1 Forstyrrelser ved bruk av trådløs telefon på sykehus: forslag til forbedring Interrupts caused by use of wireless phones in hospitals: proposal for improvement Henrik Gundersen, ntnu, Paul Martin Lello, ntnu, Arnhild Kristinsdatter Lindbach, ntnu, Åsmund Skjerdal, ntnu, Lill Kristiansen, Telematikk, ntnu, (based on EiT-course Interdisciplinary project work at ntnu)

2 Forstyrrelser ved bruk av trådløs telefon på sykehus: forslag til forbedring Interrupts caused by use of wireless phones in hospitals: proposal for improvement Henrik Gundersen, ntnu, Paul Martin Lello, ntnu, Arnhild Kristinsdatter Lindbach, ntnu, Åsmund Skjerdal, ntnu, Lill Kristiansen, Telematikk, ntnu, (based on EiT-course Interdisciplinary project work at ntnu)

3 Challenges and goals ”How can we reduce interruptions by telecommunication between clinicians” How can we reduce the harm of interruptions produced by patient signal system, phone calls and pagers toward clinicians? How can we make an economical and practical solution to the problems of interruptions in clinical settings How can we do this without making the communication praxis more complicated?

4 What is an interruption? According to New Oxford American Dictionary:

5 Methods Litterature studies from research field general on interrupts specific for health care Seminar at NSEP in January 09 (20+ attendees) showed film + discussion Interview with 1 nurse Document studies (in particular of notes on experiences from nurses during phase 1 at St.Olav’s) 3 hours participation on telephony training for doctors Doc. studies of training material (Experience as mobile phone owners, partly as patients)

6 Studies dealing with interruptions Harr and Kaptelinin (2007) classifies studies dealing with interruptions in three distinct categories dealing with: Research concerning the effects of interruptions on the individual (1) Research concerning the ways to stop disruptive interruptions from occurring (2) Research concerning the ways to limit the damage caused by interruptions (3) Based on health case research we decided that (3) was the most appropriate approach

7 Reducing the damage of interruptions Research trying to reduce the damage caused by interruptions is often focused on ’timing’, or ways to ’filter out’ irrelevant information in work situations. Other methods for reducing the damages caused by interruptions are often focused on using different modalities like heat, smell, sound, vibration and light. All as a means to reduce the interruption between perceptual and cognitive processes in organizational settings.

8 Interruptions in a clinical setting Recent studies have demonstrated that the communication situation in hospitals may result in interruptions that influence the work situation (Coiera and Tombs 1998, 673), interruptions that may result in malpractice (Kevin et al. 2003). “Selfish communication practice” (Coiera and Tombs 1998) Coiera and Tombs propose wireless (mobile) technology as a remedy This proposal may not take into account workarounds

9 From UNN,Tromsø (Scholl et al.,2007) A study of doctors use of wireless phone long walking distances: a wireless phone is very convenient to place an outgoing call (or to reply to a page) But it is interruptive in many situations They find various workarounds such as: Not listing the wireless phone in the phone book  avoiding incoming calls Not carrying the wireless phone (leaving it in the office)  also to avoid incoming calls (avoids outgoing calls as well!) Forwarding calls to the pager  Unclear if this is ‘call forward unconditional’ (Umiddelbar omdirigering’) or call forward on no reply  the latter will probably cause some callers to hang up before the page is initiated, i.e. serve as an additional ‘filtering mechanism’

10 St. Olavs Hospital: new ICT systems Our investigations is based on the existing (new) ICT systems at St. Olavs Hospital in Trondheim. Focus on economical and practical solution All clinicians (and most/all) administrative staff is equipped with wireless phone (IP-based) Used for telephony by all, messages, pager ++ Nurses use the wireless phone also as one (of several) means to receive / be aware of patient signals. Known workarounds from nurses: taking out the battery during lunch putting phone on ’silent mode’ during lunch

11 New hospital – bed courts (sengetun) Short distances between nurses Doctors are not located at the bed court Both doctors and nurses have wireless phone in the new hospital

12 Pasient PC på sengetun Vaktromsapparat PC-client to set up the responsibilities per room (i hht bemaningsplan) Rompanel Pasientterminal Anropspanel Våtsone Pasientpanel Patient signal system: from patient/room to ’some’ nurse Ignore / timeout Reject Accept

13 Telephony: from ’some’ (doc./nurse/..) towards a clinician (here: a doctor) (personal call or role based call) Cisco CallManager/ Soft PBX / sentralbord Red = (direct) interrupt "My pager has gone off five times in the past 15 minutes, while I've been trying to take Mr. Jones's history. I can't keep his complicated history straight. (Kevin et al. 2003)" ”Når calling’en [personsøkeren/ pager] piper på hylla i enden av operasjonssalen er det noen som trenger din hjelp. Men pipingen fra søkeren forstyrrer ofte operasjonen du holder på med, ” (telemed.no) Phone seems more interruptive than the pager (Scholl et al., 2007)

14 Details of the phone Used for patient signal reception Ignore Reject Accept Used for paging No details provided here Used for outgoing calls Used for incoming calls Yes (green / 13) Redirect (button 14) Silence ring signal (red / 7) Red button is DIFFERENT from the ordinary red button on a mobile phone Silence ring signal =/= Reject the call (or redirect) Red button allows a sec. delay

15 Minimizing the harm of the interrupt via a Bluetooth (BT) device Cisco Call Manager Main focus here: on the callee side (signals, calls and pages) Idea: Keep rest of technical system mostly/totally unchanged Imatis message server

16 Non-functional requirements Design req. Screen upwards Two buttons Weight Water splash, falling to the floor etc. Screen LED display Battery Standsby time Bluetooth HID (Human Interface Device Profile)  supports battery saving  The device is not an ordinary handsfree set BT2.0 Details on BT in the paper

17 Main Use Cases for BT device (brukstilfeller) UC1: Connect phone and BT device UC2: Show caller-ID on incoming call UC34: Accept call, delay the answering (via Mute/silence) or redirect (Umiddelbar omdirigering) ( ref. req. F3, F4) UC6: Show room number for pasient signal (ref. krav F6) UC7: Accept pasient signal or send further to next nurse (ignore or reject) (ref. krav F7) UC for messages. Others

18 Simplifying the communication? “How can we make the communication easier for all parties?” “How can we reduce the interruptions produced?” “...without making the communication praxis more complicating?” The device is easily visible and available. No new complicated negotiating back-and-forth between caller and callee No need for all users to use the new device, offers individual advantages (no ‘critical mass issue’)

19 Reducing Interruptions / Discussion 1 “How can we reduce the impact of interruptions on clinical personnel from mediated communication, especially with important tasks and consultations in mind?” The proposed Bluetooth-device is more easily accessible than the wireless phone, something that in turn will make it possible to quickly evade interruptions in inconvenient situations (like consultations). The device is proposed as a solution for problems that arise with phone is inaccessible in pockets. Following one design proposal from Scholl et al.(2007)

20 Reducing Interruptions / Discussion 2 Bluetooth device offers the possibility of better timing (slight delay or reject)  mute call, (silence ring signal)  redirect call,  reject patient signal

21 A realistic, economic and simple solution “How can we make a economical and practical solution to the problematics of interruptions in clinical settings “ Since the Bluetooth-device in principal functions as a supplement to existing communication systems there will be no need to replace existing systems for it to work. Since Bluetooth is a backwards-compatible technology, the device will function with newer technology. Since the device is firmly based on the pager, it is probable that this will improve the process of introducing new technology (since pagers already are in use in most hospitals). Therefore, the device may easily be introduced into the working environment.

22 Questions?

23 For discussion Showstoppers? Scenario 1: Finding the (right) BTdevice Economy: The device is ’similar’ to a handsfree unit, but will not be a mass market device  higher price Need all nurses have their personal BT device? Main interrupt issue for nurses is patient signals during an ongoing call Connect the BTdevice during the ongoing call? Other means to ’opt out’ (midlertidig melde seg ut) of patient signal responsibilities?  Some alternatives functionality without new devices are proposed in Sletten (2009)

24 Low tech / low economy version (for both nurses and doctors): Just modify the ringing sound for incoming phone calls From:  ’the phone rings and rings’ To:  ring, ring (almost silent 10 sec.), ring a final ring (i.e. an automatic variant of silence the ring signal)  or find a melody that acts like this A much simpler and cheaper solution may not solve all the relevant problems But may be discussed due to the cost benefit

25 Informing (or negotiating with) the caller: pros and cons Relevant for phone calls (and paging) i.e. when the caller is a clinical co-worker Less relevant for patient signals  patient should not worry about total work load and organizational issues Can be done prior to call ’active status’ in address book (’widget’) / visible cues / ++ Can be done during the call Can be done after the call in a separate message Will this happen in a busy day in hospitals?

26 Prior, during or after a call: informing the caller about status etc. Prior to call: See e.g. AwarePhone (Bardram and Hansen, 2004) but requires updates of the status field (i.e. manual overhead) (or the use of automatic location) During the call E.g. SE P990 (send an SMS in return) Or play a voice message: wait 10 seconds etc.  May be preset, based on current status  or chosen by callee during the ringing (an Ericsson prototype, unpublished) After the call is a totally separate message ref. SMS ’Forelesning’ received by my daughter.  more relevant for interrupts when sitting in meetings  texting for nurses with busy hands?

27 AWAREphone (Bardram ++) ihospital.dk (prior to call)

28 From the manual SE P990 Note: Mute with ’C’ is not described here, but it still exists! (ti-still-vent-litt)

29 From my own phone SE P910i 1 Answer the call 2 Reject the call, Send busy caller will hear a busy tone (or get to the voic ) the call will be logges as rejected call 3 Silence the ring signal The caller will not notice that you have silenced the call call will be logged as a missed call  if not answered within a certain time (This phone has no red or green buttons at all)

30 An existing handset Ascom 9d24 (for fieldworkers: health / fire / etc) This phone has several ’silent modes’ and even personal ’modes’ can be defined In all cases ’high prio alarms will pass through’ NB: The personal mode chosen is NOT visible to other co-workers (different from AWAREphone)

31 Mute: from the manual P990 Note: An old feature off ’all’ Ericsson phones is that a long press on ’C’ places the phone on ’silent mode’ Not described in this manual

32 Negotiating back to caller (after call) Negotiator (Wiberg&Whittaker) Several ’pros’ when not negotiating back to caller (our solution) technically simpler (  cheaper) Offer instant individual relief (not depending on critical mass to be useful) (Negotiator required that both caller and callee where using the new feature) The ’selfish clinical worker’ get the benefit him/herself (Coiera and Tombs, see also Grudin) ’Cons’: less rich context back to caller in order for caller to decide on further actions The PC version of Negot. offers a good UI NB (only when assuming that all calls shall be handled later)

33 Eller at vi hadde faste møteavtaler?

34 Further work Build the prototype and test it Or presenting to clinicians and receive feedback Look more into organizatinal issues, ways to avoid (some) interrupts regular meetings / scheduled events? more use of messages inside the EPR? The issue of communication between nurses and doctors may require special attention (ref. Ero Stig Karlsen) Using redundancy is an active way coupled with the bemanningsplan (ongoing work)  redundancy of function (nurses can cover for each other)  redundancy of data (fixed and wireless system offer redundancies)

35 Nurses and Interrupts Nurse with busy hands Even if she wants to accept the signal, she may be too late  15 sec. timer  Screen lock on when receiving signals (from interview) Patient signal on the phone (in the ear!) while in a phone conversation (St.Olav, 2006): Also causing interrupts for the other party on the phone Also some some interrupts caused to phone calls towards nurses (seems less important, Sletten, 2009) Also the general fact that many things may go on at the same time (with or without wireless phones)