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

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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 medical practice (AKA 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 EMR workflow systems. Specialty-specific EMR workflow systems combine specialty-specific screen and screenless components into modules and perform (“enact” in workflow automation terminology) specialty-specific workflows for medical specialists, 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 medical specialty workflow to save medical specialists 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 specialty 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 medical specialty 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, specialty workflow in ambulatory settings.


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

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  1. steve
    Posted June 9, 2010 at 12:15 pm | Permalink

    have you seen any graphs or charts showing the forecasted growth rates for context aware computing, or location based services?



  2. chuckwebster
    Posted June 9, 2010 at 5:28 pm | Permalink

    Hi Steve,

    No I haven’t, but then again I hadn’t looked. So I just spent 15 minutes searching. Found lots of graphs of growth in mobile devices and data traffic, but nothing specifically about location-based *or* context-aware. The best I could come up with was this account of a pricey 2010 report: $12.7 billion in revenues for location-based services by 2014. I’ll bet the several thousand British pound referenced Juniper Research report has some nice graphs in it!

    That said, location-based services are just one sixth of context awareness. It’s just the Where in the Who, What, Where, When, What, Why, and How questions a context-aware application needs to ask-answer-act in order to behave in a contextually usable way.



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