Embracing Technology is DUMB.

Embracing Well-Designed
Technology is Smart
Dr. Ben-Tzion (Bentzi) Karsh
Associate Professor
Industrial and Systems Engineering Department
Systems Engineering Initiative for Patient Safety
University of Wisconsin-Madison
(AHRQ: R01 HS013610 (PI-Karsh))
(NIH 1R01LM008923-01A1 (PI-Karsh))

Take Away Messages

We know that patient safety problems are the result of
the interaction between people, the technology they use,
and the system in which they workSO LEARN HOW
TO UNDERSTAND YOUR SYSTEM (dont focus on
technology)
There is a science devoted to understanding how to
design technology to support human performance
(physical and cognitive). Its called human factors
engineering (HFE)LEARN ABOUT IT!
Technology needs to be designed to be a team player
ANYTHING LESS IN UNACCEPTABLE
HFE research makes clear that technologies are NOT
solutions; they should be ASSISTIVE DEVICES!
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Main Take Away Message

THE ROAD TO PATIENT SAFETY AND HIGH
QUALITY PATIENT CARE RUNS THROUGH
THE PERFORMANCE OF YOU AND YOUR
STAFF
So if your technology is bad, your performance
will be bad. If your performance is bad,
quality and safety suffer
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Is there evidence HIT improves

patient safety or quality?
CPOE and CDSS?
Yes: (Kaushal & Bates, 2001; Kaushal, Shojania, & Bates, 2003; Mekhjian et al., 2002; King, Paice,
Rangrej, Forestell, & Swartz, 2003; Potts, Barr, Gregory, Wright, & Patel, 2004)

Bar coding?
Yes: (Poon et al. 2006; Kaushal, Barker, & Bates, 2001; Puckett, 1995; Wald & Shojania, 2001)

EMRs?
Yes: (Mitchell and Sullivan 2001; Gill et al. 2001; Legler and Oates 1993, Ornstein and Bearden 1994,
Solomon and Dechter 1995, Mitchell and Sullivan 2001, Garrison et al. 2002)

But something isnt right

EMR
Concerns related to cost, a lack of tested systems,
number of steps to complete tasks, problems with data
entry, inexperienced vendors, confidentiality, and security
found (Ornstein and Bearden 1994, Wager et al. 2000, Mitchell and Sullivan 2001)
Entire systems have been abandoned because of
problems with poor reliability, poor credibility, poor
consistency, and problematic user interface design (Lawler et
al. 1996)

But.
CPOE
Systems have been abandoned (Prabhu, 2003)
CPOE can increase the incidence rate of
errors, adverse events and mortality (Koppel et al.
2005, Nebeker et al. 2005, Thompson et al. 2005, Han et al. 2005)

Bar coding
Nurse dont use it as they are supposed to
and mistakes can still be made (McDonald 2006;
Patterson et al. 2002, 2006)

But.
Smart IV pumps
We found no measurable impact on the
serious medication error rate technological
and nursing behavioral factors must be
addressed if these pumps are to achieve their
potential for improving medication safety
(Rothschild et al. 2005)

CDSS in CPOE
Physicians override up to 90% of drug alerts
(Weingart et al., 2003)

Oh my

Confession
We dont know to what extent technology
DESIGN has caused patient safety
problems.
In existing studies, it is nearly impossible
to determine what was related to design,
to implementation, to new workflow.
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Whats the Problem?

The Prevailing Paradigm
for healthcare technology?
(stolen from Matt Scanlon, MD)

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How do we get beyond this state of

technology will save me and
technological determinism?
A few propositions

Proposition #1: Stop blaming

everything on human error!

 Human error?

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If the wrong number is keyed in,

is it human error?
At the bar code data committee meeting yesterday,
we discussed the fact that nurses sometimes need
to scan several times before the bar code 'takes'.
The nurse educator said that she teaches
nurses that if they don't succeed on the first couple
scans, to key in the number from the med bottle.

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Human Error?

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Proposition #2: Workarounds and

violations of technology protocols
are GOOD!
When you see them, you should
thank the violator!

Heroes or Dummies?

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Heroes or villains?
Maybe workarounds/violations are the
right choice when the technology is not
appropriate for the situation?
Maybe workarounds are responses to
poorly designed technologies and are
therefore symptoms of the actual
problems?
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Proposition #3: Healthcare

professional rejection of technology
is wonderful!

 Maybe rejection is a sign that smart

people dont want to be forced to work in
ineffective ways
Maybe the technology is not designed to
meet the needs, SIMULTANEOUSLY of
Staff
Patients
Other technologies
Physical layout
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Proposition #4: Only purchase welldesigned technology

Technology as Assistive Device

What is the goal of a
walking cane?
What makes a cane
well-designed for a
particular person?

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Technology as Assistive
Device?
What are the goals of
bar code scanner?
What makes an bar
code scanner welldesigned for the
users?

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Well-designed technology
Better feedback to the user
Better cooperation with the user
Better visibility and transparency of what
the technology is doing
Better matching of designs to mental
models of the USER, not the designer and
not the purchaser
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Example
an A300 crashed in Nagoya, Japan, after the pilots inadvertently
engaged the autopilots go-around mode. The pilots countered
the unexpected pitch-up by making manual inputs, which turned
out to be ineffective. Essentially, the pilot attempted to continue
the approach by manually deflecting the control column, which in
all other aircraftand in this aircraft in all modes except the
approach modewould normally disconnect the autopilot.
However, in this particular aircraft and in this particular mode, the
autopilot had to be manually deselected and could not be
overridden by control column inputs. Consequently, a power
struggle developed between the pilot and the autopilot, with the
pilot attempting to push the nose down through elevator control
and the autopilot attempting to lift the nose up through trim
control. This caused the aircraft to become so far out of trim that
it could no longer be controlled.

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Proposition #5: Use Human Factors

Engineering Expertise

**Use Human Factors

Engineering Design Thinking**
(modified from Sanders and McCormick 1993)

Technologies need to be designed for and to

work with people
Systems must be designed to accommodate the
range of users
How systems are designed will influence human
behavior and therefore system performance
Design needs to be evidence-based, not
common sense or designer driven
All design must take into account the system of
use

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For more information

Karsh, B. and Scanlon, M. (2007). When is a defibrillator
not a defibrillator? When it is like a clock radio. The
challenge of usability and patient safety in the real world.
Annals of Emergency Medicine, 50, 433-435.
Holden, R. J. and Karsh, B. (2007). A theoretical model of
health information technology behavior. Behaviour and
Information Technology, 1-17. DOI:
10.1080/01449290601138245. URL:
http://dx.doi.org/10.1080/01449290601138245
Karsh, B., Holden, R. J., Alper, S. J., and Or, K. L. (2006).
A human factors engineering paradigm for patient safety
designing to support the performance of the health care
professional. Quality and Safety in Healthcare, 15(Suppl
I), i59-i65.
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For more information

Carayon, P. (Ed.) (2007) Handbook of Human Factors in Health

Care and Patient Safety. Lawrence Erlbaum Associates: Mahwah,
New Jersey.
Nielsen, J. Usability Engineering. New York: AP Professional, 1993.
Norman, DA. The Design of Everyday Things. New York:
Doubleday. 1998.
Salvendy (Ed.), (2006) Handbook of Human Factors and
Ergonomics (3rd ed). John Wiley and Sons.
Sanders, M. S., & McCormick, E. J. (1993). Human Factors in
Engineering and Design (7th ed). McGraw-Hill, Inc.
Spath (2000). Error Reduction in Health Care: A Systems Approach
to Improving Patient Safety. Jossey Bass Wiley.
Wickens, C. D., Lee, J. D., Liu, Y., & Becker, S. E. G. (2004). An
Introduction to Human Factors Engineering (2nd ed.). Prentice Hall.
Woods and Hollnagel (2006). Joint Cognitive Systems. CRC Press.
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THANK YOU!
QUESTIONS???
Ben-Tzion Karsh, Ph.D.
Associate Professor
Department of Industrial Engineering
UW-Madison
Contact Information
Industrial Engineering
University of Wisconsin-Madison
1513 University Avenue, Room 3218
Madison, WI 53706
Tel: 608-262-3002
Fax: 608-262-8454
E-mail: bkarsh@engr.wisc.edu
www.engr.wisc.edu/mesh
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