1. 2010 SAAS National Conference and NIATx Annual Summit Trust in Technology Enid Montague, PhD Assistant Professor Anna Julia Cooper Fellow Director: HCI lab Industrial and Systems Engineering University of Wisconsin-Madison enidmontague.com

2. Outline Why are we implementing new technologies? Patient trust in care provider Patient attitudes about technologies Provider attitudes about technologies Tips and considerations Interactive activity 2 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

3. Why are we using EMRs? Enid Montague, PhD University of Wisconsin-Madison HCI Lab 3

4. Physician shortage 4 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

5. Nursing shortage YearSupplyDemandShortagePercent 20001,890,7002,001,500-110,800-6% 20051,942,5002,161,300-218,800-10% 20101,941,2002,347,000-405,800-17% 20151,886,1002,569,800-683,700-27% 20201,808,0002,824,900-1,016,900-36% Source: Data from the Bureau of Health Professions. (2004) US Supply versus Demand Projections for FTE Registered Nurses 5 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

6. Growth in medical technology industry Enid Montague, PhD University of Wisconsin-Madison HCI Lab 6

7. Growth in medical technology invention. Enid Montague, PhD University of Wisconsin-Madison HCI Lab 7

8. What is trust? Trust is a person’s belief that a person or object will not fail them. Enid Montague, PhD University of Wisconsin-Madison HCI Lab 8

9. Trust is a popular topic in relation to the provision of health. 9

10. Trust is a fundamental aspect of all relationships. – Human- human e.g. worker- worker, parent- child, doctor- patient, – Human-organization e.g. worker- company, patient- hospital – Human- social institution e.g. citizens- government, patient- health systems – Human-technology e.g. user- website, user- device, human- computer Enid Montague, PhD University of Wisconsin-Madison HCI Lab 10

11. Trust triad model Montague, E., Winchester, W.W. Kleiner, B.M. (in press). Trust in medical technology by patients and health care providers in obstetric work systems. Behaviour & Information Technology. 11

12. Client- Provider Trust Enid Montague, PhD University of Wisconsin-Madison HCI Lab 12

13. Patient trust in care provider predicts… Quality variables such as: – sustained enrollment in health plans – patient satisfaction – utilization of preventive services – adherence to medical advice – malpractice litigation – health status – health service seeking behaviours Organizational and economic factors such as: – decreases in the possibility of a patient leaving a care provider’s practice – withdrawing from a health plan. 13 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

14. As trust declines… The cost of providing care may increase. Patients and care providers may engage in self-protection – patients withhold information or avoid seeking care from sources they determine are untrustworthy and care providers practice defensive medicine. “People are increasingly unwilling to take risks, demand greater protection against the possibility of betrayal, and increasingly insist on costly sanctioning mechanisms to defend their interests” (p 13) (Tyler & Kramer, 1996). Distrust can also act as a barrier to the formation of interpersonal relationships Distrust can “provoke feelings of anxiety and insecurity, causing people to feel uncomfortable and ill at ease and to expend energy on monitoring the behavior and possible motives of others” (p 1) (Fuller, 1996). When patients feel unsafe, energy that could be devoted to healing is expended on self-preservation. 14 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

15. Ideal environments for interpersonal communication -Full view of the body -Full view of facial expressions -No limitations on making eye contact -Channels are free to focus on listening and responding 15 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

16. How does technology change interpersonal relationships? Nonverbal cues are important for interpersonal communication and trust in clinical encounters – Difficulty using multiple channels (i.e listening, while typing) – Time utilizing technologies might affect total visit time – Difficulty noticing the expressions of others – Difficulty showing appropriate expressions – Mistakes may cause stress and frustration – Time for social touch – Eye contact 16 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

17. Shared computer use can make interpersonal communication difficult. 17 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

18. Typical sets ups that involve technologies can bring new communication challenges. Image source: Mayo SPARC 18 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

19. Patient trust in technology Previous Experiences/ Attitudes 19 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

20. The goal is appropriate trust in technology. Enid Montague, PhD University of Wisconsin-Madison HCI Lab Using technologies to make decisions in the absence of additional information Using technologies in ways they were not designed for Using technologies to enhance human capabilities, while continuing to use medical knowledge Refusing to use technologies that could enhance the provision of care and quality of work Using technologies in lieu of medical care i.e. Google as a first or second opinion Using technologies in a way they were not designed for Using technologies appropriately to enhance health and care Refusing to use technologies that could enhance the health and the care provision process 20

21. Patient attitudes about technologies Concern over information security Lack of knowledge about technology (technology literacy) 21 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

22. Uncertainty about the health record can contribute to distrusting attitudes. Have you ever looked at your medical record? (52%) No, I have never looked at my medical record (39%) Yes, it was accurate (16%) Yes, it was inaccurate or incomplete 22 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

23. Beliefs can affect behaviors Do you believe the information in your medical record is kept secure? (70%) Yes (28%) No Have you ever avoided telling your doctor something about your health, because you did not want the information to appear in your medical record? (76%) No (20%) Yes 23 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

24. Which of the following would you not want to appear in your medical record? (43%) Number of sexual partners (43%) Previous incarcerations (26%) HIV/AIDS status (24%) Sexually transmitted diseases (22%) History of substance abuse (20%) Prior use of illegal drugs (20%) History of mental illness ( 9%) Family history of genetic illness 24 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

25. There are different attitudes about information sharing with partners, friends, family. How many people would you like to have access to your medical record? and why? Mixed results – Some said virtually everyone (doctors, nurses, clinic staff, spouse, child, parent, emergency contact) – Others said virtually no one (only doctor seeing them and only limited access to information involving the purpose of the visit) 25 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

26. Distrust in health system can affect attitudes about technologies. Studies have shown that certain populations are more distrusting of health care systems and providers – Racial/ethnic minorities (African American, Hispanic American, Arab American) – Substance abusers – Those suffering from mental illness – Chronically homeless – Those with socially stigmatizing illnesses and diseases 26 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

27. Differences can exist across age groups. Privacy literacy – Teens are aware of information privacy and information sharing. “I don’t know if the doctor is going to turn the screen off when they leave the room” “I don’t know who else can see or access the information they put it in the computer” “I don’t know if my parents can see it” “I don’t know what they are writing about me” 27 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

28. Differences can exist across age groups. Older clients might be more concerned about technology etiquette. “I don’t think its polite when my doctor types while I’m trying to talk to him” “Its bad enough that my kids text message during dinner, now I have to watch my doctor text during my check-ups” “It took me two hours to get here, I only have 30 minutes for the visit and they spent 10 minutes of my time trying to get the computer to work!” 28 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

29. Provider attitudes about technologies Provider distrust in technology can contribute to patient distrust in technology and the provider. Provider self-confidence can contribute to appropriate trust in the technology. 29 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

30. 30 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

31. New technologies can be stressful for some care providers. Techno-stress – “The negative psychological link between people and the introduction of new technologies. “ – Not unique to health care; educators have similar experiences Causes of technostress – the quick pace of technological change – lack of proper training – increased workload as result of new technology – lack of standardization within technologies – the reliability of hardware and software – Poor usability– Choose usable software that matches your organizations work flow is important! 31 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

32. Provider trust in technology 32 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

33. Things to consider. Design of work stations – Consider where and how you will introduce work stations into your practice – Don’t be afraid to role play and try different set ups User friendly solutions – Develop a personal and organizational plan for addressing technology problems during client encounters. Flexible work flow- – Be able to treat each client as an individual You may not be able to type your notes during each visit Communicate with clients about their ideas about computer technologies – Develop a working plan together 33 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

34. Practical tips and considerations For the client – Be prepared to provide information about who has access to their information and how it is kept confidential For the clinician – Consider the effects on your interpersonal relationships when choosing a system Training and be flexible… everyone may different Allow for adequate time in visits to accompany additional times or technology usage Effective implementation plan Match self trust/ self confidence with start times Establish etiquette Communicate etiquette with other workers and clients 34 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

35. Role-playing activity 1.Spend a few minutes reading about the character assigned to you. 2.With a partner you will each perform as the character assigned to you in a simulated intake process with a new client for about 10 minutes. 3.After the role-playing scenario, individually spend a few minutes writing down what worked well and what were obstacles in building rapport and trust with your partner from your perspective? – Please write down at least 5 observations for each question. 4.You and your partner will spend a few minutes discussing the role-play scenario: – Compare perspectives of the experience – Brainstorm about solutions and things that should be considered when implementing new computer systems into the clinician-client relationship. Be sure to think about different types of people, tasks, and organizations. 5.We will discuss as a group. 35 Enid Montague, PhD University of Wisconsin-Madison HCI Lab

36. Thank you! For more information please, – See the NIAtx website – Or visit my website www.enidmontague.comwww.enidmontague.com 36 Enid Montague, PhD University of Wisconsin-Madison HCI Lab