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!

Organization, Artifacts and Practices, 8th workshop in Amsterdam

Organizations, Artifacts and Practices (OAP) yearly workshops remind of the fact that work in organizations happens in certain physical spaces, need certain time and is performed with the help of artifacts – even in the digital age. The theme for this year’s conference was ”Rematerializing organizations in the digital age” An overarching theme in the sessions I attended was places where we work – working from home or working in open space offices, especially hot-desking, i.e. not having a designated desk.

Timon Beyes’s opening keynote on ”The work of disconnection” discussed the increasing trend of learning to disconnect from the digital world – for example digital detoxes. His descriptions of how digital media has invaded our ways of thinking even when we try to disconnect was quite thought-provoking. The occasional giggle in the audience indicated that we to a certain extent recognised ourselves in the descriptions.

In the final panel the three days’ presentations on locations and open office spaces were summed up, and, generally, open offices were criticised on basis of many surveys and interview studies, some of them done in universities. The lack of privacy was acutely felt. In the overall effort of creating open offices, even people with functions the really demand private spaces (counselling, for example) found it difficult to assert their needs, as in Bernadette Nooij’s study. Identity crises – “who am I without my books”, as a university staff asked. And, actually, some people felt more lonely, when chatting at the door of a colleague was no longer possible. As Marie Hasbi has found out, there can be gender issues – not only had female workers problems in finding a space for their handbags (the lockers relatively far away, and nowhere to lock away the handbag when moving from the desk), the acts to re-territorialise desks could have gender aspects, as well as being exposed to all colleagues all the time. And the negatives seemed to persist.

Increased working from home often goes hand-in hand with hot-desking (so the number of desks can be kept lower than the number of employees). Melanie Goisauf had studied a well functioning public bureaucracy, where working from home was introduced and found out that control of the employees by the managers increased when the team control, built on common ethos and responsibility and supported by daily interaction diminished. Instead of “us” having responsibility towards the public, single employees shifted their responsibility towards the management, and the team spirit deteriorated as competition regarding individual performance increased. As managerial control based on performance measures increased, tacit knowledge disappeared from managers’ view.

Joshua Firth’s study from New Zealand at an ICT development company, developing tools for healthcare goes in line with the HTO results: Practitioners/healthcare workers find it difficult to really get a voice in development processes, even if they would be formally enlisted, and this trend seems to get stronger the longer the process goes on. Firth talked of building in neotaylorism in the healthcare software, and just like Taylorism in its time, it profoundly changes work practices, disempowers the (healthcare) workers and centralises managerial power.

Also Joao Cunha’s study on how people enlist other people’s help when they have to use online communication is interesting in healthcare, where more and more communication is supposed to use electronic forms instead of personal interaction. Cunha found that when people just have to send a message to a great unknown, and, thus positional power or personal relationships cannot ensure that their request will be heard, they invent different strategies in trying to ensure that the request is dealt with swiftly.

The workshop made great efforts for breaking up traditional academic lecturing styles with a number of panels and question-answer sessions. In this context Vrije Universiteit Amsterdam had an artefact I haven’t encountered before: A conference microphone shaped like a soft cube (see image). Instead of people running around with microphones, the “dice” was thrown around in the lecture hall. Fun – but also demanding that the person who had something to say had a fair ball sense to be able to catch and throw precisely enough. Still another academic ability coming on?

ECSCW–the Rise of the Machines?

ECSCW 2018 took place in the beautiful French town Nancy and was hosted by Inria. As always there was a friendly atmosphere and a nice mix of presentations. I was there to present an exploratory paper by Rebecka Cowen Forssell and myself, on the Digital Work Environment. (A presentation most likely to remembered mainly for the art nouveau homage to Nancy, I’m afraid). However, there were a lot of interesting presentations, and here I will highlight just a few topics that I personally found interesting.*

The initial keynote by Antonio Casilli on the micro work behind AI was worth the trip alone. It was a great presentation on a very important topic. Indeed, this dispelling of the myth of AI was a theme that came up in a number of talks, not least in relation to the promises of automation in Industry 4.0. I also had the opportunity in one of the breaks to listen to Edgar Daylight’s historical perspective on this–AI being notoriously famous for recurring hypes.

The presentations covered a wide range of topics, from the Tatbeer ritual (Majdah Alshehri) over socio-technical heuristics (Alexander Nolte) to digital sticky notes (Sarah-Kristin Thiel) but somehow it all fitted together. I guess part of this can be explained by some of the traditions of the ECSCW community.  Here, Stuart Geiger’s presentation of documentation work was a fine example of the ever present ethnographic perspective. The humanistic values were evident in Renwen Zhang’s talk on online support groups for depression in China as well as in Isaac Holeman’s plea for Silence.

There were quite a few presentations that were more directly relevant for my own work, including Luigina Colfini on work-life balance, Nina Boulus-Rødje on supporting knowledge workers and Pernille Bjørn on variations in oncology consultations. I also found Yuri Lima’s poster on a tool for assessment of disruptive ICT in the workplace very promising. In their study on collaborative design projects in school contexts Netta Ilvari and her colleagues used service research as a theoretical lense, a theory I have been considering using myself. 

However, the conference had a special focus on computer support for qualified industrial work—Industry 4.0/the industrial internet of things—and the challenges were well summarised by Thomas Ludwig from Siegen. The Siegen crowd was as always strong in quality as well as in quantity. There is a lot of interesting research going on there that seems to touch on many of the same topics we are studying, although in an industrial setting. As proven by the panel discussion, similar studies are of course taking place in other countries as well, examples were given from Austria and France.

Speaking of Austria, ECSCW 2019 will take place in Salzburg and we got a glimpse of the venu and the playful new facilities that Verena Fuchsberger and her colleagues are enjoying.

Who knows, maybe I’ll be back…


*A formal note: I refer just to the presenter here, in most cases there were co-authors, see the Eusset proceedings for full information.

Article in Interactions Highlighing the SIGCHI/EIT Health Summer School

Last summer many from the HTO group joined the SIGCHI/EIT Health Summer School that was organised in Dublin and in Uppsala/Stockholm. The photo in the blog post is from the amazing library at Trinity Colleague.

The magazine Interactions highlighted the summer school in their latest edition.

The article highlights some of the learning experiences from organising such a summer school, such as that demand is high for such summer courses, patient participation is very valuable and that it was easy to recruit contributors to the summer school.

I know that the other organisers of the summer school thought that it was a lot of administration, but all agreed that it was also great fun!

Interactions also highlighted some of the HTO groups’ blog posts about the summer school found here:

Jonas Moll: https://molljonas.wordpress.com/2017/07/01/ehealth-summer-school-in-dublin-day-5/

Christiane Grünloh: https://www.htogroup.org/2017/07/08/behaviour-change-social-practice-theory-and-learned-helplessness/

Diane Golay: http://dianegolay.ch/2017/07/05/on-humans-computers-and-why-users-should-not-be-blamed-for-struggling-with-computerized-systems/

 

The trees that hide in the forest

Sometimes when we make studies on a work environment, e.g., as a preparation for software development, there seems to be a tendency to overlook the smaller things; things that actually have a greater effect on the work situation than we might think at a first glance. There is, of course, never any doubt that big software systems will play a big role in a person’s work over the day. When there are problems with these, this often causes large breaks in the workflow and are (hopefully) sorted out fairly quickly. But there are also many small things; those annoying nuances that might not be causing disasters, but merely make a person frustrated in the long run. These smaller inconveniences are often not detected or considered in the cognitive workspace design.

The idea of a cognitive, ergonomic work context was widely discussed in the 1980’s. (c.f., Hagert, Hansson and Oestreicher, 1987, Wærn 1988) . However, the overall combination of software systems as a work environment seems today to be stressed mostly as an issue of incompatibility, e.g. causing unnecessary copying and processing of data and similar issues. Even if we manage to make the systems compatible and exchanging the data between themselves there are many other environmental factors that will still be affecting the cognitive work context negatively. These factors are sometimes well hidden in the work procedures and may be difficult to assess for software designers, and sometimes they are actually not even software issues but rather involving advanced hardware solutions.

During our previous study visits at a hospital, there were many small things happening that were hardly noticeable, but which at the same time constituted important factors in the work situation. In some cases, these small things were not directly concerned with the software systems used (although it is possible to see some of them as relevant to the overall software systems design), but proper workspace design might actually include these parts in the larger software network.

Just after Easter, in 2018, I was hospitalised for a week with an evil strand of pneumonia. Apart from being sick it also meant an interesting and close view of the nurses’ work context and the tools that they used. Since I was actually a real patient (albeit of an observing kind) I think that the nurses were more relaxed than during the earlier study visit. So, I started to observe several things that happened all around me and in this and some following articles I will go through some of the ideas that fell well into the work context situation.

One thing that was quite apparent, both in the study visits and during my week-long stay at a clinic, was the fragmented workflow for the nurses. Among the ordinary work tasks, there were many local interruptions, from alarms for a certain patients medical condition (mostly false ones, but more about this later), to calls for non-urgent requests from patients for water, tending or other less acute matters. Also, there were incoming medical transports and phone calls which, although part of the work, often tended to interrupt the nurses in their work. This kind of phenomenon is very difficult to catch in a work design study since it more or less requires a longer period of observation in order to properly judge its significance for the work. In this way, we tend to see the forest (of tasks) as a single unit, whereas the nurses instead are working on all the small trees and shrubs (of smaller activities) that actually constitute it.

Another factor that has appeared is that while the design of the main computer systems often is very thoroughly prepared, both in terms of requirements on the software and the hardware, much less effort seems to be spent on the personal software and hardware(!). This means that even if we get very advanced software systems on the ward, the personal equipment often seems to be pretty much left out of the equation. Essentially, this is also very similar to working hard on defining the forest, but lacking the ability to see all the trees making it up.

In my following blogs, I will try to disseminate these issues into a few more concrete examples of this and even make some suggestions for how to proceed and also enhance the situation at a hospital ward with these observations as a base.

Lars Oestreicher,
DISA

(this blogpost is also published on my personal blogpage: moomindad.wordpress.com)

Digitaliseringen och arbetsmiljön – en nyutgiven bok av Bengt Sandblad mfl.

Boken som Bengt Sandblad från HTO-gruppen har varit med och skrivit finns nu att köpa! Du kan besälla boken tex här. 

 

Vad är en god digital arbetsmiljö? Hur går man till väga för att skapa en sådan? Trots att det i dag finns mycket kunskap om detta, ser vi fortfarande it-projekt som havererar och missnöjda användare. Det är uppenbarligen svårt att lyckas i praktiken. Teorier måste omsättas i praktisk handling.

När användningen och betydelsen av de digitala stödsystemen i arbets­­livet ökar handlar det i allt större utsträckning om en digital arbetsmiljö. Om alla ska kunna utföra sina arbetsuppgifter på ett effektivt och säkert ?sätt, med hög kvalitet och utan onödiga belastningar, måste man ställa höga krav på de digitala systemens utformning och införande. Erfarenheterna i dag är tudelade: dels bidrar it-systemen till förnyelse ?och verksamhetsnytta, dels uppvisar de alltför ofta stora brister vilket medför påtagliga arbetsmiljöproblem. Många användare är frustrerade över att deras it-verktyg inte stödjer dem eller fungerar som de borde.?

Den här boken ger en grundläggande beskrivning av kunskapsläget om digitalisering och digitala arbetsmiljöproblem, samt en omfattande vägledning i hur man kan utnyttja digitaliseringens möjligheter och samtidigt försäkra sig om en god och hållbar digital arbetsmiljö.

Presentation by Åsa Cajander and Jonas Moll at Medical Informatics Europe

During the first day of the Medical Informatics Europe (MIE) Conference Åsa Cajander and I presented the paper that was introduced in this blog post. Actually, this was the first presentation held by representatives from the HTO group during this year’s combined MIE/Vitalis event, but certainly not the last – we were active on stage, or as workshop leaders, during each and every day!

This particular presentation was based on a study that was conducted within the scope of a master’s thesis project at Uppsala University by Sara Englund and Anastasia Hansman. The project focused on the Swedish patient accessible electronic health record system Journalen (and hence was tightly connected to the DOME consortium) and more specifically on how nurses see that Journalen has affected their work environment and their communication with patients.

The result of the semi-structured interviews conducted with the nurses at a primary care center in Region Uppsala, first of all showed similar as our earlier interviews with physicians – Journalen has changed the interaction with patients, created an increased workload and created uncertainty regarding when to inform patients of results now that the patients can read even unsigned notes. Even though most of the results were in line with results from our earlier research in DOME, one new theme arose from the interview analysis – the need for new knowledge. Several nurses indicated that education was needed, focusing on how Journalen should be used both by patients and in the clinician-patient relationship. This is an important result, which should be taken very seriously.

All conference papers are published open access, so you can find all research presented at MIE here. You can find the paper that Åsa and I presented here.

Stay tuned for more posts about the HTO activities at MIE/Vitalis 2018! 🙂

Cognition in the Wild – Halfway PhD Seminar by Rebecca Andreasson

Rebecca Andreasson from the Department of Information Technology, Uppsala University, held her halfway seminar this week. She did an excellent presentation and many from the HTO group were there and listened to the presentation and discussion with Professor Henrik Artman from KTH. Rebecca started off her presentation with a description of what her papers included in her thesis have in common. The questions that she is addressing in her work are:

  • How do humans accomplish daily work activities in complex work environments?
    • How do we use tools and artefacts in practice?
    • How do we coordinate internal (memory, attention etc.) and external structures (tools, computers etc.) to accomplish a task?
  • How can workers be supported in their execution of tasks? 

Rebecca’s work is based on the theoretical framework of Distributed Cognition (DCog), introduced by Ed Hutchins, which emphasizes that thinking/cognition does not take place in isolation, but is the result of the interactions between the human, and his/her social, physical and cultural environment. All elements of the cognitive system are considered equally important.

Rebecca identifies four of her (numerous) publications as the foundation for her continuing work towards a PhD. :

  1. A study on interruption handling at an assembly line in a manufacturing company:
    Andreasson, R., Lindblom, J., & Thorvald, P. (2017). Interruptions in the wild: Portraying the handling of interruptions in manufacturing from a distributed cognition lens. Cognition, Technology & Work, 19(1), 85-108.
  2. A study on collaboration and tool use in dock assembly:
    Andreasson, R., Lindblom, J., & Thorvald, P. (2017). Tool use and collaborative work of dock assembly in practice. Special Issue in Production and Manufacturing Research, 5(1), 164-190.
  3. A study on the need for a system perspective in railway HF:
    Andreasson, R., Jansson, A. A., & Lindblom, J. (accepted for publication). Past and future challenges for railway research and the role of a systems perspective. To be published in Proceedings of the 20th Congress of the International Ergonomics Association. August 26-30, Florence, Italy.
  4. A study on coordinating activities in operational railway traffic:
    Andreasson, R., Jansson, A. A., & Lindblom, J. (under review). The coordination between train traffic controllers and train drivers: a distributed cognition perspective on railway. Cognition, Technology & Work.

Rebecca’s overall aim, in her own words, is to: enhance the understanding of the distributed work practices of cognitive cooperative work and to explore the interaction between human beings, tools, and technology in complex work settings where the theoretical framework of DCog has previously not been applied in depth.

Her contribution to the field, thus far, is the ethnographically founded descriptions of real work practices in real work situations and the application of DCog to new domains of complex work. This includes creating new concepts as well as complementing on existing concepts. She introduces DCog to the theoretical “toolbox” of Human Factors and Ergonomics (HF&E) research.

Her ideas for the future are:

  • To investigate how the results of a DCog analysis could be used to (re)design a socio-technical system through workshops and/or vision seminars with examples from real situations (based on the DCog analysis made).
  • To provide a structured “how-to” method for DCog users through analysis of comparison of current DCog methods (e.g. by analysing the same empirical material with the use of multiple DCog methods) and iteratively developing and validating a new (or modified) method. A final validation could potentially be done with students or practitioners in a HF&E domain.

With this account of her research and progress so far, Rebecca finished her presentation and the seminar continued with a critical discussion by invited guest Henrik Artman from KTH. Overall, Henrik was quite impressed and opened the discussion by relating that in his experience Rebecca is already way ahead of the halfway mark for her PhD. He then guided the discussion into the details of the foundation Rebecca has laid and suggestions on  how to strengthen it in Rebecca’s final sprint towards her PhD.

With such an impressive start, we certainly look forward to seeing what Rebecca will have achieved and contributed with to the field when it is time for her dissertation a few years from now!