Contextual Usability, My Apple iPad, and Process-Aware Clinical Groupware for Pediatric Practice

Short Link: http://j.mp/dbhBvw

Apple started selling iPads today. I bought one. I published this post from it.

There’s an important relationship between

• iPad-like form factors, task-at-a-time workflow, and contextual usability in mobile settings on one hand and
• process-aware clinical groupware for pediatric practice (AKA pediatric EMR workflow systems) on the other hand.

I’ll use as a springboard Todd Biske’s Context Aware Computing and the iPad (please read the original!) in which he writes (though I’ve replaced “meeting room” with “exam room”, “meeting” with “patient encounter”, and “subject of the meeting” with “type of patient encounter”):

“Now, we have the potential for device with a larger form factor that can present a touch-based interface, completely tailored to the task at hand…Imagine going into an [exam] room where your iPad is able to determine your [exam] room…where it knows what [patient encounter] you’re in and who else is in the room…it knows the [type of patient encounter], and can now present you with a purpose-driven interface for that particular [patient encounter]…How many times have you been in a [patient encounter] only to wind up wasting time navigating around through your files…trying to find the right information. What if you had an app that organized it all and through context awareness, presented what you needed?…As we have more use of BPM [business process management] and Workflow technologies, it is certainly possible that context awareness through location, time, presence of others, and more can allow more appropriate and efficient interfaces for task display and execution, in addition to providing context back into the system to aid in continuous improvement.” (my emphasis)

Compare Todd Biske’s account of contextual awareness with a quote from my own 2005 HIMSS proceedings paper about EHR workflow management systems. EHR workflow management systems use specialty-specific process definitions to create specialty-specific clinical groupware, such as pediatric EMR workflow systems. Pediatric EMR workflow systems combine pediatric-specific screen and screenless components into modules and perform (“enact” in workflow automation terminology) pediatric workflows for pediatricians, staff, and patients:

“The process definition saves the user from having to navigate manually through a thicket of menus, tabs, or popup lists; the EHR presents the correct screen given the context of the user’s tasks. If an EHR can be instructed (that is, customized) in what to do—automatically—based on who, what, why, when, where, and how, the EHR is not just a patient documentation system, it is an EHR workflow management system….Process definitions are used by the workflow engine in a similar way to rules being used by an expert system. The workflow engine reasons about who, what, why, when, where, and how in order to save the user work. Who is the user? (Dr. Jones or Dr. Smith?) What is their role in the office? (Physician, nurse, technician?) Why is the patient here? (Well child? Chronic disease management?) When is ‘now’, relative to what has been accomplished and what remains? Where is the user? (Exam room? Tech station?) How does this specialty accomplish its tasks? Each step in the process definition corresponds to a specialized data presentation, acquisition, or transformation task. The process definition describes the event that triggers the presentation of the screen as well as a context that informs its content and behavior. For example, the Review of Systems screen allows the nurse to do just that, review the patient’s systems. It is triggered by the completion of the preceding screen (or by the nurse logging into the EHR in the exam room in the presence of the patient after all the preceding tasks in the process definition have been accomplished).” (my emphasis)

Todd Biske writes about business meetings and I pediatric ambulatory encounters, but we address the same thing: contextual usability. In conversation (though this is the first time I’ve blogged about it) I often refer to what I call my journalism theory of usability. Journalism is all about context. To achieve contextual usability clinical groupware needs to ask itself the same questions journalists ask themselves to write compelling and useful news reports—who, what, why, when, where, and how? Automated answers to these questions drive context-aware automatic behaviors, such as offering the right screen at the right time and place or accomplishing useful tasks in the background without need for human intervention.

Biske also refers to “providing context back into the system to aid in continuous improvement.” This is business process management’s (BPM) “process optimization process.” Process-aware clinical groupware is more systematically improvable using business process management techniques than EMR/EHR/clinical groupware without process models (which is most). From a recent post intended to be something of a manifesto:

“The only practical means by which [systematic improvement] will be achieved will be if modular EMR/EHR/clinical groupware systems also include within their very technological nature the ability to systematically change internal processes and workflows to better meet set objectives while working in typical environments.” (Usable Clinical Groupware Requires Modular Components and Business Process Management)

A workflow engine executing process definitions (an “executable process model”) makes it possible for clinical groupware to automatically present the right screen, data or order entry options, and presentation format at the right time and place in pediatric workflow to save pediatricians time and concern. The workflow engine automatically does the right thing at the right time and place because it consults a process model, that is, the set of process definitions that model pediatric workflow and processes for a particular pediatric office. The executable process model makes clinical groupware both context aware *and* flexibly so (that is, editable by users, without the special technical knowledge of a computer programmer).

If a pediatric task languishes beyond customizable parameters (such as duration), it automatically escalates to the attention of a care coordinator or physician. The “severity” of the escalation (such as passive visual cue versus pop-up alert that requires dismissal versus flashing red lights and a siren) and to whom (user versus supervisor versus emergency response team) are also part of the executable process model. Tasks are escalated in a manner that is contextually appropriate because the process model represents actionable knowledge about escalation context and is under control of clinical staff who understand this context.

So, all hail process-aware/context-aware, EMR/EHR/clinical groupware! And especially for fast paced, but frequently interrupted, pediatric workflow in pediatric ambulatory settings.

Reference

Contextual Usability: Rigour meets relevance when usability goes mobile, Lindroth & Nilsson, 2001.

P.S. A long quasi-personal note: The Apple iPad is programmed in Objective-C, which was developed by Brad Cox, a graduate (Ph.D. Mathematical Biology) of my alma mater, the University of Chicago. For C# programmers there’s MonoTouch, which still requires a Mac to deploy to the iPad. I encountered object-oriented languages such as SmallTalk (Objective-C combines features of the C and SmallTalk programming languages) while a graduate student in Industrial Engineering at the University of Illinois and then medical student at the University of Chicago (through an elective course in the Department of Mathematics). I was interested in simulating biological systems embedded in simulated social systems. Techniques for doing so have potential for simulating (and understanding) changes in patient clinical state within simulated (and understood) socio-technical systems for improving patient clinical state. Sounds theoretical, right? However, there are potential practical applications of this approach for systematically improving clinical outcomes, patient satisfaction, and practice productivity. The key is to take a complete systems engineering view of the pediatric medical home. As an industrial engineer, I was already familiar with the use of FORTRAN for discrete-event modeling and simulation of patient flow through medical offices, emergency rooms, and hospitals. One such project at the university health clinic paid my tuition and stipend for one year during graduate school. Object-oriented programming languages are a natural for simulating complex systems (the EncounterPRO Pediatric EMR Workflow System uses object-oriented technology to achieve its highly componentized and modular platform architecture). I later considered use of Objective-C for simulating patient flows in a medical office combined with a Markov model of evolution of patient clinical state (a now standard technique). Every interesting idea does seem connected to every other interesting idea, in a six-degrees of separation sort of way. Objective-C influenced design of the Java programming language for which I eventually certified as a programmer. I recently developed some simulations of pediatric patients flowing through pediatric clinics (based on actual, though deidentified, data using workflow/process mining techniques, I’ll blog about it soon). Wouldn’t it be cool to run it on the iPad? The point being to give a pediatrician or primary care physician a tool to understand and improve patient flow through their office. (Warning! flight of fantasy ahead!) And then climb in a time machine to go back and hand it to my past-self! Of course, I don’t remember anyone materializing in front of me with an iPad, so the time machine part probably won’t happen—fun to think about though! Regardless, the iPad’s form factor, task-at-a-time workflow, and contextual usability make it a great user interface for the process-aware clinical groupware I advocate, for busy pediatricians or any high-volume, low-margin ambulatory specialty. By the way, we also have Brad Cox and Objective-C to thank for paving the way to modular component-based clinical groupware.

From the Wiki entry about component-based software engineering (IC = Integrated Circuit, such as the memory sticks you click into PC and laptop slots to add memory):

Brad Cox of Stepstone largely defined the modern concept of a software component. He called them Software ICs and set out to create an infrastructure and market for these components by inventing the Objective-C programming language.

P.S.S. Follow me on Twitter @chuckwebster.