1. ©2003 Sowerby Centre for Health Informatics at Newcastle The PC, the Patient and the Practitioner Paul Robinson Informatics seminar 12-14. 11. 3

2. ©2003 Sowerby Centre for Health Informatics at Newcastle What am I doing here??

3. ©2003 Sowerby Centre for Health Informatics at Newcastle What am I doing here? Presentation Talking about the iiCR project Thinking about perception, attention and consciousness Looking at the background to computer use at the point of care Teaching the skill set Communication skills

4. ©2003 Sowerby Centre for Health Informatics at Newcastle What effect have computers had? Information superhighway Convergence of older technologies Printing press Telegraph Typewriter Radio/ TV

5. ©2003 Sowerby Centre for Health Informatics at Newcastle Context (At the point of care…..) COMPUTERS CHANGE EVERYTHING

6. ©2003 Sowerby Centre for Health Informatics at Newcastle Computers change everything Records Knowledge flows The medium

7. ©2003 Sowerby Centre for Health Informatics at Newcastle Records Paper: Filing cabinet EHR: Broadcast/ publishing

8. ©2003 Sowerby Centre for Health Informatics at Newcastle Knowledge flows (old)

9. ©2003 Sowerby Centre for Health Informatics at Newcastle Knowledge flows (new)

10. ©2003 Sowerby Centre for Health Informatics at Newcastle The medium Computer screens are more engaging than sheets of paper. Interactive programmes are seductive of attention. Working with a computer is active, not passive

12. ©2003 Sowerby Centre for Health Informatics at Newcastle Neural Monism Mind stuff and physical stuff are the same stuff Mind emerges from the network Brain Body Social This takes time (.03 to.05 second)

14. ©2003 Sowerby Centre for Health Informatics at Newcastle Most human behaviour is automated This includes the consultation

16. ©2003 Sowerby Centre for Health Informatics at Newcastle Research and Development Information in the consulting room (iiCR)

17. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR team Nick Booth Judy Kohannejad Paul Robinson (PRODIGY evaluation team) (Durham and Darlington EHR project team)

18. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR: aims 1.Identify the skills that help the GP to maintain rapport with patient and use the computer during the consultation. 2.Develop and pilot a teaching package that supports the training of GPs and the development of these skills. (Calgary-Cambridge Guide)

19. ©2003 Sowerby Centre for Health Informatics at Newcastle Research Questions Can these skills be identified? What are they? Can they be taught? Can people divide their attention?

20. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR: phases of the project Phase 1: video-tapes of GP consultations ( grounded theory ) Phase 2: simulated patient consultations with immediate facilitated review of tape ( IPR, Calgary Cambridge ) Phase 3: iterative development of teaching package ( action research )

21. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR Phase 1: sample GP Trainers (purposive sample) Self selected Familiar with using computer in the consultation

22. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR Phase 1: method GPs taped a surgery Looked at all consultations on tape One or two consultations selected and transcribed by JK (CA transcription) 2 columns (Dr – Pt interaction: interpretation) added to transcript (PJR)

23. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR phase 1: what we saw A lot of use of paper! Most GPs do the minimum of typing/ data entry while the patient is present

24. ©2003 Sowerby Centre for Health Informatics at Newcastle 3 types of behaviour: Controlling (the flow of consultation) Responsive/ Opportunistic Ignoring iiCR phase 1: what we saw

25. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR phase 1: what we saw 3 strategies: Signpost Blather Respond (every time)

26. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR phase 1: what we saw Variation in sharing of: Screen Knowledge sources

27. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR (phase 1): what we saw Failures to respond to speech-act When in prescribing or template filling modes Were they deliberate??

28. ©2003 Sowerby Centre for Health Informatics at Newcastle Multi-tasking Can GPs do it? Can researchers do it?

30. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR Phase 2: method GPs own surgery Trained simulator, loosely defined scenario: demands computer use Video of consultation and video feed from screen Immediate facilitated review of tapes

31. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR phase 2: consultation 2 Patient has asthma, inhaler use increasing: (is anxious and has started smoking again) Computer glitch was major distraction to GP In discussion: GPs skills Interpretation issue Undivided attention (on the screen) for 105 seconds

32. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR Phase 2: findings F my impression is that you explained very well what you were doing. (to Patient) did you understand what he was doing? P Yes from my point of view, computers are part of the culture: F so did you know what he doing? P I just guessed that he was like writing things down.

33. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR Phase 2: findings F It looks to me Alison like you were looking at the computer when you came in P Its like I said before when someone else is focussed on something you are drawn to it. F if I was just looking at this tape, Id think that you were reading the screen P no

34. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR Phase 2: findings F now what Ive seen in the last 10-15 seconds is Alison, moving around in her seat, looking up, looking away: did any of that impinge on you? D No D No she was off limits, completely off

35. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR Phase 2: findings P Its difficult to say with all the distractions going on. You were distracted for quite a long time. So its difficult to say. D the chunk… was long, much longer than I thought it was. … it just goes to show how you can lose track of time when you are busy with something else.

36. ©2003 Sowerby Centre for Health Informatics at Newcastle iiCR: phases of the project Phase 1: video-tapes of GP consultations ( grounded theory ) Phase 2: simulated patient consultations with immediate facilitated review of tape ( IPR, Calgary Cambridge ) Phase 3: iterative development of teaching package ( action research )

37. ©2003 Sowerby Centre for Health Informatics at Newcastle Competencies: Rapport Adapts behaviour to take into account relative position of doctor, patient and computer Maintains open posture when using computer Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctors attention is on the computer Responds to patient cues when attending to the computer

41. ©2003 Sowerby Centre for Health Informatics at Newcastle Competencies: Involving the Patient Explains to patient why computer is being used If the computer is to be used as an information source, negotiates the use of such information with the patient Lets the patient read information from the screen when appropriate

42. ©2003 Sowerby Centre for Health Informatics at Newcastle Competencies: Explanation and planning If using screen-based information (shared screen, PIL etc) Checks that patient can see the screen clearly Remains quiet, and gives the patient time to read the text Checks that patient has understood the text Gives patient opportunity to ask questions On a busy screen indicates (points etc) relevant information

43. ©2003 Sowerby Centre for Health Informatics at Newcastle Phase 3: the training package Iterative development Used with over 200 GPs, community nurses and pharmacists Workshop style Role plays, scenario consultations Works best in facilitated small groups Can be adapted to larger numbers

44. ©2003 Sowerby Centre for Health Informatics at Newcastle Phase 3: the training package More details available on: http://www.schin.ncl.ac.uk/iiCR/ (final report tab) Or from p.j.robinson@ncl.ac.ukp.j.robinson@ncl.ac.uk