History, How Bad Design Kills, Posture and Metaphors

This entry is part 1 of 7 in the series Tracking Systems

The following historical account is based on personal experience as a child being taken to ERs in the 1950s, as an observer in ERs in the 1960s, an EMT and then street medic training in ERs in the 1970s, and then as an emergency physician since the 1980s. Some names may have been changed or ambiguated to protect the innocent (or guilty).

1950s Emergency Room

1950s Emergency Room

In the 1960s and before, the emergency room (“ER”) was just that – a big room, with some curtains to divide the stretchers. The ER was staffed by a nurse or two, and at the bigger hospitals, there would be more nurses and an intern or two, and maybe an upper-level resident would supervise from time to time. There was no standard of care, nor any quality improvement (QI) processes.

Emergency Room circa 1924

Emergency Room circa 1924

Gradually, medical technology improved, and we could do more (a lot more) for patients, especially in the acute setting. Primary physicians started referring (and deferring) patients to the ER rather than seeing emergencies in the office; indeed, now that emergency medicine is a specialty, many primary care doctors don’t think it’s appropriate for them to care for anything except minor emergencies in the office. Primary care doctors now don’t leave time each office day for add-on emergencies, as they used to back in the 1950s and 1960s. And ERs gradually morphed into busy, high-tech EDs, with lots of patients, and with nurses and doctors who specialize in emergency care. A standard curriculum in emergency medicine evolved, as well as postgraduate emergency medicine residency training programs for MDs and DOs.

But EDs became so busy that they made the job of an Air Traffic Controller look easy. And, as with air traffic control, specialized management tools evolved. Read the rest of this entry
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Interruptions, Memory and Situational Awareness

This entry is part 2 of 7 in the series Tracking Systems

“Unless it produces action, information is overhead.” –Thomas Petzinger

First, a caveat: vendors of HISs (hospital information systems) and EDISs (emergency department information systems) insist that a tracking system is just one component of an integrated system. They point out that there are interactions between a tracking system and CPOE (computer-based practitioner order entry) systems, EMR (electronic medical record) systems, and charting systems. Nonetheless, it’s worth focusing on tracking systems, as central facets of an EDIS, while recognizing it is deeply interconnected (or should be) with other aspects of a full EDIS or HIS.

Slate review of  Consilience

Slate review of Consilience

Dr. Todd Taylor’s article Information management in the emergency department in Emergency Medicine Clinics of North America tells how a bad tracking system can slow down an Emergency Department (ED). There are also multiple reports of how a good tracking system can make an ED more efficient. The trouble is that many of these reports are from people who are deeply invested in the tracking system, either financially or emotionally, and whose objectivity may be questioned. It’s also true that it’s hard to show that tracking systems improve efficiency, as most EDs didn’t have good data on efficiency until they installed a tracking system. Read the rest of this entry
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The Magic Number 7 (or maybe 4?), Forced Errors, Triage, and Color-Blindness

This entry is part 3 of 7 in the series Tracking Systems

In its most pedantic definition, an ED tracking system is a system for tracking things in the ED. Tracking things that, well, things that we need to keep track of. People. Orders. Labs. Consults. Messages from docs. Many different bits of information that are needed to keep the ED running smoothly. One of the reasons for such a system for keeping track of things is that the human mind is limited in the number of things it can keep in short-term/working memory. And unlike humans, computer are great at remembering things. (Not so good at figuring out what do do with this information, or, as is evident from many of the posts on this blog, currently not so good at presenting information to humans.)

Anyone who has attended a standard adult-learning course (e.g., first aid, CPR, ACLS or PALS or ATLS instructor course) will remember one of those principles of adult learning: we can only keep “X” things (I have been told four, five, three, and seven) in short-term memory at once. We’re told to limit the text bullets on our overheads, slides or PowerPoint screens to five.

This actually has some basis in science.

The limits on short-term memory (or working memory, to use a more modern term; the links provide the pedantic differences between the two) were popularized in a landmark study by Miller in 1956, entitled The magical number seven, plus or minus two: Some limits on our capacity for processing information. But even as far back as 1905, Wilhelm Wundt, a physician trained at the University of Heidelberg, and known as the father of experimental psychology, had established a similar limit (Wundt’s Limit). More modern studies suggest a smaller number, about four, for the number of similar items we can hold in mind at one time. A recent study suggests that short-term memory decays quickly over time, especially if, as Wundt observed, competed with by other sensory processes. Read the rest of this entry
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Where is my [fill in the blank]? and Passive Tracking

This entry is part 4 of 7 in the series Tracking Systems

Where is the Chart!?!?

SAR team looking for patient's chart

SAR team looking for patient's chart

If you visit different EDs, one of the most common tracking-type refrains you hear is “Where is Room 5′s chart? I’ve been looking for it for fifteen minutes!” Such problems delay ED patient care, and are one of the great motivators for moving to an all-electronic chart, one that can be found and used on multiple PCs at the same time-and can’t be lost. But in the meantime, EDs have developed some tricks to keep track of the printed chart.

Some EDs have glued large blocks to the ED’s chart clipboards, so they can’t be as easily hidden or lost. A more common system is to color-code the charts based on a particular area. For instance, in the author’s ED, yellow clipboards are used for rooms 2-4, green for 5-8, red for 9a-9d, blue for 10-12, and purple for the pediatric ED.When you’re looking for a chart, at least you know what color clipboard you’re searching for. Corresponding colored dots have been stuck on the room’s number-signs. (Attempts to place similar colored dots on the nurses responsible for each set of rooms had some variable success, but the process was pursued so enthusiastically by certain members of the staff that the supply of sticky colored dots was soon exhausted.)

A novel, high-tech solution was pursued by the ED at Akron City Hospital. The hospital installed a PC-based tracking system for tracking the movement of patients (discussed further below). These “passive” tracking systems generally use infra-red or radio-frequency badges on patients and staff, along with sensors in the ceiling. The system notes when patients moved from one area to another (a different room, X-ray, CT) and update the tracking board appropriately. The system also notes when staff are in a room with a patient and logs this (helpful when there are patient complaints that “nobody paid any attention to me”). If no doctor or nurse is assigned to a patient, simply being next to the patient for several minutes is enough to assign staff to a patient. This can be changed on the tracking board, but is almost always right.

Akron City simply extended this by placing such badges on the clipboards they used for their charts, so that one could always go to a PC and find the location of a chart. Sometimes the badges wouldn’t work if the chart was covered up with books, for example – but the system still “remembered” where it had last seen the chart, which ended up being the correct location. Read the rest of this entry
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Information Design 2

This entry is part 5 of 7 in the series Tracking Systems

God is in the details
–Mies van der Rohe

The primary function of an ED tracking system – at least if you look at it from the right direction – is to display relevant, timely data to the user. A tracking system may do other things, but this function of data display is arguably its most important function. If a tracking system displays the wrong data, or outdated data, or is so poorly designed that users miss important data, then it’s not doing a good job.

Minard's Map of Napoleon's March to Moscow, courtesy Edward  TufteMinard.gif

Minard's Map of Napoleon's March to Moscow, courtesy Edward Tufte

So, we should focus on the way tracking systems display data, which falls squarely in the domain of information design. I’ve already discussed many of aspects of information design in the Medical Computing series, particularly to the first essay on Information Design, to which I will refer incessantly in this post. You may think of this as an executive summary of that series to date, with a few extensions and elaborations unique to tracking systems.

A good tracking system will meet all of the following criteria. A great tracking system will do so with panache and style. As far as I can tell, the best of today’s “niche” ED tracking systems (systems designed specifically for the ED) are not quite up to this standard, and the offerings of the big HIS (hospital information systems) vendors fall far below.

Users such as Donna, Bill, Jill, and Joyce must be able to, when they come up to the tracking system for the first time, be able to quickly and correctly learn how to use it: learnability. And, when they come back to it for the second, third and subsequent times, they must have retained what they learned that first day: memorability. And, it should be easy for them to accomplish their daily tasks using the tracking system: usability. These concepts are discussed in more detail in Usability, Learnability, Memorability. A tracking system that is usable, memorable, and learnable will be praised by its users, even if it only provides a few essential tracking functions. Read the rest of this entry
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