Notes to go w/ PPT given at AMIA’s Annual Symposium.

1. Intuitive Information Technology
AMIA
1. Intro
2. Warren Bennis quote – Intro of technology vendors
a. Gabe from Salar
b. Jay from Expedata
c. Lloyd from AVS/Medical
3. Objectives
4. If the heart of the matter is about how to pass information back and forth between the EHR – then
the next mental leap forward is really about speed, ease of use, economy of movement, portability,
flexibility, reliability, predictability, efficiency, and patient safety. But, in order to be truly
intuitive, healthcare technology must be as natural and uninhibited as the most common things we
do every day. Things we don’t think twice about. There’s a balance, though, between making the
technology transparent to the user yet allowing them to interact with information in a digital
environment that promotes efficiency, familiarity, and knowledge. Most importantly, technology
should “do what you expect or anticipate it to do.”
5. Tom Graves quote on Intuitive Technology
6. Patient Safety slide:
Green: Dinamaps, BCMA -> Workarounds -> Pt A, Pt B Safe/Excellent Care? Perceptions vary
Yellow: Neg Attitude, Rn away from Pt -> BR (Fall, Skin, Incont, Neuro, CCU), Rapid R Team,
Pain Meds
Red: Order Sets, CarePlans (Familiar, Evidence Based, Homegrown) -> CPOE (where’d it go?) ->
Freelance, Lack of standardized care, care based from memory, not all sets in CPOE(?)
7. Technology also impacts an entire organization in ways that can either upset or promote the
balance of the infrastructure. To depict this, we used the Organizational Balanced Scorecard.
The four quadrants:
-Customer Relations.
-Positive Work Environment.
-Financial Health of the organization
-Finally, Patient Care quadrant, we’ve labeled it Quality Care, you might find patient safety
initiatives in this area or things that impact patient outcomes
What we’re depicting here is the traditional interaction of information systems and clinician
efficiency:
We don’t want to focus on one quadrant to the detriment of the other three or the overall lack of
organizational health.
8. First discussion stop: Impact of technology upon Clinician Efficiency

2. 9. Here is one consulting firm’s depiction of the “IT footprint” found within hospitals today. It’s not
a bad depiction.
Very disparate. Systems chosen by either best of breed or best of suite. In any case we end up
with a facility whose systems either do not interoperate or one in which we have to work
exceedingly hard at getting them to “talk” to each other – and even then, that interoperability has
it’s limits.
In an environment where “speed to value” is prized, this piebald approach to technology reflects a
“long time to value” reality. And it definitely impacts the entire facility.
10. I don’t need to read through this list for you to get the drift – physicians feel that EHRs have a
long way to go.
They have not been implemented on nearly as grand a scale as people might suppose them to be.
Some implementations have failed miserably – and the HIS vendors struggle as they continue to
improve themselves with each version. And they will improve – I’m sure of that.
So, what, generally, have physicians voiced an opinion about with regards to EHR?
-cost: is always an issue. EHR’s are expensive. This is especially a concern for the ambulatory
care setting, where budget for an EHR comes directly out of the physician’s pocket.
-usability: Anything that impacts efficiency, impacts a physician's ability to see more patients –
and that hits the bottom line.
-training: If it causes more pain to learn the application than the pain it’s supposed to alleviate,
people are not going to show up for training – and if they don’t show up for training, they won’t
use the technology, at least not efficiently.
-support: Who’s there to help you when you can’t get it to do what you need it to? The better an
application is supported (with quicker response times) – the more likely it is to be used. The more
reliable a technology is – the more likely it is to succeed.
-involvement: Did they have a say in it? Did anyone ask them their opinion? If they sat on the
committee that helped evaluate technology and the vendors that create that technology – then
there’s some pride and ownership involved at the end-user level. Perhaps they will put more effort
into making the technology a success.
11. We see here that clinicians, specifically, nurses feel much the same way about the technology they
are currently using as the practitioners do.
Again, we have seen some trends in what nursing has to say about EHR technology:
-Reliability, Usability, & Functionality are some of the key components we found in our review
of the literature. Tied into that is that vendors are having a difficult time making applications
scalable. Nursing represents the largest workforce within Healthcare today and the systems we ask
them to use demand the capability to sustain high volume traffic with quick response times to a
high degree of reliability. If this need is not met – nurses are not going to use it.
-Training, again is a similar headache for nurses as it is for practitioners. Nurses are a major
workforce to rotate through courses (paying for extra hours to come in on their days off) and to
develop special material to bring them up to speed on today’s technology – considering the
average age for a nurse is well above 40. This is not to say that nurses are old or stupid, by any
means. We have nurses flying helicopters, running the ICU, OR, and ED, managing balloon
pumps and Art Lines. What we do need to consider is that the training material is paced correctly,
meets their initiatives, sets the proper expectations, and treats all end-users with respect.

3. -Involvement is another prime way to gain adoption and ensure success on the clinical floor. Ask
your nurses to help choose the technology that is going to impact them – what is going to make
their lives more efficient and keep their patients safer. For now, variety tends to play a role in
device selection – and this seems to be perfectly normal. We see this more and more as we
consider the end user, such as social workers and case management or respiratory therapy and PT
but we also need to keep the personality, culture, layout, and workflow of specific units in mind.
What works on the Renal floor or the Rehab unit may not work in ICU, the OR, or the ED.
12. This diagram and the accompanying Hypothesis is rather simple. It states that: When the
technology provided to clinicians and practitioners works smoothly intuitively (in other words
with the subtle twists of reality rather than trying (and failing) to overcome them by brute force)
this is when the critical balance between efficiency, safety, and quality will come into play.
13. Values of Various Technologies slide
14. Earlier tonight, Gabe showed us some interesting ways tablets are being used. But how are tablets
being effectively and successfully deployed today in healthcare?
We have heard so much noise in the marketplace about tablet technology, how wonderful it is,
how healthcare is going mobile, and how clinicians love this concept. But we have not found
widespread evidence of this in our review of the literature. We have found very few examples of
hospitals that have enjoyed widespread success of standalone tablet technology deployed to their
nursing staff. What hospitals have done is replaced their wall-mounted or push-cart or desktop PC
with a tablet. This is not truly using tablets as a tablet – a truly mobile device. Hospitals have
resorted to this because initially they thought tablets could be used as the end-all be-all interface
for clinical documentation and those experiments failed miserably when used by clinicians, for
multiple reasons.
One way of making a better fit for tablets is to build tablet applications around specific tasks and
with the end user in mind. Hospitals that have deployed tablets in this manner have enjoyed a
higher user adoption rate with better use of tablets as a resource because they planned ahead as to
how, when, and who would be using the tablets for which specific tasks.
Finding ways to use tablets where tablet technology makes sense includes using tablets for their
best, inherent qualities: taking photos, biometric processing, RFID, bar-code scanning, writeable
interface with a stylus, intelligent forms, and specifically, the primary user groups.
It then makes sense to look at when, where, and why those interfaces need to be used and make a
determination based off of the primary user. Are the users surgeons and anesthesiologists? Are
they clinicians on the Med-Surg unit? Are they the registration staff doing bedside admits? Are
they the entire social services team that travel over several floors? Are they perhaps the patients?
Hospitals that have approached tablets in this manner have reported very favorable results.
They’ve deployed tablets more intuitively and intelligently having designed applications where
tablets meet a specific need within the healthcare environment which, in turn, provide measurable
results within that user group and the patients they serve.
All in all, this becomes a case of really looking at how you want to use tablets as tablets and in a
way that embraces what the technology represents as well as how it best fits your intended user.

4. There are a few general considerations a facility needs to keep mind; however, when
contemplating a tablet rollout:
Wireless: 100% coverage basically means wall-to-wall and floor-to-ceiling. You have to have this
type of architecture in place to effectively support tablet rollout. Otherwise, your clinicians and
practitioners are going to be very frustrated with limited usage. And that’s the case with any
wireless device, so this is nothing new, really.
Infection Control: Briefly, there was a recent survey of 100 physicians who indicated that the
risk of infections from mobile computing devices is a barrier that must be addressed before more
practitioners use this technology
15. Discussion Stop
16. Digital pens – what a fascinating technological tool.
We heard earlier from Jay about how they work and saw their capabilities, but how are people in
Healthcare using digital pens?
Suburban Hospital’s ED physicians were using an EHR but feeling the pains we outlined on
previous slides. Physicians were encumbered in a system where data entry was completely
manual, training was intensive, and the system was hard to use. They were losing 30% of their
patients and their productivity was greatly hampered. Something had to give. The physician’s
designed and standardized paper templates and then thought hard about how best to get the
information into their EHR most efficiently. They trialed tablets – but tablets were too
cumbersome and although 2 lbs doesn’t sound like a lot of weight – carrying it around for 12
hours adds up. So, the ED physicians turned to a digital pen solution and have been thrilled with
the result. For a Level II Trauma Center that sees 40k ED visits a year, that’s noteworthy. The ED
physicians have seen an increase in productivity, efficiency, and have enjoyed flexibility in
charting methods. They have even helped another ED in Houston launch a similar solution
successfully.
Country Villa Health Services has 50 healthcare centers, 20 skilled nursing facilities, and consults
to 20 hospitals nationwide. They deployed digital pens to track pressure ulcer development in
patients. Through use of digital pens, they were able to collect this data faster and more efficiently,
providing more reliable reports that could be shared across all caregivers. The result was a 30%
reduction in pressure ulcers. What started as a trial in their skilled nursing facilities is now being
launched throughout all of Country Villa Health Services.
Cherokee Indian Hospital Authority took a different approach to integrating digital pens. They
were among one of the first health care organizations to test this type of technology and they chose
to deploy it in their billing department for insurance coding. To manually code a transaction costs
them $2, but coding a transaction using digital pen only costs them 50 cents. For this facility –
they found a huge ROI in using digital pen technology.
Thomas Jefferson Hospital is using digital pens for asset tracking and logistics management.
17. Discussion Stop…

5. 18. Lloyd showed us this evening just how far Voice Recognition software has come in recent years.
But who’s using it today in healthcare?
Heritage Ministries Management in New York is using voice recognition in 3 Skilled Nursing
Facilities. In fact, their nurses are using it for all of their charting and, by doing so they have
eliminated 30 minutes at the end of each shift. [This is exactly the type of Batching example we’ve
discussed on the grid we’re building with the flip chart – latent charting.]
Some specialty Physician practices are using voice recognition, such as plastic surgery and
ambulatory care, in fact, Advanced Healthcare, an Ambulatory Surgical Center that operates 14
clinics and 3 ASCs has over half of their physicians using voice recognition software. They have
been impressed by how robust the software has become as well as its ability to instantly recognize
individuals with foreign accents.
19. Discussion Stop
20. We saw earlier some video examples of what surface technology looks like and briefly discussed
what it’s capabilities were. As a basic technology, it’s easy to recognize that it breaks down many
of the traditional barriers. But who is using it today – and how?
InterKnowlogy has developed two healthcare products using surface technology. One is a virtual
viewer for the cath lab – angiography - that is currently being used at InterMountain Health. The
other is a molecule viewer developed for Scripps Research Institute for the scientists trying to
unlock the mysteries of breast cancer.
Teliris is a company that specializes in delivering virtual meetings for organizations where
conference calls play a big role. Naturally, Teliris saw a huge opportunity with surface technology.
They have developed the interactive virtual flip-chart and whiteboard for telepresence designed
specifically for collaborative business use. They have also integrated surface computing into what
they call a “revolutionary TouchWall” and “TouchTable” that allows documents, video, audio,
presentations, and other content to be shared instantaneously and easily across multiple locations.
Harrah’s Rio All-Suite Hotel and Casino in Las Vegas has also implemented surface technology to
give their guests an engaging and uniquely personalized experience when they visit. They have
developed custom applications that allow guests to locate information, play games, or order items
off the menu.
Finally, AT&T has deployed surface technology in key locations that focus on the technology’s
ability to recognize devices placed, well, on its surface. Customers wishing to find out more
information about the cell phones they’re interested in purchasing, simply lay the model on the
surface and watch as information spills out onto the interface. If more than one cell phone is
placed on the surface machine, a comparison between devices is displayed.
21. Discussion Stop.
What do we do, though when the IT department is pushing towards a mobile platform that is more
aligned to tablet technology but the end-users, perhaps clinicians are more in favor of a mobile
platform such as digital pens? In this scenario, we’ve seen clinicians become very excited about
technology like digital pens but then the IT department sees digital pens as two steps backward in
accomplishing the Strategic Vision.

6. 22. In everything there needs to be a balance. The right tool for the right job and in the hands of the
right person.
Combining tablets and digital pens by intelligently and thoughtfully examining how each might be
used for unique purposes and workflows is truly a way to be intuitive about implementing
technology for clinicians and practitioners. Considering that perhaps 70-80% of all charting is
done in the EHR on wall-mounted units, it might make sense to use tablets to capture signatures
on Informed or Procedural Consents. In the same way we could undock tablets when we need to
use the camera feature to track wound or pressure ulcer progression. Your physicians might want
to use tablets for daily use of charting progress notes, discharge orders and summaries, or
treatment plans. With this last user group we start to see that we can narrow the scope by looking
at user groups. Do we want to consider physician practice groups and specialties as a specific user
group that might approach tablets in a unique way as a daily tool to use more than another?
Digital pens come into play as a parallel technology that brings value in being able to p pick up the
rest of the paper trail that has been left out of the EHR. By looking at things that EHR doesn’t
provide for us today, or things that it doesn’t do to our satisfaction, we can look at ways to address
additional printed items that are currently in circulation. Depending on your stage of EMR rollout,
this could be a lot of paper or only the items that are patient-facing – things like Discharge
Instructions, MRI Questionnaires, Coding and Abstracting, or patient journals. Anesthesia
Assessments are an interesting item to consider for digital pen because we begin to look, again, at
a very specific, yet mobile group of user – anesthesiologists. The interview they perform as part of
their assessments at the bedside of patients tends to be standardized, including the Mallampati
scores – but equipping anesthesiologists with a digital pen provides them a mobile technology that
is both very portable, lightweight, and still sends all the pertinent data directly into the EHR once
the assessment is completed. It’s an interesting area to consider. Along the same line – surgeons
also tend to visit their prospective patients. Would a digital pen be an asset in the hands of a
surgeon? How often do surgeons create drawings of the upcoming procedure (or perhaps in Post-
Op explaining how things went) and then wish that drawing could somehow be digitally
represented in the patient’s chart because it was part of a really great patient interaction? A digital
pen would allow them that flexibility. Again, this is a specific task and a specific user group.
Thinking of situations where specific types of technology makes the best sense, especially in light
of the end user, we start to see that technologies previously thought to be antagonistic to each
other –can actually work in synergy.
One example of this is the EMS Squads in Ireland. They are using both tablets and digital pens for
their paramedics – to a high degree of success. They provide digital pens for squads in very rural
communities without immediate access to computers but then provide tablets for squads in more
urban areas. They have found that offering this variety has improved user adoption and likelihood
of accessing the electronic Patient Care Reports enhancing flexibility, functionality, and
affordability.
This is an example of combining technologies to use their best feature functionalities in the best
use cases. Why not use each for their strengths?
23. Discussion Stop
So how do we tie all these wonderful technologies together in a way that truly embraces the focus
of today’s discussion – Intuitive Technology?

7. 24. This is where the rubber has to meet the road.
Combining speech technology with a surface interface could be one of the most innovative and
intuitive ways to integrate technology in a healthcare setting.
If clinicians charted verbally (as many of us were taught to do in our clinical assessment classes)
could we eliminate the need for manual input of data.
When we pair speech recognition with surface - can you imagine the impact this would have in an
ED trauma bay? If the room is wired “hot” it could record what is being said without the need for
a designated code recorder. How would this work in a trauma bay where there are multiple people
talking at once? Radio technology today has the capability to recognize primary speakers. For
instance, when the pilot of an aircraft is speaking, the microphone of the copilot is automatically
subdued. We could adapt this same type of technology for healthcare to use in trauma. For
instance, we could wire the MCP and the lead trauma nurse setting a priority protocol that the
room would recognize above the general room noise level when it’s recording information as well
as when requests for information are being voiced.
If we continue the scenario, we might see: vitals from the code displayed on the wall of surface
technology as soon as the patient was hooked up to the monitor; resuscitative drugs listed in the
order, dosage, and route given – immediately after they’ve been pushed; and the physician able to
verbally call up any existing data from the patient’s chart that might assist with the trauma at hand.
Additionally, whatever information the paramedics have – a run sheet for instance – can be placed
on the surface wall and instantly digitized and synced into the patient’s legal record, available for
viewing so that the entire trauma team knows exactly what happened on scene in a matter of
seconds.
The possibilities are endless – so intuitive and natural!
Finally, when the code has been mediated, well – the event has already been recorded and charted.
The physician has the option to record a short narrative. We have just severely limited latent
charting yet provided instant patient-specific clinical decision support during one of the most
strenuous patient events that takes place in our hospitals today.
I know some of you are worried about gooping up the Surface Wall in a messy GSW. But that’s
the beauty of voice recognition being paired with this. Just say it and it’s there. Additionally, they
are now looking at a touchless technology that doesn’t require direct touch, so the ability to
gesture away from the wall might also be a possibility – and it would save a little clean up time in
the end.
Other than being an interesting place to work; however, how might intuitive technology like this
really impact the healthcare organization?
25. Discussion Stop
26. TS Elliot quote