This document discusses communication challenges in healthcare systems. It makes three key points: 1. Modern healthcare systems still struggle with quality and safety issues despite resources allocated to information technology (IT), and health IT has a history of large-scale implementation failures. 2. The communication space within healthcare, including interactions between people, is very large but often ignored. It contains much of the system's information and is where most errors occur due to issues like transitions of care, multitasking, and interruptions. 3. Understanding communication challenges through cognitive science lenses can help redesign clinical environments to minimize boundaries, multitasking, and interruptions in order to make clinicians more effective and reduce errors.

1. Communication informatics
E Coiera
e.coiera@unsw.edu.au
www.chi.unsw.edu.au

2. A few problems to focus the mind
• Modern health systems still struggle to
improve quality and safety despite genuine
motivation and resource allocation
• While hope springs eternal, Health ICT does
have a history of repeated large scale
implementation failure
• Why after so many years is all this still so
hard in health, when other sectors like
finance seem to have moved to fully digital
work processes?

3. Four levels of system analysis
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1. Algorithms 2. Computer 3. Human 4. Socio-
Programs Computer technical
Interaction systems

4. How many possible conversations can happen
in a health service?
nurse nurse
3
doctor patient doctor patient
10
n!
m= GP Lab
r!(n-r)!

5. Computer
interpretation
Lab Lab
Nominated Lab
clinician Data store
3rd party staff
Laboratory
Patient Doctor office
Doctor’s office Courier
office
Practice Courier Courier
Data store Data store

6. The communication space is large
• Covell et al. (1985): 50% info requests are to
colleagues, 26% personal notes
• Tang et al (1996): 60% of clinic is talk
• Safran et al. (1998): ~50% information
transactions face to face, EMR ~10%,
remainder was e/v-mail and paper

7. What happens in the communication
space?
• Wilson et al. (1995): communication errors cause
17% of system problems, 84% potentially
preventable
• Donchin et al. (1995): doctor nurse communication in
ICU is 2% of work, but figures in 37% of errors
• Bhasale et al. (1998): communication contributes to
~50% adverse events in primary care

8. The communication space
• is the largest part of the health system’s
information space
• contains a substantial proportion of the health
system information ‘pathology’
• is largely ignored in our informatics thinking
• is where most information is acquired and
presented

9. Consequences of interaction complexity
• Many tasks, Many teams, task heterogeneity,
parallelism, lead to …
• Breakdowns at interfaces: incomplete, inaccurate,
delayed or failed message transmission
• Multitasking: Concurrent execution of two or more
different tasks. Individual has control of sequencing
etc
• Interruption: Forced multitasking. Individual suspends
current task with variable warning.

10. Communication breakdowns at interfaces
of care

11. Transitions at the boundaries of care
• Communication breakdowns often occur at the
interfaces or transitions between care
• E.g.: sign-off, hand-off, handover, shift changes, sign
out of patient from ED
• Involve the transfer of rights, duties and obligations
for care of a patient
• Inverse relationship between shift length and n times
care is transferred
• Patients admitted by one resident and transferred to
another next day have more tests and longer stay
(J Gen Intern Med 1990;5:501-5)

12. Communication breakdowns
• 2007 Review of 444 US surgical malpractice claims:
– 13% involved 81 communication ‘breakdowns’
– 73% breakdowns verbal, and 64% involved just 2 people
– Commonly associated factors with breakdowns:
• Status asymmetry (74%)
• Ambiguity about responsibilities (73%)
– Most common events:
• Resident failing to notify attending surgeon of critical events
• Attending to attending handoffs
– 43% breakdowns associated with patient handoffs
– 39% breakdowns associated with transfer in patient location
(J Am Coll Surg 2007 204(4);533-40)

13. Managing talk at the boundaries
• 89.5% of US EDs report no formal policy on patient sign out,
50% sign out only verbally, and 43% ‘rarely’ documented
transfer of attending responsibility
(Acad Emerg Med 2007;14(2):192-6)
• Strategies:
– Communication triggers e.g. ‘two challenge rule’ if unsafe
situation not dealt with
– Read-backs e.g. confirm understanding at handover
– Standardised sign-out templates, which include critical fields
such as resuscitation (“code”) status
– Computerised rounding and sign out - can halve n patients
missed at resident rounds and improve allocation of resident
time to seeing patients pre-round
(J Am Coll Surg 2005;200(4):538-45).

14. Multitasking

15. Multitasking in the primary care consultation
room
• Doctor’s use of a desktop resulted in:
– Shorten responses to patient
– Delayed responses to patient
– Dr looked less at patient because looking at screen
– Dr not hearing patient comments
– Patients tried to judge when to talk based upon Drs
interactions with the computer
– (Greatbatch et al., 1993; Booth at al., 2001)

16. Impact of task switching
• Switch costs: responses take longer to initiate cf
repetitive tasks 200 vs 500 ms; higher error rates
• Preparation costs: advanced knowledge of a switch
and time to prepare reduces switch cost
• Residual costs: Even with preparation (600 ms or
more) can’t avoid some baseline switch cost
• Mixing costs: Performance recovery after switch
always slower for mixed cf single task repetition
(Trends Cog Sci 2003:7;134-140)

17. "If a teenager is trying to have a conversation on an e-mail
chat line while doing algebra, she'll suffer a decrease in
efficiency, compared to if she just thought about algebra
until she was done. People may think otherwise, but it's a
myth. With such complicated tasks [you] will never, ever be
able to overcome the inherent limitations in the brain for
processing information during multitasking."

18. Interruptions

20. Communication in the Emergency
Department
• Face-to-face conversation 89.6%.
• 30% of communication events were interruptions,
rate of 11.2 per hour
• 10% of communication time involved two or more
concurrent conversations (multitasking).
• 12.7% of all events involved formal information
sources like the medical record.
(MJA, 2002;176:415-8)

21. Task and Role effects
ED interruption rates vary according to:
• Task loads measured by ‘shift intensity’ or time to
see patients
(Isr J Emerg Med 2005;5:35-42)
• Clinical role (and presumably task)
– 15 interruptions/hr average
– Registrars - 23.5/hr, 35% time
– Nurse shift co-ordinators - 24.9/hr
• Most interruptions f2f and related to patient
management
(Ann Emerg Med 2004;44:268-273)

22. ICU Ward rounds - conversation
interrupted
• 75% time in communication
• Conversation initiating interruptions
– 14/hr, 37% communication time
• Turn-taking interruptions
– 20/hr, 5.3% communication time
(IJMI, 2005;74:791-6)

23. Why the Interruptions?
• Poor asynchronous channels (email, voice mail), and
reliance on synchronous ones (face to face, phone)
and pager.
• Synchronous bias amongst staff
– pressure of work and ‘ticking-off’ the list
– need for acknowledgement
– face to face is high bandwidth
– selfish local, not global reasoning
• A multitasking environment (requirement for parallel
task execution) (BMJ, 1998;316:673-677)

24. Communication Policies
• UK Medical staff generated 2x as many interruptions
as they received (43 vs 23)
• Policies are tactics to filter and prioritise messages
(e.g. secretary).
• “I want to always be available…”
• “...but I don't want to be interrupted.”
• Receivers tried to assess urgency, caller, task based
upon poor information
• Callers had no information about availability and so
either interrupted or failed to contact

25. Interruption and Error
• WM = those mechanisms involved in control,
regulation and active maintenance of task information
• Interruptions challenge working memory (WM)
capacity
• New tasks given during an interruption may interfere
with existing tasks leading to disruption of WM
processes:
– forgetting of tasks.
– believing events have occurred, repeating forgotten events
– decreased performance of original task

26. Resumption lag
• Time to restart a task after interruption double for an
interrupted vs initiated task resumption (1.9 vs 3.8 s)
• Cue availability prior to interrupt reduces resumption
lag
• Suggests preparatory cognitive processes to mitigate
interruption, similar to multitasking
• “interruption lag” - brief period prior to interrupt
provides opportunity to prepare to resume and
encode retrieval cues to facilitate resumption of
primary task
(Altman, Trafton Cog Sci 2004)

27. The true costs of interruption
• Time penalty?
– Experimentally, resumption lag can double when a task
switch is externally forced via an interruption.
– Empirically, clinicians spend 29-55% shorter amount of
time on interrupted tasks (Westbrook, Coiera et al., QSHC,
2010 in press)
– The clinical risk is cutting corners on tasks because of
reduced available time
• Errors?
– increase risk and severity of medication administration errors
(Westbrook, Day et al, Arch Int Med 2010 in press)

28. Reducing interruptions
• Shift from synchronous to asynchronous
– Training clinicians to understand impact of interruptions and
costs of multitasking
– More voice and e-mail + acknowledgment eg asynchronous
notification of lab results BUT unintended consequence is
that if poorly designed, can result in more interruptions
– How? requests: e-directories - locally maintainable, rapidly
updated, clinically oriented, personally annotated
– Who? Requests: Role-based call forwarding via
programmable switch
– Making work ‘visible’ - whiteboards, active signs -> reduce
memory load, recover from memory disruptions.

29. The Sacred and the Profane
Sacred (classic) making Profane (in the wild)
• The computer • Paper
• The EMR • Communication
• Terminologies • To-do lists
• System architectures • System implementation
• Intelligent decision • System failures
support technologies • Local customisation

30. Design challenges for health services
1. Clinicians operate with scarce cognitive resources, multiple
team interfaces, multitasking and interrupting, leading to
inefficiency and error.
2. We need to understand the current cognitive science literature
about communication and task handling e.g. multitasking and
interruption
3. We need to study communication and reasoning “in the wild”
to discover just how it impacts clinical work
4. We need to start designing clinical environments which
minimise boundaries, multitasking and interruption, and
support clinicians becoming more effective at task
management and resumption

31. Thank You
e.coiera@unsw.edu.au

32. Cape Town International Convention Centre
www.medinfo2010.org