PEN&PAD (Geriatrics): A Collaborative Patient Record System for the Shared Care of the Elderly Heather Heathfield, John Kirby, Anthony Nowlan and Alan Rector Medical Informatics Group, Department of Computer Science, University of Manchester, Manchester M13 9PL, UK Tel: +44-61-275-6133. Fax: +44-61-275-6236. Internet: [email protected] oped a clinical workstation for General Practitioners using a User Centred approach to design and development[2]. We begin by describing our initial phase of work, and the results obtained from it. These results highlight the need to preserve the diversity between the different practitioner groups. The current approaches which may be taken to the design of a unified patient record are discussed and shown to be inadequate based upon the user requirements obtained in this preliminary work. An architecture for collaboration which supports the diversity between practitioner groups is presented. The following section discusses the role of User Centred design in eliciting the requirements of the different practitioner groups involved in collaborative care.
Abstract The PEN&PAD (Geriatrics) project seeks to develop a Collaborative Patient Record Systemfor the hospital based shared care of the elderly. The goal of the project is to produce a single, integrated information system which is both useful and usable by the different practitioner groups involved in geriatric care. A User Centred Design methodology is proposed which makes users and human issues central to the design and development process. Preliminary results indicate that the specification of a Minimum Basic Data Set as the basis of a shared record system is infeasible and undesirable. An architecture is presented which illustrates how the diversity between the different disciplines may be preserved in a Collaborative Patient Record System.
INTRODUCTION The proportion of aged in the UK population is steadily rising and represents an increasing burden on the National Health Service(NHS). The elderly already occupy 40% of all acute hospital beds in the UK[1]. Shared care of the elderly is a collaborative process, concerned with the clinical, preventative, remedial and social aspects of illness in elderly people. Practitioners involved include doctors, nurses, physiotherapists, clinical psychologists, occupational therapists and social workers. However, the collaborative nature of geriatric care is not reflected in the current record keeping practice. Different practitioner groups maintain essentially separate records and there is a growing awareness of the need for a unified approach. The PEN&PAD (Geriatrics) project seeks to develop a Collaborative Patient Record System for the shared care of the elderly. The goal of the project is to produce a single, integrated information system which is both useful and usable by the different practitioner groups involved in geriatric care. The project is based in a small NHS local hospital which has beds for 240 geriatric patients. The staff of this hospital recognise the need for a unified approach to geriatric care, and have played a central role in the project. This work is based upon previous research which devel-
This work was supported by the UK Computer Board for Universities and Research Councils under the KBS Initiative. 0195-4210/92/$5.00 (©1993 AMIA, Inc.
INITIAL WORK ANALYSIS OF GERIATRIC CARE The initial phase of this project has analysed the work practices and some user requirements for four practitioner groups involved in geriatric care (nurses, doctors, physiotherapists and occupational therapists) at the hospital site. Preliminary discussions with the four user groups and an introductory workshop which launched the project, prompted the decision to begin by concentrating on the "Initial Patient Assessment". This is performed independently by each practitioner group and serves as a reference document for their patient care. It was also apparent from this preliminary work, that the four disciplines should be treated as separate user groups during the initial phase of analysis. Our approach to User Centred Design(UCD) consists of 5 stages; background reading around the subject area in order to gain a basic knowledge of users terminology; observation of users undertaking their Initial Patient Assessment; talkthrough, i.e. asking users to discuss the rational behind the notes of one or more specific patient assessments, and using this as a basis for general discussion; story-boarding, presenting designer's ideas concerning the nature of work practices, back to users for their evaluation; and formative evaluation workshops, in which prototype systems are evaluated by users and their comments related back to the design team via social scientists. To date the first four stages of this cycle have been completed with four user groups. The following section present some of the results from this work. Initial Results Each of the four practitioner groups (nurses, doctors, physio-
147
therapists and occupational therapists) have some information requirements in common. For example, basic patient information such as name and address, the medical diagnoses, current medications and some social details. This information is duplicated in the records of each practitioner group. However, the majority of the information recorded is different, which reflects the fact that each group has a different perspective on patient care. Doctors seek to identify and treat medical diagnoses or problems thorough an assessment of the patient's symptoms and signs. Patient information is recorded in a structured manner, under headings such as presenting complaint, history of presenting complaint, past medical history, family and social history, body systems review and physical examination. The doctors assessment seeks to identify and document medical diagnoses or problems and treatment plans, and must adhere to certain legal requirements such as attributability and permanence. Doctors do not obtain information from the records of other practitioners, nor do they write in the records of others. Instead, information may be exchanged either verbally, or via formal reports. Nurses are primarily concerned with a patients day to day living needs whilst they are on the ward. The care plans written by nurses are generally structured around the concepts of patients problem or needs, goals to be achieved, actions to be taken by the nurses or patient in achieving the goals, and evaluation of progress. Nursing care plans fulfil three roles. Firstly, they represent a care plan which has been negotiated between the patient and nurse, and serves as a reference document for the patient. Thus, it must be written in simple english, with detailed explanations where necessary. Secondly, it functions as a communication document, which can be used by other nurses involved in the care of the patient. Thirdly, they may be used by physiotherapists and occupational therapists to convey their patient care instructions to the nurses. Nurses generally do not contribute to the notes of other practitioners, with the exception of the doctors case notes, in which they may record supplementary social details of a patient. Physiotherapists treat patient problems using physical measures, such as exercise, heat and massage. Patient mobility is central to their assessment, including the patients ability to stand, walk, sit and transfer to and from chairs, beds, toilets, etc. A patients course of treatment is usually carried out by a single physiotherapist, thus the notes recorded about the assessment and therapy plan are written using specific terminology and abbreviations. Physiotherapists consult the doctors case notes for basic patient information and medical data relevant to therapy, and write explicit instructions in the nurses care plans, for those aspects of therapy which need to be maintained on the ward. Occupational therapists aim to help the patient achieve maximum independence in all aspects of daily living. For example, mobilising, washing, dressing, cooking and eating. An important aspect of occupational therapy is the provision of
aids or adaptations, such as wheelchairs, walking aids, bed raisers and stocking gutters, which can assist the patient in maintaining an independent life. As with the physiotherapists, patient information is recorded using specific terminology and abbreviations. Occupational therapists consult both the doctors case notes and nurses care plans for patient information. Instructions for those aspects of patient care which involve the nurses are written in the nurses care plan. Designing a Unified Patient Record There are two approaches which have been suggested for the design of a single, unified patient record. The first approach is to define a Minimum Basic Data Set (MBDS) which consists of those data items which are common to all uses i.e. the union of each discipline's data set. However, this MBDS will not meet the goal of a single shared patient record for the reason that its contents are inadequate as the sole information source of any single user group. Thus users will be forced to maintain additional records to satisfy their own requirements, increasing their workload and adding to the problem of data duplication. As a second approach, a data set may be devised which attempts to meet "the most extensive range of uses" [3]. In this case the data set must fulfil the needs of all the disciplines it seeks to serve, and by implication is a superset of all their information requirements. Whilst this approach preserves the professional roles of its users, such a composite data set is potentially large and unmanageable. Furthermore, as new disciplines are incorporated into the unified record system, the data set expands still further, forcing each individual discipline to cope with inaccessibly information, outside their interest and scope of care. We argue that the professional roles of users must be preserved in the development of a shared record system. Our philosophy is that an integrated system should support diversity rather than eliminate it. However, it is important that the different perspectives of users are not destroyed and that unique views on the patient record are supported. Our initial stages of User Centred Design have shown that the requirements of an integrated system include: * Users should be able to access common data items such as basic patient information, medical diagnoses and social details. * Users should be able to record patient information from their own perspective, using the terminology of their domain. * Users should be able to access the records of other disciplines in a manner which is useful to their purposes. * Users should be able to communicate information and instructions to other disciplines. For example, physiotherapists and occupational therapists may wish to contribute instructions to the nursing care plan.
148
An Architecture for Collaboration Figure 1 shows a proposed architecture which facilitates different views and perspectives on a single patient record. There are four issues involved in facilitating collaboration: * An integrated terminology base which combines the terminologies of the different disciplines into a coherent whole. This should represent the different perspectives on patient care, in terms of what can sensibly be said about the observations of a patient by each discipline. * An integrated record structure which relates statements about a specific patient in a meaningful way. For example, that a patients chest infection is viewed as a bacterial infection by the doctor, a breathing problem by the nurse, and a physical problem, treated by massage, by the physiotherapist. * Support for different views on the record. The record structure of a discipline depends on the process model they employ for patient care. For example the underlying theme of one nursing model is Activities of Living. * Support for personalised interfaces. Each individual practitioner within a group may have personal preferences concerning the manner in which patient data is displayed and recorded.
explicit representation of domain knowledge in a unique manner: * Information Storage. If information is to interpreted within a computer it must be structured and given some semantics. PEN&PAD represents patient data as instantiations of medical concepts attributed to a person, at a particular place and time. * Data entry. Given that there are potentially infinite situations in which a clinician may wish to record data, there must be some facility to dynamically generate all those things which it is "sensible to say" in any given situation. PEN&PAD achieves this through "Predictive Data Entry" which uses an underlying representation of the terminology of a domain. * Adaptation and extension. Instead of embedding models of medical practice and interface formats (including data display) in system code, PEN&PAD allows such design information to be explicitly represented as knowledge about the application, therefore facilitating easy development and modification. The PEN&PAD Interface is based upon Structured Meta Knowledge, a semantic network language developed specifically for building patient record systems. SMK is used to represent medical terminology and pragmatic knowledge about medical procedures (e.g. protocols) and interface formats, as well as actual patient data. It has already been successfully used in the development of a clinical workstation for General Practitioners and will be extended as necessary to meet the additional requirements of collaborative records.
USER CENTRED DESIGN FOR COLLABORATION AND DIVERSITY A recent survey conducted by Young et al. (1990) showed that although few UK doctors use a computer in the course of their daily practice, more than half of them use a computer at home[4]. This illustrates that doctors are not resistant to the use of computers, rather that they do not perceive existing clinical systems to be useful to their work. The development of clinical systems is generally technology driven and not based on a concrete analysis of the computer needs of doctors and how these might be met. In contrast, the basic aim of the PEN&PAD project is to produce useful and usable workstations for use by healthcare practitioners in dayto-day patient care. In this section we briefly describe the UCD methodology known as Supportive Evaluation Methodology(SEM) which has been successfully used in the development of the PEN&PAD(GP) prototype system[2]. We also discuss ways of extedning this methodology for use in the hospital setting.
Figure 1. An Architecture for Collaboration
The PEN&PAD Intelligent Interface System is a set of software tools for developing patient record systems. It uses techniques taken from Artificial Intelligence, in particular the
149
Supportive Evaluation Methodology SEM was developed on the basis of the following consider-
ations: * User involment in the design process is important in order to focus the designers's thoughts on user needs. * Software development is a highly iterative process and users must be involved throughout the process. * Users who have little or no experience of computer technology often have no clear idea about their requirements at the beginning of the design process. The creation of working mock-ups and prototpes has been shown to be necessary for users to make meaningful and informed decisions about design ideas[5] * Designers engaged in an iterative design process which includes users are still likely to made sweeping, untested and often incorrect assumptions about users [6]. Attempts to improve designer's understanding of users, by means of Human Factors guidelines is unlikely to be successful [7]. This raises the need for more direct input from social scientists into the development process. Social scientists working with the PEN&PAD(GP) project have been involved in all stages of the development cycle described below, except Prototype Development. * Work Analysis - to obtain an understanding of the tasks and current work practices of the doctors. * Requirements Workshops - to elicit user requirements using techniques such as role playing, interviews and questionnaires * Rapid Prototyping - the rapid creation of working mockups or prototypes to meet user requirements. * Evaluation Workshops - to obtain direct feedback concerning the usefulness and usability of prototypes by potential users. * Feedback -knowledge gained during user evaluation is used as a basis for the modification or redesign of the prototype. The Evaluation and Feedback cycle is repeated until relevant aspects of the prototype are satisfactory to users. It was originally intended to apply SEM to the development of the PEN&PAD(Geriatrics) system. But after a preliminary six months work there appear to be two interrelated problems which indicate that the methodology requires further extension. The first problem is that unlike the GP project, which deals with a single user discipline who essentially work autonomously, the PEN&PAD(Geriatrics) project must consider a number of different healthcare professions working collaboratively. This raises a number of complex human issues. Thus the design team must have an awareness of organisational, social, psychological, professional and cultural issues when engaged in the design process. The second problem relates to the design process, which leads to the production of prototypes. In the current SEM, social scientists are not involved explicidy in the analysis of work practices and formulation of user requirements. Consequently, incorrect design decisions maybe embodied in proto-
types, and therefore cause wasted effort in the Evaluation and Feedback stages. Greater user involvement in the more conceptual stages of prototype design would be useful. Our future work will be directed to exploring such issues. DISCUSSION The PEN&PAD (Geriatrics) project has highlighted the need for a consideration of human issues in the design and development of collaborative systems. This has led us to propose a UCD approach which advocates the close involvement of social scientists. The form in which this involvement is most useful has yet to be determined. However, we foresee that social scientists will have the most impact on the design process through the education of designers, equipping them with a whole new set of skills with which to tackle design problems. It is hoped that educating designers in this way will contribute to a long overdue paradigm shift in medical informatics, turning away from the cognitive and methodological naivete of the AI tradition, toward a more difficult, more complex, but far richer and more useful approach to the use of computers in healthcare. REFERENCES [1] Department of Health and Social Security/Office of Population Census and Statistics (1983). Hospital In-Patient Morbidity Enquiry. HMSO, London. [2] Howkins TJ, Kay S, Rector AL, Goble CA, Horan B, Nowlan WA, Wilson A. An overview of the PEN&PAD project. MIE 90; Lecture Notes in Medical Informatics No 40. Berlin. Springer-Verlag 1990: 73-8. [3] Parkin D, Hutchinson A, Fisher PJ. Minimum data sets for ambulatory care. Proceedings of MIE 90. In Lecture Notes in Medical Informatics, 40. R O'Moore, S. Bengtsson, JR Bryant and JS Bryden (Fds.). Springer-Verlag 1990. [4] Young, D; Chapman, T; & Poile, C (1990). Physician reveal thyself. In British Journal of Healthcare Computing, Vol 7, No 9, pp 16-21. [5] Harker, S (1987). Rapid prototyping as a tool for user centred design. In Salvendy, G (Ed), Cognitive Engineering in the Design of Human-Computer Interaction and Expert Systems. Elsevier Science Publications, Amsterdam. [6] Hammond, N V; Jorgensen, A; MacLean, A; Barnard, P J; & Long, J (1983). In Janda, A (Ed), Human factors in computer systems: Proceedings of the CHI '83 conference, Boston. North-Holland, Amsterdam. [7] Eason, K D (1991). Ergonomic perspectives on advances in human-computer interaction. Ergonomics, Vol 34, No 6, pp 721-741.
150
Abstract The PEN&PAD (Geriatrics) project seeks to develop a Collaborative Patient Record Systemfor the hospital based shared care of the elderly. The goal of the project is to produce a single, integrated information system which is both useful and usable by the different practitioner groups involved in geriatric care. A User Centred Design methodology is proposed which makes users and human issues central to the design and development process. Preliminary results indicate that the specification of a Minimum Basic Data Set as the basis of a shared record system is infeasible and undesirable. An architecture is presented which illustrates how the diversity between the different disciplines may be preserved in a Collaborative Patient Record System.
INTRODUCTION The proportion of aged in the UK population is steadily rising and represents an increasing burden on the National Health Service(NHS). The elderly already occupy 40% of all acute hospital beds in the UK[1]. Shared care of the elderly is a collaborative process, concerned with the clinical, preventative, remedial and social aspects of illness in elderly people. Practitioners involved include doctors, nurses, physiotherapists, clinical psychologists, occupational therapists and social workers. However, the collaborative nature of geriatric care is not reflected in the current record keeping practice. Different practitioner groups maintain essentially separate records and there is a growing awareness of the need for a unified approach. The PEN&PAD (Geriatrics) project seeks to develop a Collaborative Patient Record System for the shared care of the elderly. The goal of the project is to produce a single, integrated information system which is both useful and usable by the different practitioner groups involved in geriatric care. The project is based in a small NHS local hospital which has beds for 240 geriatric patients. The staff of this hospital recognise the need for a unified approach to geriatric care, and have played a central role in the project. This work is based upon previous research which devel-
This work was supported by the UK Computer Board for Universities and Research Councils under the KBS Initiative. 0195-4210/92/$5.00 (©1993 AMIA, Inc.
INITIAL WORK ANALYSIS OF GERIATRIC CARE The initial phase of this project has analysed the work practices and some user requirements for four practitioner groups involved in geriatric care (nurses, doctors, physiotherapists and occupational therapists) at the hospital site. Preliminary discussions with the four user groups and an introductory workshop which launched the project, prompted the decision to begin by concentrating on the "Initial Patient Assessment". This is performed independently by each practitioner group and serves as a reference document for their patient care. It was also apparent from this preliminary work, that the four disciplines should be treated as separate user groups during the initial phase of analysis. Our approach to User Centred Design(UCD) consists of 5 stages; background reading around the subject area in order to gain a basic knowledge of users terminology; observation of users undertaking their Initial Patient Assessment; talkthrough, i.e. asking users to discuss the rational behind the notes of one or more specific patient assessments, and using this as a basis for general discussion; story-boarding, presenting designer's ideas concerning the nature of work practices, back to users for their evaluation; and formative evaluation workshops, in which prototype systems are evaluated by users and their comments related back to the design team via social scientists. To date the first four stages of this cycle have been completed with four user groups. The following section present some of the results from this work. Initial Results Each of the four practitioner groups (nurses, doctors, physio-
147
therapists and occupational therapists) have some information requirements in common. For example, basic patient information such as name and address, the medical diagnoses, current medications and some social details. This information is duplicated in the records of each practitioner group. However, the majority of the information recorded is different, which reflects the fact that each group has a different perspective on patient care. Doctors seek to identify and treat medical diagnoses or problems thorough an assessment of the patient's symptoms and signs. Patient information is recorded in a structured manner, under headings such as presenting complaint, history of presenting complaint, past medical history, family and social history, body systems review and physical examination. The doctors assessment seeks to identify and document medical diagnoses or problems and treatment plans, and must adhere to certain legal requirements such as attributability and permanence. Doctors do not obtain information from the records of other practitioners, nor do they write in the records of others. Instead, information may be exchanged either verbally, or via formal reports. Nurses are primarily concerned with a patients day to day living needs whilst they are on the ward. The care plans written by nurses are generally structured around the concepts of patients problem or needs, goals to be achieved, actions to be taken by the nurses or patient in achieving the goals, and evaluation of progress. Nursing care plans fulfil three roles. Firstly, they represent a care plan which has been negotiated between the patient and nurse, and serves as a reference document for the patient. Thus, it must be written in simple english, with detailed explanations where necessary. Secondly, it functions as a communication document, which can be used by other nurses involved in the care of the patient. Thirdly, they may be used by physiotherapists and occupational therapists to convey their patient care instructions to the nurses. Nurses generally do not contribute to the notes of other practitioners, with the exception of the doctors case notes, in which they may record supplementary social details of a patient. Physiotherapists treat patient problems using physical measures, such as exercise, heat and massage. Patient mobility is central to their assessment, including the patients ability to stand, walk, sit and transfer to and from chairs, beds, toilets, etc. A patients course of treatment is usually carried out by a single physiotherapist, thus the notes recorded about the assessment and therapy plan are written using specific terminology and abbreviations. Physiotherapists consult the doctors case notes for basic patient information and medical data relevant to therapy, and write explicit instructions in the nurses care plans, for those aspects of therapy which need to be maintained on the ward. Occupational therapists aim to help the patient achieve maximum independence in all aspects of daily living. For example, mobilising, washing, dressing, cooking and eating. An important aspect of occupational therapy is the provision of
aids or adaptations, such as wheelchairs, walking aids, bed raisers and stocking gutters, which can assist the patient in maintaining an independent life. As with the physiotherapists, patient information is recorded using specific terminology and abbreviations. Occupational therapists consult both the doctors case notes and nurses care plans for patient information. Instructions for those aspects of patient care which involve the nurses are written in the nurses care plan. Designing a Unified Patient Record There are two approaches which have been suggested for the design of a single, unified patient record. The first approach is to define a Minimum Basic Data Set (MBDS) which consists of those data items which are common to all uses i.e. the union of each discipline's data set. However, this MBDS will not meet the goal of a single shared patient record for the reason that its contents are inadequate as the sole information source of any single user group. Thus users will be forced to maintain additional records to satisfy their own requirements, increasing their workload and adding to the problem of data duplication. As a second approach, a data set may be devised which attempts to meet "the most extensive range of uses" [3]. In this case the data set must fulfil the needs of all the disciplines it seeks to serve, and by implication is a superset of all their information requirements. Whilst this approach preserves the professional roles of its users, such a composite data set is potentially large and unmanageable. Furthermore, as new disciplines are incorporated into the unified record system, the data set expands still further, forcing each individual discipline to cope with inaccessibly information, outside their interest and scope of care. We argue that the professional roles of users must be preserved in the development of a shared record system. Our philosophy is that an integrated system should support diversity rather than eliminate it. However, it is important that the different perspectives of users are not destroyed and that unique views on the patient record are supported. Our initial stages of User Centred Design have shown that the requirements of an integrated system include: * Users should be able to access common data items such as basic patient information, medical diagnoses and social details. * Users should be able to record patient information from their own perspective, using the terminology of their domain. * Users should be able to access the records of other disciplines in a manner which is useful to their purposes. * Users should be able to communicate information and instructions to other disciplines. For example, physiotherapists and occupational therapists may wish to contribute instructions to the nursing care plan.
148
An Architecture for Collaboration Figure 1 shows a proposed architecture which facilitates different views and perspectives on a single patient record. There are four issues involved in facilitating collaboration: * An integrated terminology base which combines the terminologies of the different disciplines into a coherent whole. This should represent the different perspectives on patient care, in terms of what can sensibly be said about the observations of a patient by each discipline. * An integrated record structure which relates statements about a specific patient in a meaningful way. For example, that a patients chest infection is viewed as a bacterial infection by the doctor, a breathing problem by the nurse, and a physical problem, treated by massage, by the physiotherapist. * Support for different views on the record. The record structure of a discipline depends on the process model they employ for patient care. For example the underlying theme of one nursing model is Activities of Living. * Support for personalised interfaces. Each individual practitioner within a group may have personal preferences concerning the manner in which patient data is displayed and recorded.
explicit representation of domain knowledge in a unique manner: * Information Storage. If information is to interpreted within a computer it must be structured and given some semantics. PEN&PAD represents patient data as instantiations of medical concepts attributed to a person, at a particular place and time. * Data entry. Given that there are potentially infinite situations in which a clinician may wish to record data, there must be some facility to dynamically generate all those things which it is "sensible to say" in any given situation. PEN&PAD achieves this through "Predictive Data Entry" which uses an underlying representation of the terminology of a domain. * Adaptation and extension. Instead of embedding models of medical practice and interface formats (including data display) in system code, PEN&PAD allows such design information to be explicitly represented as knowledge about the application, therefore facilitating easy development and modification. The PEN&PAD Interface is based upon Structured Meta Knowledge, a semantic network language developed specifically for building patient record systems. SMK is used to represent medical terminology and pragmatic knowledge about medical procedures (e.g. protocols) and interface formats, as well as actual patient data. It has already been successfully used in the development of a clinical workstation for General Practitioners and will be extended as necessary to meet the additional requirements of collaborative records.
USER CENTRED DESIGN FOR COLLABORATION AND DIVERSITY A recent survey conducted by Young et al. (1990) showed that although few UK doctors use a computer in the course of their daily practice, more than half of them use a computer at home[4]. This illustrates that doctors are not resistant to the use of computers, rather that they do not perceive existing clinical systems to be useful to their work. The development of clinical systems is generally technology driven and not based on a concrete analysis of the computer needs of doctors and how these might be met. In contrast, the basic aim of the PEN&PAD project is to produce useful and usable workstations for use by healthcare practitioners in dayto-day patient care. In this section we briefly describe the UCD methodology known as Supportive Evaluation Methodology(SEM) which has been successfully used in the development of the PEN&PAD(GP) prototype system[2]. We also discuss ways of extedning this methodology for use in the hospital setting.
Figure 1. An Architecture for Collaboration
The PEN&PAD Intelligent Interface System is a set of software tools for developing patient record systems. It uses techniques taken from Artificial Intelligence, in particular the
149
Supportive Evaluation Methodology SEM was developed on the basis of the following consider-
ations: * User involment in the design process is important in order to focus the designers's thoughts on user needs. * Software development is a highly iterative process and users must be involved throughout the process. * Users who have little or no experience of computer technology often have no clear idea about their requirements at the beginning of the design process. The creation of working mock-ups and prototpes has been shown to be necessary for users to make meaningful and informed decisions about design ideas[5] * Designers engaged in an iterative design process which includes users are still likely to made sweeping, untested and often incorrect assumptions about users [6]. Attempts to improve designer's understanding of users, by means of Human Factors guidelines is unlikely to be successful [7]. This raises the need for more direct input from social scientists into the development process. Social scientists working with the PEN&PAD(GP) project have been involved in all stages of the development cycle described below, except Prototype Development. * Work Analysis - to obtain an understanding of the tasks and current work practices of the doctors. * Requirements Workshops - to elicit user requirements using techniques such as role playing, interviews and questionnaires * Rapid Prototyping - the rapid creation of working mockups or prototypes to meet user requirements. * Evaluation Workshops - to obtain direct feedback concerning the usefulness and usability of prototypes by potential users. * Feedback -knowledge gained during user evaluation is used as a basis for the modification or redesign of the prototype. The Evaluation and Feedback cycle is repeated until relevant aspects of the prototype are satisfactory to users. It was originally intended to apply SEM to the development of the PEN&PAD(Geriatrics) system. But after a preliminary six months work there appear to be two interrelated problems which indicate that the methodology requires further extension. The first problem is that unlike the GP project, which deals with a single user discipline who essentially work autonomously, the PEN&PAD(Geriatrics) project must consider a number of different healthcare professions working collaboratively. This raises a number of complex human issues. Thus the design team must have an awareness of organisational, social, psychological, professional and cultural issues when engaged in the design process. The second problem relates to the design process, which leads to the production of prototypes. In the current SEM, social scientists are not involved explicidy in the analysis of work practices and formulation of user requirements. Consequently, incorrect design decisions maybe embodied in proto-
types, and therefore cause wasted effort in the Evaluation and Feedback stages. Greater user involvement in the more conceptual stages of prototype design would be useful. Our future work will be directed to exploring such issues. DISCUSSION The PEN&PAD (Geriatrics) project has highlighted the need for a consideration of human issues in the design and development of collaborative systems. This has led us to propose a UCD approach which advocates the close involvement of social scientists. The form in which this involvement is most useful has yet to be determined. However, we foresee that social scientists will have the most impact on the design process through the education of designers, equipping them with a whole new set of skills with which to tackle design problems. It is hoped that educating designers in this way will contribute to a long overdue paradigm shift in medical informatics, turning away from the cognitive and methodological naivete of the AI tradition, toward a more difficult, more complex, but far richer and more useful approach to the use of computers in healthcare. REFERENCES [1] Department of Health and Social Security/Office of Population Census and Statistics (1983). Hospital In-Patient Morbidity Enquiry. HMSO, London. [2] Howkins TJ, Kay S, Rector AL, Goble CA, Horan B, Nowlan WA, Wilson A. An overview of the PEN&PAD project. MIE 90; Lecture Notes in Medical Informatics No 40. Berlin. Springer-Verlag 1990: 73-8. [3] Parkin D, Hutchinson A, Fisher PJ. Minimum data sets for ambulatory care. Proceedings of MIE 90. In Lecture Notes in Medical Informatics, 40. R O'Moore, S. Bengtsson, JR Bryant and JS Bryden (Fds.). Springer-Verlag 1990. [4] Young, D; Chapman, T; & Poile, C (1990). Physician reveal thyself. In British Journal of Healthcare Computing, Vol 7, No 9, pp 16-21. [5] Harker, S (1987). Rapid prototyping as a tool for user centred design. In Salvendy, G (Ed), Cognitive Engineering in the Design of Human-Computer Interaction and Expert Systems. Elsevier Science Publications, Amsterdam. [6] Hammond, N V; Jorgensen, A; MacLean, A; Barnard, P J; & Long, J (1983). In Janda, A (Ed), Human factors in computer systems: Proceedings of the CHI '83 conference, Boston. North-Holland, Amsterdam. [7] Eason, K D (1991). Ergonomic perspectives on advances in human-computer interaction. Ergonomics, Vol 34, No 6, pp 721-741.
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