November 27, 2015

Designing Reminders that Older People Can Remember #BAAConf

Posted in research tagged , , , , at 12:22 pm by mariawolters

Reminders only work if you can hear them – as I found out to my cost this morning. I had been looking forward to a scrumptious Yorkshire breakfast, served from 7am to 10am, only to wake up at 10.17am.

Why did I sleep through my trusty phone alarm? Because my phone hadn’t been charging; I had forgotten to switch on the socket into which I had plugged it. (In the UK, we need to switch on sockets before they will provide electricity).

Now imagine that you can no longer hear the alarms you set not because you failed to charge your phone, but  because your hearing is going. What do you do?

This is what my talk at this year’s Conference of the British Academy of Audiology is all about. (The slides are on Slideshare, as always.)

I discuss a few strategies that I have discovered when working with older people as part of my research into human-computer interaction.

All of these ideas are inspired by what older people have told me and my colleagues, or by what we have seen them do.  This is perhaps the most important point of my talk. People are experts in what works for them. Very often, all it takes is a bit of active listening to uncover a solution that builds on their existing habits, their routines, and the layout of the spaces and places where they live.

This is really the most important trick – make the action to be remembered as natural and habitual as possible.

Once you have ensured that, the rest is icing on the cake:

  • ensure that people choose reminders that they actually choose to hear. (That includes reminders which are so irritating that you just have to get out of bed to silence them.)
  • ensure that people can understand what the reminder is all about. Again, you can take advantage of associations people already have. For example, people may choose a snippet from their favorite love song to remind them to take their heart medications
  • ensure that the reminders are not stigmatizing. It can be hard to admit that one’s memory is going, that one is no longer coping. Having one’s style cramped is even harder.

If you would like personalized advice or talk further, please do not hesitate to contact me via email (maria dot wolters at ed dot ac dot uk) or on Twitter (@mariawolters).

I also provide tailored consulting and training packages  at



June 1, 2015

Skype for Video Consultations – A Personal Perspective

Posted in research tagged , , , , , , , , at 10:00 am by mariawolters

I was motivated to write this short piece by looking through the material for the Remote Consulting unit of the Telehealth and Telemedicine course for the Edinburgh MSc in Global eHealth.

Helen Atherton, an active researcher in email consulting, created a fascinating set of resources on the topic for the students of that course, which I co-organise with Brian McKinstry (i.e.: Brian provides the wisdom of (sometimes bitter) experience, I implement and add my two cents from a Human Computer Interaction point of view.).

One of the topics that came up was the use of Skype for remote consultation. Skype is a good alternative to traditional phone consultations because

  • everybody can sign up for free
  • in situations where you need video, it is easy to switch on
  • it can be used by people who do not have a landline or access to a landline phone
  • it can be used anywhere with WiFi access, which means that people do not have to use or pay for call minutes

But from my own experience, there are two important issues here that make me question whether Skype is suitable for video consultations.

1) Is Skype stable?

Not really, especially not if you use the video facility. I am typically online via fast Wifi at work courtesy of eduroam (yes, University of Edinburgh eduroam works well!), and I never have any trouble uploading or downloading big papers, large data sets, or Apple system updates. But when I’m asked to take part in a Skype meeting, I will never switch on video unless the other party insists, because that is a recipe for disaster.

I haven’t systematically kept track of the number of times a multi party Skype call failed because one of the people had switched on video, and worked well once the video had been switched off, but I’d guess this has happend in about half the Skype conferences (with video) that I have been involved in.

2) Is Skype safe?

I am not going to start discussing privacy features and whether conversations can be overheard by third parties here – that’s a whole other topic which is best discussed by somebody with expertise in the area.

What I mean is safety from unsavoury contacts. While my Skype handle is gender neutral (mkwolters), I have my full name associated with it, and my name is searchable, so that collaborators who wish to add me can easily find me on Skype. I also have a portrait photo with my own face, which clearly marks me as a female.

This means that every week or so, I get a contact request from a random account pretending to be a man. Half of these use an icon that would suggest that they are a member of the US Army, and are looking to talk to somebody while on active duty. The only time I was accosted by an account that pretended to be a woman, the person was recruiting for the web cam version of phone sex, which only became clear after a longer exchange. (I like to see what’s behind those scammers. I’m nosy like that.)

A good friend of mine (male) who has locked down his own Skype profile gets so many contact requests from women that he now refuses to leave his Skype open.

On one level, this is the Skype equivalent of the good old Nigerian scam or phishing email. On another level, I can see how this might make people highly uncomfortable. (It makes me extremely uncomfortable, and I’ve been on the Internet since 1994.)

It wasn’t always like that. Before the recent wave of scammers hit, I was on Skype for years with nary an incident. But the climate has changed, and I regard Skype as fundamentally unsafe.

*** *** ***

So, if I were a health care practitioner, offering telehealth consultations to older patients at home, would I be keen to introduce Skype video consulting?

Short answer: No.

Long answer: Not unless they already have a Skype account, are comfortable with using the service, are experts at fending off unwanted online attention, and have good experiences with one to one video calls.

I would not advise or expect older people to invest in Skype just to be able to access their health care from home – just as I wouldn’t advise them to spice up their social life by chatting to that nice man who has come by their door with an unbeatable offer for triple glazed windows.

May 17, 2015

The Promise and Perils of Computerised Prescription Systems

Posted in research tagged , , , , , , at 2:00 pm by mariawolters

Prescribing medications to sick people is a difficult task. The person prescribing needs to choose the right medication, choose the right dose, choose the right timing for delivering those doses, and check whether the medication will interact with any other medications that the patient might already be on.

Clearly, computerised prescription order entry systems (or CPOE) systems have vast potential benefits here. Computers are much better than humans at storing masses of information. In principle, computer systems allow much faster and better access to all kinds of records, which means no more rustling through paper records distributed across several locations.

What’s more, CPOE also allows better stock management. Once medication has been ordered, the system knows exactly how much is needed, how much is still in stock, and can create valuable data sets that can be used to optimise stock management and anticipate demands.

CPOE also generates a data stream that can make it easy to audit prescription patterns and compare those patterns to best practice and evidence-based guidelines.

In short, CPOE is a win-win proposition, and if there is a module that fits with an existing medical record system, there’s no reason why it should not be implemented quickly and efficiently.

That’s what one children’s hospital thought. They were linked to a University Hospital System and treated many children who required urgent access to top specialist medical care. So they rolled out CPOE.

And then, the children died.

In the words of Han and coauthors:

Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94–5.55) after adjustment for other mortality covariables.“ (from the abstract)

The authors looked at the data first. They surveyed all children who were transferred to their hospital’s Intensive Care Unit from other hospitals within a time span of 18 months, 12 before and 6 after CPOE introduction. Then, they looked for the reasons.

These children were a special case. They needed the correct treatment, fast. Over the years, the hospital ICU team had evolved procedures that enabled them to be as fast as possible. They were as finely tuned as the team changing the wheels on a Formula 1 racing car.

The new system destroyed these processes, because it was slow. Before, doctors would pass quick written notes to nurses, who were always on the lookout for new instructions. Now, it took up to ten clicks to enter a medication order. Low bandwidth then added another delay until the order was transmitted to the pharmacists. Before, everybody was free to help tend to the patient, if needed. Now, one member of staff had to be at the computer, tending to the CPOE system. Before, staff could just grab what they needed to stabilise the patient. Now, everything went through central ordering.

With hindsight, it is easy to criticise the hospital team for what seems to be a rushed introduction of a system that was not ready for prime time. But if you look at the hype surrounding much of telehealth and telemedicine (“Act now! We know it works! You OWE it to your PATIENTS! (And to the taxpayers …)“), it is easy to see how this might have happened.

You will often hear telemedicine and eHealth evangelists say that the world could be so much better and brighter if it weren’t for those pesky practitioners who are clinging on to the old way of doing things.

In this case, the old way of getting medication to very sick children on arrival in the hospital ICU was actually working very well. Speed, and having as many hands as possible on deck, were essential.

The new way, with its ten clicks to achieve a single order, was more suitable for a situation where prescriptions were not urgent, where safety was paramount, and where there was spare personnel to focus on data entry.

In short, the new way was not usable.

Usability is far more than “do people like it?”. At the very minimum, per ISO 9241 definition, a usable system has to do what it is designed to do (effectiveness), and it has to do so with an appropriate speed (efficiency). If the users like it, that’s nice (user satisfaction), but it’s far from the whole story.

The key point where the CPOE system that Han and colleagues describe fell down was efficiency, which made it unsuitable for the task.

In theory, CPOE is a great idea, but it has to be usable in practice. Otherwise, it just won’t work. Han, Y. et al. (2005). Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System PEDIATRICS, 116 (6), 1506-1512 DOI: 10.1542/peds.2005-1287