©2003 Sowerby Centre for Health Informatics at Newcastle The PC, the Patient and the Practitioner Paul Robinson Informatics seminar 12-14. 11. 3

©2003 Sowerby Centre for Health Informatics at Newcastle

The PC, the Patient and the Practitioner

Paul RobinsonInformatics seminar

12-14. 11. 3


What am I doing here??


What am I doing here?

• Presentation• Talking about the iiCR project• Thinking about perception, attention and

consciousness • Looking at the background to computer use

at the point of care

• Teaching the skill set• Communication skills


What effect have computers had?

• Information superhighway

• Convergence of older technologies• Printing press• Telegraph• Typewriter• Radio/ TV


Context

(At the point of care…..)

COMPUTERS CHANGE

EVERYTHING


Computers change everything

• Records

• Knowledge flows

• The medium


Records

• Paper: Filing cabinet

• EHR: Broadcast/ publishing


Knowledge flows (old)

Expert-client: traditional. The expert dispenses knowledge that has been acquired elsewhere

Expert Client

Initial

training

cpd

colleagues


Knowledge flows (new)

Expert-client: triadic. The same information source is potentially available to expert and client at the same time. The question is how much of this can the client make use of.

Expert Client

?


The medium

Computer screens are more engaging than sheets of paper.

Interactive programmes are seductive of attention.

Working with a computer is active, not passive


Neural Monism

• “Mind stuff” and “physical stuff” are the same stuff

• Mind emerges from the network• Brain• Body • Social

• This takes time (.03 to .05 second)


• Most human behaviour is automated

• This includes the consultation


Research and Development

Information in the consulting room(iiCR)


iiCR team

Nick BoothJudy KohannejadPaul Robinson

(PRODIGY evaluation team)(Durham and Darlington EHR project

team)


iiCR: aims

1. Identify the skills that help the GP to maintain rapport with patient and use the computer during the consultation.

2. Develop and pilot a teaching package that supports the training of GPs and the development of these skills.

(Calgary-Cambridge Guide)


Research Questions

• Can these skills be identified?

• What are they?

• Can they be taught?

• Can people divide their attention?


iiCR: phases of the project

• Phase 1: video-tapes of GP consultations (grounded theory)

• Phase 2: simulated patient consultations with immediate facilitated review of tape (IPR, Calgary Cambridge)

• Phase 3: iterative development of teaching package (action research)


iiCR Phase 1: sample

• GP Trainers (purposive sample)

• Self selected

• Familiar with using computer in the consultation


iiCR Phase 1: method

• GPs taped a surgery • Looked at all consultations on tape• One or two consultations selected

and transcribed by JK (CA transcription)

• 2 columns (Dr – Pt interaction: interpretation) added to transcript (PJR)


iiCR phase 1: what we saw

• A lot of use of paper!

• Most GPs do the minimum of typing/ data entry while the patient is present


3 types of behaviour:• Controlling (the flow of

consultation)

• Responsive/ Opportunistic

• Ignoring




3 strategies:

• Signpost

• Blather

• Respond (every time)



Variation in sharing of:

• Screen

• Knowledge sources


iiCR (phase 1): what we saw

Failures to respond to speech-act•When in prescribing or template filling modes

•Were they deliberate??


Multi-tasking

• Can GPs do it?

• Can researchers do it?


iiCR Phase 2: method

• GP’s own surgery• Trained simulator, loosely defined

scenario: demands computer use• Video of consultation and video

feed from screen• Immediate facilitated review of

tapes


iiCR phase 2: consultation 2

Patient has asthma, inhaler use increasing: (is anxious and has started smoking again)

Computer glitch was major distraction to GP

In discussion:GP’s skillsInterpretation issueUndivided attention (on the screen) for 105 seconds


iiCR Phase 2: findings

F my impression is that you explained very well what you were doing. (to Patient) did you understand what he was doing?

P Yes from my point of view, computers are

part of the culture: F so did you know what he doing? P I just guessed that he was like writing

things down.



F It looks to me Alison like you were looking at the computer when you came in

P It’s like I said before when someone else is

focussed on something you are drawn to it. F if I was just looking at this tape, I’d think that

you were reading the screen P no



F now what I’ve seen in the last 10-15 seconds is Alison, moving around in her seat, looking up, looking away: did any of that impinge on you?

D No D No she was off limits, completely off



P It’s difficult to say with all the distractions going on. You were distracted for quite a long time. So it’s difficult to say.

D the chunk… was long, much longer

than I thought it was. … it just goes to show how you can lose track of time when you are busy with something else.


iiCR: phases of the project

• Phase 1: video-tapes of GP consultations (grounded theory)

• Phase 2: simulated patient consultations with immediate facilitated review of tape (IPR, Calgary Cambridge)

• Phase 3: iterative development of teaching package (action research)


Competencies: Rapport• Adapts behaviour to take into account relative

position of doctor, patient and computer• Maintains open posture when using computer• Uses verbal and non-verbal behaviour to indicate

when attention is being paid to the computer screen

• Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctor’s attention is on the computer

• Responds to patient cues when attending to the computer


Competencies: Involving the Patient

• Explains to patient why computer is being used

• If the computer is to be used as an information source, negotiates the use of such information with the patient

• Lets the patient read information from the screen when appropriate


Competencies: Explanation and planning

If using screen-based information (shared screen, PIL etc)

• Checks that patient can see the screen clearly

• Remains quiet, and gives the patient time to read the text

• Checks that patient has understood the text• Gives patient opportunity to ask questions• On a busy screen indicates (points etc)

relevant information


Phase 3: the training package

• Iterative development• Used with over 200 GPs, community

nurses and pharmacists• Workshop style

• Role plays, scenario consultations• Works best in facilitated small groups• Can be adapted to larger numbers


Phase 3: the training package

More details available on:http://www.schin.ncl.ac.uk/iiCR/

(final report tab)Or from [email protected]

Documents

©2003 Sowerby Centre for Health Informatics at Newcastle The PC, the Patient and the Practitioner Paul Robinson Informatics seminar 12-14. 11. 3