Decisional Architectures
June 19, 2013
Bradford W. Hesse
Tuesday, October 29, 2013
Two Cases
Tuesday, October 29, 2013
Two CasesNo Insurance -- ER Presentation• Woman (Edna) presents with detached
breast. Explains that she has known about problem for nine years. Cancer is advanced; now fatal. Death would have been avoidable with preemptive care.
Tuesday, October 29, 2013
Two CasesNo Insurance -- ER Presentation• Woman (Edna) presents with detached
breast. Explains that she has known about problem for nine years. Cancer is advanced; now fatal. Death would have been avoidable with preemptive care.
Private Insurance -- Cadillac Care• Woman (Helen), age 50, detects a lump
in breast and is sent for a mammogram with follow-up needle biopsy. Tumor at 4 centimeters, estrogen- and progesterone-receptor negative diagnosed at Stage II. Private oncologist prescribes aggressive treatment with prolonged hospital stays, complications, nosocomial infections, depletion of insurance and eventually death.
Tuesday, October 29, 2013
Symptom Checklist Preventable medical error:✦ accounts for 48,000 to 98,000 deaths per year
(1999 IOM esAmate)✦ results in $17.1 billion in extraneous costs per
year (Health Aff. Apr 2011;30(4):596-‐603).✦ most errors occur from communicaAon
breakdowns (Mazor et al, 2012)
4
Tuesday, October 29, 2013
Symptom Checklist Preventable medical error:✦ accounts for 48,000 to 98,000 deaths per year
(1999 IOM esAmate)✦ results in $17.1 billion in extraneous costs per
year (Health Aff. Apr 2011;30(4):596-‐603).✦ most errors occur from communicaAon
breakdowns (Mazor et al, 2012)
Public health awareness system:✦ Lack of adherence to public health
recommendaAons (smoking cessaAon, diet, exercise, adherence to screening recommendaAons) doubles mortality rates
✦ Lack of “medical home” for preempAve support leads to paAent confusion, fragmented care, personal de-‐acAvaAon, and debilitaAng outcomes.
5
Tuesday, October 29, 2013
Symptom Checklist Preventable medical error:✦ accounts for 48,000 to 98,000 deaths per year
(1999 IOM esAmate)✦ results in $17.1 billion in extraneous costs per
year (Health Aff. Apr 2011;30(4):596-‐603).✦ most errors occur from communicaAon
breakdowns (Mazor et al, 2012)
Public health awareness system:✦ Lack of adherence to public health
recommendaAons (smoking cessaAon, diet, exercise, adherence to screening recommendaAons) doubles mortality rates
✦ Lack of “medical home” for preempAve support leads to paAent confusion, fragmented care, personal de-‐acAvaAon, and debilitaAng outcomes
Living with cancer✦ Failures to remain vigilant result in recurrence ✦ InaXenAon to sequelae from treatment reduces
quality of life, makes vulnerable to co-‐morbidity✦ Lack of coordinated care leaves paAent feeling
“lost in transiAon,” abandoned, alone, and prone to post-‐traumaAc symptoms. 6
Tuesday, October 29, 2013
Institute of Medicine’s “Crossing the Quality Chasm” Report
Tuesday, October 29, 2013
*Norman, D. A. (1988). The psychology of everyday things. New York: BasicBooks.
Knowledge in the Head*
Knowledge in The World*
The Psychology of System Design
Tuesday, October 29, 2013
What happens with bad design?
Tuesday, October 29, 2013
What happens with bad design?
Tuesday, October 29, 2013
Attention to Decision Architectures Has Become Essential in I.T. Enabled Business
“UX” = (User Interface)
Tuesday, October 29, 2013
Successful Architecture in Business
Browsing to encourage familiarity
Relational cues to promote trust
Tracking for transparency, accountability
Ease of use makes desired behavior easy
Multiple delivery options for personalized service
Participatory options encourage engagement
Tuesday, October 29, 2013
But what about medicine?
Tuesday, October 29, 2013
Many Computer Systems in Medicine Follow Anachronistic Assumptions
Wrong Question:
X What can the computer do?
X How do we automate cognition?
X What is the transactional gain?
X How do we get users to conform?
Better Questions:
✓ What can humans do?
✓ How do we augment cognition?
✓ What is the relational gain?
✓ How do we optimizesociotechnical balance?
Source: Hesse BW, Shneiderman B. eHealth research from the user's perspective. Am J Prev Med 2007;32(5 Suppl):S97-103.
Tuesday, October 29, 2013
National Research Council Report Advocates for “Rebalancing Investments”
Computational Technology for Effective Health Care advocates re-balancing the portfolio of investments in health care IT
• Greater cognitive support for physicians, patients, and caregivers
• Observing user-centered design principles
• Accelerating research related to health care in the computer and social sciences and in health/biomedical informatics
January 2009
Tuesday, October 29, 2013
“What we thought about EHRs was wrong; benefit came from restructuring care.”
Edward H. Wagner, M.D., M.P.H., F.A.C.P.
Source: InformaAcs for Consumer Health Summit, November 5-‐6, Potomac, MD.
Tuesday, October 29, 2013
But progress in behavioral support still lags -- leading to physician outcry.
Tuesday, October 29, 2013
The Case of Hugo
Progress for patient support lags even further, leading to vocal dissatisfaction.
Tuesday, October 29, 2013
The Case of Hugo
Progress for patient support lags even further, leading to vocal dissatisfaction.
Tuesday, October 29, 2013
The Case of Hugo
Progress for patient support lags even further, leading to vocal dissatisfaction.
Tuesday, October 29, 2013
Eric Topol, a cardiologist who directs the Scripps Translational Science Institute in San Diego, says apps that monitor blood pressure or glucose rates can be more valuable than prescriptions to keep these conditions in check.
"When we use a medication, we don't know if it's going to work or not. It's much better when a person's taking their blood pressure on a frequent basis," says Topol.
"The average person looks at their smartphone 150 times a day, so all of a sudden they're able to diagnose if their blood pressure's adequately controlled and what are the circumstances when it's not."
Tuesday, October 29, 2013
Source: Hesse BW, Hansen D, Finholt T, Munson S, Kellogg W, Thomas JC. Social Participation in Health 2.0. IEEE Computer. 2010;43(11):45-52.
Creating a new “ecology” of decision support technologies.
Tuesday, October 29, 2013
How about cancer care?
Tuesday, October 29, 2013
Architectural Failures in Cancer Care
Zapka JG, Taplin SH, Solberg LI, Manos MM. A framework for improving the quality of cancer care: the case of breast and cervical cancer screening. Cancer Epidemiol Biomarkers Prev. 2003;12:4–13.
Zapka JG, Puleo E, Taplin SH, Goins KV, Yood MU, Mouchawar J, et al. Processes of care in cervical and breast cancer screening and follow-up--the importance of communication. Prev Med. 2004;39:81–90. [PubMed]
Tuesday, October 29, 2013
Oncology as information science: “The Learning Health Care System”
The ASCO Blueprint: November 2011
Tuesday, October 29, 2013
Hospital Based EHR Data
Hospital Based EHR Data
Health Information Exchange
MedicalTeam
Patient &
FamilyHospital System
DecisionSupportNeeds
Subjective• Chief complaint• Patient Reported Outcomes
• Risk modeling• Diagnostic support • Treatment selection • Guideline adherence• Error detection/correction
Medical Researcher
• Situational awareness• Population health• Continuity of care• Identify side effects• Inform discovery
Objective• Clinical measures• Laboratory findings • Sensor data
Assessment• Diagnosis• Categorical reporting• Prognosis
Plan• Treatment planning• Self-care planning• Post treatment• Surveillance
Tuesday, October 29, 2013
iNcentivesUnderstand mappingsDefaultGive feedbackExpect errorStructure decisions
iNcentives
Source: Thaler RH, Sunstein CR. Nudge : improving decisions about health, wealth, and happiness. Rev. and expanded ed. New York: Penguin Books; 2009.
Tuesday, October 29, 2013
Self Determination*
* E.g., Hesse BW. Enhancing Consumer Involvement in Health Care. In: Parker JC, Thornson E, editors. Health Communication in the New Media Landscape. New York, NY: Springer Publishing Company; 2008. p. 119-149.
iNcentives
• Autonomy• Mastery• Connectedness
Tuesday, October 29, 2013
Self Determination*
* E.g., Hesse BW. Enhancing Consumer Involvement in Health Care. In: Parker JC, Thornson E, editors. Health Communication in the New Media Landscape. New York, NY: Springer Publishing Company; 2008. p. 119-149.
iNcentives
• Autonomy• Mastery• Connectedness• Mastery
Tuesday, October 29, 2013
Self Determination*
* E.g., Hesse BW. Enhancing Consumer Involvement in Health Care. In: Parker JC, Thornson E, editors. Health Communication in the New Media Landscape. New York, NY: Springer Publishing Company; 2008. p. 119-149.
iNcentives
• Autonomy• Mastery• Connectedness
• Autonomy
Tuesday, October 29, 2013
Self Determination*
* E.g., Hesse BW. Enhancing Consumer Involvement in Health Care. In: Parker JC, Thornson E, editors. Health Communication in the New Media Landscape. New York, NY: Springer Publishing Company; 2008. p. 119-149.
iNcentives
• Autonomy• Mastery• Connectedness• Connectedness
Tuesday, October 29, 2013
Understand mappings
• Navigation• Illness Representations• Navigation
* E.g., Hesse BW, Hanna C, Massett HA, Hesse NK. Outside the box: will information technology be a viable intervention to improve the quality of cancer care? J Natl Cancer Inst Monogr. 2010;2010(40):81-89.
Tuesday, October 29, 2013
Understand mappings
• Navigation• Illness Representations• Illness Representations
* E.g., Finney Rutten LJ, Blake KD, Hesse BW, Augustson EM, Evans S. Illness Representations of Lung Cancer, Lung Cancer Worry, and Perceptions of Risk by Smoking Status. J Cancer Educ. Jun 19 2011.
Tuesday, October 29, 2013
Default
Default access to healthcare system:
• preventive services
• reminder systems
• shared decision-making
• easy communication
• up-to-date knowledge
* E.g., Hesse BW. Time to reboot: resetting health care to support tobacco dependency treatment services. Am J Prev Med. Dec 2010;39(6 Suppl 1):S85-87.
Tuesday, October 29, 2013
Default
Default access to healthcare system:
• preventive services
• reminder systems
• shared decision-making
• easy communication
• up-to-date knowledge
* E.g., Hesse BW. Time to reboot: resetting health care to support tobacco dependency treatment services. Am J Prev Med. Dec 2010;39(6 Suppl 1):S85-87.
Tuesday, October 29, 2013
Give Feedback
* E.g., Hesse BW, Hansen D, Finholt T, Munson S, Kellogg W, Thomas JC. Social Participation in Health 2.0. IEEE Computer. 2010;43(11):45-52.
Tuesday, October 29, 2013
Expect Error
Tuesday, October 29, 2013
Structure Decisions
* E.g., Hesse BW, Suls JM. Informatics-enabled behavioral medicine in oncology. Cancer J. Jul-Aug 2011;17(4):222-230.
Tuesday, October 29, 2013
Discussion• How do we create interdisciplinary bridges between
medicine, behavioral science, systems engineering, and medical informatics?-- e.g., “Envisioning a Digital Future” report from the President’s Council of Advisors on Science and Technology
• How do we move decision science from the lab into real-world, high demand clinical environments?
• How do we optimize the affordances of decisional architectures to support the process demands of healthcare reform (Accountable Care Organizations, Patient-Centered Medical Home, Affordable Care provisions)?-- “Health Information Technology in the U.S.: Driving Toward Delivery System Change,” Robert Wood Johnson, 2012
Tuesday, October 29, 2013