervisor. These meetings opened me to a wide variety of ideas to work on with my interview data and they look promising. I also took a training session at the University Library on the use of Nvivo 12 for analysing interviews and organizing my literature review section. I also presented my analysis work in the Vi2 research seminar. We had some interesting discussions and I received good feedback. I am now in the process of writing chapters of my thesis. Discussions with other group members and my office-mates also were extremely helpful in this regard. The most helpful aspect of being at Uppsala university is to be able to meet so many PhD students at the department (or at the local watering hole) who may not be from my area and who are doing some really amazing work and be able to discuss research.

Uppsala never ceases to amaze me! I got a good cultural experience when I got to be a part of the staff Midsummer party. The music and the dancing was just amazing. Interacting with a multi-cultural community also helped my research work immensely. I hope to share my research work through this blog site soon!