Seminar with Lina Nilsson on “Social Challenges when Implementing eHealth in Healthcare – Organisational Experiences from Research and Development Projects”

Lina Nilsson’s does research on implementation of eHealth. She is a senior lecturer at the Linneaus University and works in health informatics. She has a background in sociology with leadership and management.

Lina did her PhD project in Applied Health Technology (up until 2014), on using IT to improve communication between patients and healthcare staff. In her thesis, she identified social challenges when implementing Information systems in a Swedish healthcare organization: power, alienation, professional identity and encounters are aspects that may influence the implementation process.

Today, she is engaged in education but also research and development projects with focus on eHealth at Linnæus University.  

During her talk she discussed the professional identity of being a good nurse that is not the same thing as being good at IT systems. That working with IT was not seen as a part of the core professional nursing profession, and that previous bad experiences of implementations affect future ones.

Suspicions based on previous experiences of implementations, attitudes along the lines of “it didn’t go that well last time, why should we trust this one to be any better?” are challenging for an implementation project in health care. eHealth can provide tools that are appreciated by health care professionals, but also affect their work in ways that they do not. For example by affecting traditional power structures between professions.

Today Lina Nilsson has focused her research on nursing. One thing that she has found is that ICT implementations solve certain problems related to work, but that it also introduces new problems. She is also working in a project, ePATH, directed at supporting patients and empowering patients in care at home. In another project, she is involved in researching how small and medium sized enterprises can compete more fairly with larger actors on the market for providing HIT to health care organisations.

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.

A social event in celebration of our new financial system

At Uppsala University, the administrative system Raindance has been updated to a new version. The HTO-group is doing collaborative work in relation to this project (the EASY project). Last Thursday afternoon, the project celebrated that the implementation phase in now complete, by inviting the users to a network meeting. Approximately 100 users came to the meeting. From the HTO-group, Gunilla and Thomas went.

The afternoon started with information regarding the process as a whole: from the procurement phase until today. Edrun Eriksson (Head of the Ledger Office unit at the Financial Administration and Procurement Division) reminded the users of what expectations and hopes they had forwarded themselves, early on in the process. She gave us some illustrative examples. Furthermore, she had made a printout of the complete list, which was put up on the wall, so that all participants could read them later on during the afternoon. She also presented a summary of all sub groups and sub projects that have been active in the process. They were quite many! For meetings, she had just marked the amount with a question mark – being a bit over conscious regarding the great number of hours put into the project!

Edrun also took the opportunity to express a big “Thank you!” to all the people that have contributed with energy, experience, and time! It is nice for everyone to be reminded about the great effort that has been put into the project, and to hear of everything that is already achieved. Furthermore, the audience was asked a couple of questions with the aid of Menti.com and participants’ cell phones. The first question was “In what area are you presently in biggest need of support?” By choosing from given alternatives, the answers showed up in a pie chart. The other question was regarding ideas for future improvements, which was a free text question; so that the participants could write whatever answers they wanted.

The presentation then continued with a section where we (Gunilla and Thomas) got the chance to present ourselves to the audience. We, of course, have not met so many of all the users previously. We talked in general about IT artifacts, and of how people in an organization often experience them at times of changes. IT artifacts holds not only the technological dimension, but also a social dimension. It is OK to feel lost sometimes, and one needs to hear someone tell you this. 🙂 We ended our section by talking more specifically about the survey we are preparing to distribute to the users. The purpose of the survey is to evaluate some issues that can – hopefully! – be described as successes, and to point out some specific areas where users would like to see further improvements.

After us, we all got some information regarding the closing of the year 2018, presented by Hanna Mörtberg (newly appointed University Director of Finance at the University Management and Management Council). She showed us some comparative numbers from the years 2010 until today. The university is growing at an amazing speed and has now reached over a 7 billion turnaround!

Spirits were quite high when the presentations were over and we started on some nice snacks with a glass of bubbling refreshments. Anyone had the opportunity to write down whatever ideas they wanted to share about the project, on a writing wall that was positioned at the back of the room. Still, I believe people mostly wanted to chat with friends, have some good food, and just relax after a great job done! Overall, the afternoon was a well-spent time to mark the end of the implementation phase. Now, the system will continue to change over time, as any IT system would. It is a never-ending story.

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

 

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!

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)

Vad kan vi lära av Ladok?

Nya Ladok har nu införts på Lunds universitet. Med denna milstolpe avslutas projektet.  (Grattis till alla inblandade!) Arbetet tar inte slut utan övergår istället i en utvecklingsfas, som hanterar fortsatt utveckling och driftsättning. 

Vi har följt förberedelserna för det lokala införandet vid Uppsala universitet. Under våren 2018 kommer jag att vidga perspektivet för att försöka se vilka lärdomar som kan dras. Min förhoppning är att jag ska hinna intervjua både en del av dem som arbetat i projektet och en del av dem som arbetar med lokala införanden.

Det kan finnas anledning att understryka att jag inte gör någon utvärdering av projektet utan att det handlar om just att fånga upp goda och mindre goda erfarenheter. Det är onekligen ett intressant projekt, när ett så komplext system rullas ut till så många verksamheter. Det faktum att förutsättningarna varierar så mycket gör inte heller att det går att tala om rätt eller fel. Däremot är det väldigt intressant att förstå olika vägval och strategier, både i projektet och i de lokala införandena.

Att lärosätena befinner sig i olika faser ger också en ögonblicksbild av utmaningar i olika skeenden av ett införande.

Den första intervjun ägde rum idag och om allt vill sig väl följs den snart av fler. Alla kommer jag inte att hinna intervjua, inte ens alla projektledare. Därför ska jag komplettera intervjuerna med en mindre enkät eller rundfråga. Men – finns det mer att berätta om arbetet med nya Ladok än vad som ryms i enkäten får du förstås gärna kontakta mig.

Automated Bots – the Mission of Creating Filter Bubbles

Are you aware of that even the smallest actions you do and the likes you give online, can put you into a filter bubble? In our investigation of filter bubbles we use automated bots as our own test subjects. If you don’t know what a filter bubble is, read our first blog post to find out more (https://www.htogroup.org/2018/02/13/what-is-a-filter-bubble/). This Wednesday, 14th of March, we are speaking at the Women in Data Science conference in Stockholm about our work.

For the mission of creating filter bubbles we are using a large social media platform as our tool. A user of this platform has access to a flow of information. This flow is individualized for each user based on its actions and behavior on the platform. We are creating 14 unique accounts on this site, extremely similar to one another, with the exception of username, email and IP address. The purpose is to have the individualized flows exactly alike in the beginning. For each of the 14 accounts, we are creating a bot (total of 14 bots). A bot is an automated software, designed to click and use the website just like a human would. In this case, each bot is hitting a like-button for a certain type of information, a certain amount of times per day. This is simulating a real user’s actions on the site. The information that is liked by the bot, is uploaded to a storage on the cloud, that we are using to investigate the behavior, potentially leading up to a filter bubble.

In order to get the data from the individualized flow, we use a crawler. The crawler go through the individualized flow and save the important parts to a file which is then uploaded to the cloud. The data is later used to evaluate the content of the flow to establish whether the user is put in a filter bubble or not. To get a deeper understanding of filter bubbles and whether they can be harmful, we conduct a literature study as well.

Our names are Anna Normark and Rebecca Oskarsson. We are two master students in the IT engineering programme, currently working on our master thesis. Our thesis consists of investigating filter bubbles and their effects, and have the title “Individualizing Without Excluding: Ethical And Technical Challenges”. We are invited to write some blog posts here by our reviewer Åsa Cajander and this is our second part.

Can Digital Forms with Contextual Instructions Improve Medical Certificates for Sick Leave? – A Master Thesis Study

To get paid sick leave in Sweden, one must obtain a medical certificate from a physician and get it approved by the Social Insurance Office (Försäkringskassan). A recent report showcase that 9,7 % of all medical certificate forms are sent back to the issuing physician by Försäkringskassan (2017), needing completion or re-phrasing of the filled in data. The biggest culprit in the form is the field where one should describe how the patient’s condition hinders them from working.

In collaboration with EPJ, Region Uppsala and the company Inera, I will in my master thesis evaluate if a digital version of the form can help mitigate the frequent rejection of forms (due to phrasing). With a number of different prototypes, we will try to uncover if contextual instruction to each form field can help physicians fill in the form in a way that better corresponds with Försäkringskassans expectations.

The project has a great potential not only to ease the burden of an already strained health care system (and their patients), but also in regards of understanding physicians’ needs when it comes to IT. In the best of worlds, the results can help us design better health care systems and ensure a sound health care. It is truly exciting to work on projects that has the potential to impact many patients’ life quality, where an early approved medical certificate can mean the world to many.

Author background

Anton Björsell, Uppsala University. The study is my master thesis project within HCI and is planned to be executed throughout February to May this year. Except my focus on HCI, I also hold a bachelor’s degree in Media and Communication Studies. My favourite kind of research is the one which makes an honest attempt to understand humans and their needs. I am very excited about the project and grateful for having the opportunity to work with a topic that concerns so many people.

A Seminar (in Swedish) on the Implementation of IT in Healthcare

Back in December I was invited to give a seminar in Swedish at the EPJ department of Region Uppsala, the department in charge of many of the health-related IT systems used at the hospitals and primary care facilities in the region. My seminar was on the the current state of research in relation to how to implement IT in healthcare. Out of all the perspectives one can use to approach this area of challenges for healthcare, I devoted most of the seminar to presenting barriers and enablers to change management projects as well as IT development projects, and discussing these with the participants. The seminar was recorded and is now available on YouTube, if you find the topic interesting (and are comfortable with the Swedish language).

The HTO group, and more generally the HCI group at the Department of Information Technology, Uppsala University, have an ongoing collaboration with the EPJ department at the region, and there will be more seminars on a variety of topics given by us during the spring.