I avoid saying I told you so, but this is a post I posted in April 2008. It summarizes a study by Oulasvirta and Saariluoma (2004) that shows the detrimental effects of distracting readers by alerts. And I must mention, Jef Raskin’s  legendary book: the humane interface, that addresses this point.

Effect of point-of-care computer reminders on physician behaviour: a systematic review

Law, A. et al., 2005. A Comparison of Graphical and Textual Presentations of Time Series Data to Support Medical Decision Making in the Neonatal Intensive Care Unit. Journal of Clinical Monitoring and Computing, 19(3), 183-194.

Another big mistake is the concept of an application. Applications are programs that prevent you from using most of the power of your computer. They are walled cities. When I am using my CAD package, I am prevented from using the spelling checker in my word processor. When I am using my word processor, I am prevented from adjusting the gray scale of the lettering as I can in my image processor. When I am using my image processing program, I am prevented from solving equations, and so on. Make up your own list. Some operating systems build tunnels between applications that we can crawl through (Microsoft’s OLE, Apple’s Publish and Subscribe features, HP’s New Wave, for example), but we want to run aboveground.

This is quote from an article by the diseased guru of of interface design Jef Raskin. This article was published by WIRED magazine in Dec 1993. This is a link.

This quoute deserves no further explanation. Within health care the design of workstation should be reconsidred using Jef Raskin’s recommnedations. If you have not read his book “The Humane interface” then it is time for it.

I will leave you with another quote form the same article:

Designers forget that humans can only do what we are wired to do. Human adaptability has limits and today’s GUIs have many features that lie outside those limits, so we never fully adapt but just muddle along at one or another level of expertise. It can’t be helped: Some of the deepest GUI features conflict with our wiring. So they can’t be fixed. Like bad governments, they are evil, well entrenched, and must be overthrown.

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We all agree that formatted text and text within forms cannot convey the subtleties conveyed by freely written natural language. Yet, informaticians push for standardized text entries. Using today’s technology, codifiable and formatted text allow for easy extraction of data. The extracted data can be flexibly used in foreseen and unforeseen uses. Two foreseen uses are conducting studies and designing smart decision support systems.

On the other hand, extracting data from naturally written text (non-codifiable and non-formatted) is hard, and with today’s technology unreliable.

Is there a compromised? That is having data within EMR that can convey the subtleties of language and at the same time be flexible enough for utilizing this data for things as research, QI and designing smarter decisions support systems.

I do believe that writing naturally and conveying the full meaning of text comes first. We should wait for technology to change and improve instead of forcing people to change their writing style to a less effective style. Yet, if I am to compromise I would present the following rule:

use codifiable and formatted text entry only when the writer and reader have similar background knowledge

Follows is the rational for this rule:

The goal of text is to transmit meaning through time and space. Whatever ‘meaning’ is enclosed in written text will need to be read for this meaning to be transmitted. In my post titled ‘understanding reading’, I illustrated how readers use their previously held knowledge to fill in the gaps present in text. I illustrated how McNamara and Kintsch (1996) showed that broken text can be comprehended by knowledgeable readers. Therefore, readers with the appropriate background knowledge may be able to understand codifiable/formatted text. For such readers, the use of the full range of language may not be necessary.

The only possibility for the writer and the reader to have the same knowledge is for them to be the same person. A close enough proposition in healthcare is when the reader and writer have similar: specialty and/or experience.

Here are three examples that apply this rule:

Progress notes in an outpatient office will have limited number of writers and readers. These will have similar background knowledge. Therefore, we may be able to use codifiable and formatted text in outpatient progress notes. However, progress notes in in-patient settings have diverse writers and readers. Likewise, discharge summaries have diverse writers and readers. In these two situations, allowing for natural language will assure better transmitting of meaning.

McNamara, D.S. & Kintsch, W., 1996. Learning from Texts: Effects of Prior Knowledge and Text Coherence. Discourse Processes, 22(3), 247-88.

Finally, it is worth mentioning, included in our subsidiary awareness is our previous experiences, biases, beliefs, tasks and goals.(Brohm 2005) Out of these subsidiary awareness components our focal awareness is formed.

If our brains only had the two processes of information perception of Shiffrin and Schneider (1997) , than our subsidiary awareness is probably formed by automatically perceived information. The meanings formed from these perceptions are meanings we started attaching since or birth or even before that. Our previous experiences, biases, and beliefs are some of the meanings we are attaching to perceptions every day of our lives. We do need to take care to what meanings we attach. Especially knowing that it takes extra efforts to unlearn and relearn new meanings to our perceptions. And even if we are unconscious of it, these meanings play a role in our focal awareness. Shiffrin and Schneider (1977) found that automatic processes are hard to stop. Once started they usually finish. We can try to attenuate the stimulus that started them or try to start another automatic process to stop them. An example of an ingrained meaning that is attached to a stimulus is one that I mentioned in another post. In china’s stock market red means the opposite of what it means in the US and most of the world. In china red means the price is up!

I do need empirical evidence to support my above claim. There is already empirical evidence that connects automatic perception to racial biases. But, more evidence is needed to support my claim.

I will end with restating the implications to health informatics:

When we design even the simplest interface we are designing a virtual reality environment (a theatre stage). This necessitates the care for the smallest details; as these will be parts of users’ subsidiary awareness. This environment needs to make sense to users. Over time, consistency in this environment’s details will form the users’ logical expectations which in turn will allow users to make sense of things.

1. Given the documents in paper form

2. Documents given as PDF documents

3. One page summary of documents in PDF format. These participants were allowed to download the full document if the desired to.

Although the first two categories relevance score was higher (63%) than the third category (57%), the difference was not statistically significant. Yet, the behavior of assessing these documents was quite different between these three categories. Probably the most striking is that within the digital categories, participants spent most of their time on the first page (64%) and 34% did not even scroll down the first page! When comparing the second group (Full PDF document group) with paper group, this group spent more time scrolling (15%) and less time stationary reading (17%) compared to the paper group (<5% and 50% respectively)!

This study shows that computers’ affordances does not guarantee use. The presence of scrolling, document download, and page flipping did not lead to their use by the participants. We need to understand human’s psychology. And, then design better computer affordances.

Buchanan, G. & Loizides, F., 2007. Investigating Document Triage on Paper and Electronic Media. In Research and Advanced Technology for Digital Libraries: 11th European Conference, ECDL 2007, Budapest, Hungary, September 16-21, 2007, Proceedings. Springer-Verlag New York Inc, p. 416.

Oxford’s definition of skimming is similar to what Nygren and Heriksson intended it to mean. Oxford defines skimming as to read through quickly, noting only the important points. The goal is to assess the relevance of text. In skimming we use as many clues as possible to assess relevance.(BBC) Therefore, skimming is a form of information relevance judgment. The search within health informatics literature did not reveal information on this process. Yet in library science there are similar concepts as the more general information triage and the more specific document triage and document relevance judgment. Buchanan and Loizides (2008) define information triage as the activity where a user determines the relevance of a piece of information for a particular information task.

The focus of literature in document relevance judgment went through three stages. (Buchanan and Loizides 2008) All of these three stages point to how skimming is performed and how we can support it through providing affordances. The three stages are:

1. Focusing on properties of the document as title and abstract. In this stage, there was no focus on how the properties of the document were assessed.

2. How to operationalize above document properties to support document retrieval and search.

3. Shifting the focus on the documents to the focus on the corresponding human processes.

To better understanding information triage, Cool et al (1993) conducted a study to assess document features that helped 300 freshmen student to assess the relevance of scholarly documents to their assignment topic. Cool et al were able to categories these features into six categories. Only two were directly related to the documents’ content. These two are the topic and content of the document. The remaining four features are as follows:

1. Format characteristics of the document. Features as the presence of diagrams, tables and sub-headings were categorized under this heading.

2. How document was written and presented. Features as precision, writing style and understandability were categorized under this heading.

3. Dimensions of judgment that modified other facets. Features as authority and biases of authors and age of document was placed hear.

4. Oneself relationship between person’s situation and the other facets. The need and desire of reader were placed here.

I can conclude that information triage literature can be used to understand how clinicians skim medical records, yet there should be studies that directly assess this within clinicians practice context.

Buchanan and Loizides (2007) study compared the behavior of document triage using paper and PDF documents. Their study adds to our understanding of human psychology and the affordances of paper and computers. In the coming post I will summarize their study.

Buchanan, G. & Loizides, F., 2007. Investigating Document Triage on Paper and Electronic Media. In Research and Advanced Technology for Digital Libraries: 11th European Conference, ECDL 2007, Budapest, Hungary, September 16-21, 2007, Proceedings. Springer-Verlag New York Inc, p. 416.

Cool, C., Belkin, N. J. , Frieder, O. , and Kantor, P., 1993. Characteristics of texts affecting relevance judgments. PROCEEDINGS OF THE 14TH NATIONAL ONLINE MEETING, 77–84.

Nygren, E. & Henriksson, P., 1992. Reading the medical record. I. Analysis of physicians’ ways of reading the medical record. Computer Methods and Programs in Biomedicine, 39(1-2), 1-12

Understanding text is the conversion of text to a representation of it in our brains. This representation can be multilevel. The lowest is the surface drawings of letters. The highest representation is commonly called situation model (SM).(Graesser, Millis and Zwaan 1997) Situation model is a multidimensional representation of the text that is formed by the interaction of the text and the reader’s previous knowledge. The reader performs different inferences based on the text and his or her previous knowledge to create this high level representation. There is agreement on the content of this representation as proved by empirical evidence. The structure and storage location of this representation is still debatable.

Here is an illustration of the presence of situation model (SM). Read the following two sentences: (Zwaan 2003, p94)

Harry put the wallpaper on the table. Then he put his mug of coffee on the paper.

Harry put the wallpaper on the wall. Then he put his mug of coffee on the paper.

You probably balk with the second sentence. The reason is as you were creating a representation (unconsciously) of the text, the formed SM is impossible. It is impossible to have a mug of coffee on a vertical surface. If readers did not create this representation and only rely on the surface meaning of text they would not balk with the second sentence.

Empirical evidence illustrates five dimensions or contents of situation model. These are:

· Space (location)

· Time (sequence and duration)

· Protagonist (entities and objects)

· Causality (cause and effect)

· Intentionality (goals and motivation)

(Therriault, Rink and Zwaan 2006)

Two of the methods used to test for the presence of these dimensions are:

1. Participants read text where information about a dimension is not explicitly present. Readers then, need to answer questions that require them to make inferences based on the read text.

2. Participants read text with shifting in a given dimension as a shift in space or time. The reading time will be compared to similar text where there is no such shift. Readers usually take longer to read the text with shifts. The following passage is from a research conducted by Therriault, Rinck and Zwaan (2006). You can notice continues shifts in protagonist, location and time. Such text takes longer to read when compared to text that does not contain all these shifts.

Paul took care of the garden, which he had declared his territory, whereas Frieda started to tidy up the house. The morning air was pleasant and refreshing, so she opened all the windows and let spring reach every corner of the house. Then, in a spirit of adventure, she climbed up to the attic. There she searched old boxes and shaky cupboards, and she checked for mice. At noon, she cleaned the winter dust out of the hall and tidied up her beloved cabinet. The noon sun was quite warm already, so she interrupted this work for some time while she closed all the windows to keep the house pleasantly cool.

Readers strive to create a coherent representation or SM. (McNamara 2001) (McNamara and Kintsch 1996) (McNamara et al, 1996) As there will never be a text that ‘tells’ everything readers will always need to fill in gaps based on the text they just read and based on previously held knowledge. (Walsh 2006) McNamara conducted three studies to assess the relationship of the level of coherences (less gaps within text) and level of readers’ comprehension. Coherence was improved by adding more explanations and definitions to possibly unfamiliar text. McNamara studies showed that for answering questions that require making inferences, knowledgeable readers did better. On the other hand, readers with less background knowledge did better with the more coherent text.

In conclusion, reading that leads to understanding is a process of creating a coherent multidimensional representation (situation model) by combining what is read and the readers’ previous knowledge.

Walsh (2006) went further in pointing out the shift in today’s readers and learners. Today’s, readers and learners receive multimodal inputs. Text is only one mode. Graphs, images and multimedia are other modes. Walsh also describes this interaction as being dynamic. Walsh points out that all these inputs will play a role in forming SM. I will go a bit further is stating that for clinicians there is even more input modes. When a clinician is assessing a patient, all senses are providing inputs. Therefore, all these inputs are probably playing a role in creating the representation of reality; situation model.

Graesser, A.C., Millis, K.K. & Zwaan, R.A., 1997. Discourse comprehension. Annual Review of Psychology, 48, 163-189.

McNamara, D.S., 2001. Reading both high-coherence and low-coherence texts: effects of text sequence and prior knowledge. Canadian Journal of Experimental Psychology = Revue Canadienne De Psychologie Expérimentale, 55(1), 51-62.

McNamara, D.S. & Kintsch, W., 1996. Learning from Texts: Effects of Prior Knowledge and Text Coherence. Discourse Processes, 22(3), 247-88.

Mcnamara, D.S., Kintsch, E.,  Songer, N.,  Kintsch, W., 1996. Are good texts always better? Interactions of text coherence, background knowledge, and levels of understanding in learning from text. Cognition and Instruction. Vol. 14, No 1.

Therriault, D.J., Rinck, M. & Zwaan, R.A., 2006. Assessing the influence of dimensional focus during situation model construction. Memory & Cognition, 34(1), 78-89.

Walsh, M. 2006. The ‘textual shift’: Examining the reading process with print, visual and multimodal texts.Australian Journal of Language & Literacy.Vol. 29, No.1, p24-37

Zwaan, R., 2003. Text comprehension. Handbook of Discourse Processing, Lawrence Erlbaum Associates. Mahwah, New Jersey, USA.

Having took the time to write posts on medical records goals and on affordance,  I will re-write a post on the divide between affordances and goals. In my previous post, I used the term purpose instead of goals. In this post I will stick with goals.

The focus of this post is the study conducted by Nygren and Henriksson (1992). It is the only study I passed by that truly tries to understand what actually takes place when physicians are using medical records. This study only focused on paper medical records. Conducting a similar study to understand how physicians use electronic medical records (EMR) would be much more challenging due to EMRs diversity.

This study illustrates neatly the more elusive goal of using medical records which is as an intellectual tool. P-MR is a tool that supports physicians’ cognitive processes including decision making.

Yet, I differ with the authors in using the term ‘goals’ in describing their main findings. They found that physicians used P-MR to: (link to a summary of the study)

· Gain overview

· Trigger memory

· Search for facts

· Problem solve

I still stand by my opinion that physicians use medical records for the two goals I mentioned in my previous post: communication and intellectual tool to support cognitive processes.

These four points are more off affordances than goals. Yes, authors did mention three other affordances of P-MR:

· Reading

· Skimming

· Skipping

But, I believe all of these seven should be called affordances. To reap the first four affordances you need to perform the latter three. Gaver (1991) call affordances that can only be appreciated after performing the action with proceeding affordances sequential affordances.

The purpose of Nygren and Henriksson (1992) study was to find how physicians use P-MR to match these to develop better computer interfaces. However, matching affordances should not be our goal. Matching the ultimate goal of P-MR is a more worthy goal. Computers may offer better affordances that if utilized will reach the goals of P-MR without the need to match paper affordances. Yet, Nygren and Hendrickson enrich our knowledge on the application of affordances in a more critical way. If you recall the definition of affordance:

an action possibility available in the environment to an individual

-McGrenere and Ho, 2000

Affordances relate to individuals. For example, when designing stairs the height of steps must allow humans to easily use them. Too high steps will make climbing hard if not impossible. Affordances of EMR should address how can humans use them. Nygren and Henriksson study does just that. It allows us to understand how physicians think. This knowledge is needed to design tools that will be used by our brains. This knowledge is needed to design EMR affordances.

In following posts I will try to understand how humans of read, skim and skip. This knowledge will be necessary to design EMR affordances.

Gaver, William W. (1991): Technology Affordances. In: Robertson, Scott P., Olson, Gary M. and Olson, Judith S. (eds.) Proceedings of the ACM CHI 91 Human Factors in Computing Systems Conference April 28 – June 5, 1991, New Orleans, Louisiana. pp. 79-84.

An Affordance is an action possibility available in the environment to an individual, independent of the individual’s ability to perceive this possibility.

-McGrenere and Ho, 2000

Affordance as a concept was imported into the world of design and human computer interaction by Norman (1988). He imported it from the work of Gibson on visual perception. Yet, Norman’s views differ from Gibson’s. For a discussion of these differences and a better understanding of affordance you can review this summary at Interaction design.org.

I will adopt Gibson’s view as it is the most agreed on. (McGrener and Ho 2000). Affordances are properties that can be used by an actor as a human whether these properties are perceived and realized or not. Norman discounts affordances that are not perceived by actors. While Gibson account for all properties that can be acted on whether perceived or not. A designer may design a useful device that a given user can only use some of its features. For example, paper has the affordance of being written on and being carried. Paper has also the affordance of being turned into a paper airplane whether you realize this affordance or not.

In this post, I am proposing that one of the main reasons for poor computerization of manual processes in health care is the poor understanding of computer affordances. There are valid reasons for this suboptimal computerization that I will mention at the end.

I will take you through a scenario. Imagine the presence of a paper form that represents a single encounter with an asthmatic patient. Being a physician, you need to fill out the form and then sign it off. It is expected that you don’t make changes to the form after you sign and date it. This form was computerized. When this form was computerized, computer affordances were ignored. The Designer required physicians to sign off the electronic form to prevent any modifications afterwards. More, the designer did not allow physicians to update signed forms, claiming the need to know who made which updates and assuming that this cannot be offered by computers.

If the designer of this computerized form realized the full potential of computers s/he would have realized that computer forms afford features like the ability to store different versions. More, computers afford the ability to know each update and who made these updates. What Google is trying to do with transforming e-mail through its upcoming product Google Wave is an example of deep understanding of what computers afford.

Now for the excuses for not embracing the full range of computer hardware and software affordances: Technology changes fast. Technology is also complex and expensive. When technology changes affordances change. The adoption of these new affordances will require the understanding of complex technology and expenditure of money. For example, e-ink was introduced in 2002 and only now has it been spreading when Amazon released its e-book, the kindle. This computer technology affords better readability and better mobility due to its long battery life and low weight. Adapting such technology will require the embracing of advances in networking and software development. However, it seems that in health care we are always lagging behind. In healthcare, it is time to be more agile.

In a coming post will discuss some of the ignored paper affordances.

McGrenere, Joanna and Ho, Wayne (2000): Affordances: Clarifying and Evolving a Concept. In: Proceedings of Graphics Interface 2000 May 15-17, 2000, Montreal, Quebec, Canada. pp. 179-186.
Norman, Donald A. (1988): The Design of Everyday Things. New York, Doubleday