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.

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


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.

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.

Final Seminar Related to PhD Thesis about Inertia and Deployment of IT systems

Thomas Lind will defend his PhD thesis the 15th of September 2017. This week we had a seminar where the work was discussed with an external reviewer, José Abdelnur Nocera.

José Abdelnour Nocera and Thomas Lind

The thesis is about the deployment of IT systems. Thomas Lind’s PhD thesis has several contributions:

  1. The development of a theory for understanding deployment: Inertia.
  2. Deeper understanding of deployment of IT from a sociotechnical perspective.
  3. The evaluation of the method “Vision seminars” as a method to use when deploying IT systems.

During the seminar Thomas Lind first presented his work, and this was followed by a discussion with José Abdelnour Nocera. The discussion concerned both the six papers that are included in the thesis as well as the introductory text for the papers.

In the evening we had a nice dinner at Basilico.

The HTO group thanks José Abdelnour Nocera for a very valuable discussion. Now we are looking forward to the final defense of the PhD thesis. 🙂

La la Ladok

Our research group has a long tradition of doing action research. Action
Research has been defined as having dual aims, research as well as involvement. The latter implies things happening, action, change–a bit like agile development if you wish. At the same time, this is relative to scale. In a small project, things are happening fast and various actions by practitioner and researcher alike have direct consequences. In large projects, this is not always so. In retrospect it will be easier to see the change and trace a trajectory. In real time, especially in the periphery of a large project, it can be hard to experience any action.

One of ongoing action research projects we are following the local preparations for a major new system implementation. Deadlines have been pushed forward on numerous occasions–by years.

The system in question is the nationwide Swedish Student Information System (SIS) – better known by the name Ladok. The system holds all student records for students in Swedish higher education and is critical from a legal perspective but it is also the backbone for most other student related ICT as it is used to generate directory information that is used by learning management systems (LMS), campus cards etc. The system is long overdue for an upgrade and a completely new version is just in its early phase of implementation. This is a 50 million Euro project with an estimated user base of 400 000 students and 50 000 staff in higher education.

We have been following the local preparations at one university, rather than the development as such. The collaboration has included activities such as:

  • coaching,
  • seminars,
  • participation in information efforts and
  • surveys.

The major effort though, were the vision seminars that were conducted with students and staff (users that is) in order to establish high level goals. Thus, our focus has been on local preparations for a huge change in work processes that the new system will require.

While the constraints and uncertainties can be at times frustrating this is also the reality behind many large system implementations. In the next few posts we will further discuss some of our experiences from the project – so far.