Decisional architectures june 2013

Decisional Architectures

June 19, 2013

Bradford W. Hesse

Tuesday, October 29, 2013

Two Cases


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.


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.


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






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






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


Institute of Medicine’s “Crossing the Quality Chasm” Report


*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


http://www.nsra-adnf.ca/images/pageimages/3babieslow.JPG

http://www.nsra-adnf.ca/images/pageimages/3babieslow.JPG

What happens with bad design?


What happens with bad design?


Attention to Decision Architectures Has Become Essential in I.T. Enabled Business

“UX” = (User Interface)


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


But what about medicine?


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.


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


“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.


But progress in behavioral support still lags -- leading to physician outcry.


The Case of Hugo

Progress for patient support lags even further, leading to vocal dissatisfaction.


The Case of Hugo



The Case of Hugo



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."


http://www.scripps.edu/research/faculty/topol

http://www.scripps.edu/research/faculty/topol

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.


How about cancer care?


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]


http://www.ncbi.nlm.nih.gov/pubmed/15207989

http://www.ncbi.nlm.nih.gov/pubmed/15207989

Oncology as information science: “The Learning Health Care System”

The ASCO Blueprint: November 2011


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


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.


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


Self Determination*


iNcentives

• Autonomy• Mastery• Connectedness• Mastery


Self Determination*


iNcentives

• Autonomy• Mastery• Connectedness

• Autonomy


Self Determination*


iNcentives

• Autonomy• Mastery• Connectedness• Connectedness


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.


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.


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.


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.


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.


Expect Error


Structure Decisions

* E.g., Hesse BW, Suls JM. Informatics-enabled behavioral medicine in oncology. Cancer J. Jul-Aug 2011;17(4):222-230.


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


Health & Medicine

Decisional architectures june 2013