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"Benevolent" Social Engineering for Behavior Change!

The health care industry is heavily regulated and health care workers need to be aware of these rules and regulations that relate to personal and patient safety, security of data, etc.

The big question is whether the training leads to changes in behavior.  Of course, being aware of the information is necessary; no one would dispute that.  But education alone is in most cases a weak intervention for behavior change unless it is accompanied by something I call "benevolent social engineering".  The phrase social engineering has evil connotations and thus the modifier "benevolent".  

What do I mean by this?  Lets take the story of recycling.  

Say, someone crawls out from under a rock and sees a blue recycle bin somewhere.  He would have no clue what to do with it.  He would benefit from a brief training on importance of recycling and how to do it.  Suppose after the training, he decides he wants to recycle his can of soda   If the nearest recycle bin is 250 meters away, but there are 3 trash cans within 10 meters, he is  somewhat unlikely to recycle the can.  On the other hand if there were recycle bins within easier reach, a fewer trash cans, we could change behavior relatively easily.

What implications does this have for health care?  

The IDSA and ATS guidelines for community acquired pneumonia recommend either a fluoroquinolone or macrolide+beta lactam for inpatient cases.  For some hypothetical reason (like local susceptibility patterns), your institution guideline is to not use fluoroquinolone alone for community acquired pneumonia (CAP).  What if you notice that the residents in your hospital are using inappropriate antibiotics to treat patients admitted CAP.  You educate them about the guidelines, formulary, costs and susceptibility patterns and advise them to use azithromycin + ceftriaxone unless there are contraindications like allergies.  You study the effect of your intervention and notice no change in behavior.  You do a focus group of residents to see why they still use a fluoroquinolone alone.  It is possible that you may find that there is an order set in the electronic health record that makes it easier to order a fluoroquinolone rather than the preferred combination.  You change the order set and it is quite possible that you will see a big change in behavior.

Besides making things easier or more convenient, benevolent social engineering sends a message that something is more important.  Otherwise the hidden curriculum of the education intervention is, "We are just paying lip service to this.  Keep doing whatever you were doing."  Seeing the old order set for fluoroquinolone sends the same message as the multiple trash cans - "We don't think recycling is important".  When an institution backs up its educational efforts with the measures that make action easier, it tells the health care worker that it is a priority!  Its like putting your money where your mouth is!

3 Case Studies for managing information and staying organized

At a several recent meetings, colleagues have mentioned how they are finding it increasingly difficult managing information in various different settings.

Some examples:

1.  One colleague needs to have regularly scheduled meetings with a group of physicians.  They need to share and collaboratively author documents.  Not everyone can attend these meetings consistently.
2.  Another colleague finds it difficult to keep up with literature in his specialty.  He gets a lot of print journals, but does not have a streamlined way of recalling recent studies and finding them quickly when needed.
3.  A third colleague finds that she is getting disorganized, gets distracted and is unable to complete elective but high stake tasks.

Three very common problems and here are the solutions I proposed to them.  One criteria I used was to use  tools that were free.

1.  I suggested that he start using Google+ and Google Docs.  It is very surprising how many people do NOT know about these tools.  Sure there are other ways to do this but the sheer simplicity of Google Docs is a winner for any group with members that might be technically challenged.  The commonest question I get is, "How do I save the document?" Some other questions are, "How do I share this document?" or "Does it track versions?" 

I suggested he set up a Google circle with the participants.  He could then start a Google document and set it up to be editable by anyone with a link.  He could then copy the link and share it with the Google circle.  He could also start a Hangout at the next meeting to discuss the document and those who could not attend live, could participate via the Hangout.  Using Google Hangout with extras they could collaboratively edit the document.  

The part he loved was that at the end of the Hangout, the document was finalized and he did not have to send it to anyone.  They could all see it on Google Docs.  

2.  This conversation started when the colleague was complaining about the flood of lab results, copied charts, refill requests etc in his EHR inbox.  I mentioned a recent Archives article where they found that 50% of such messages and alerts are not important.  Even in the important messages 80% of the text is irrelevant to the critical message.  He was surprised I was able recall the article and pull it up quickly on my laptop.  

I described how I use Google Reader to subscribe to key journals in my area of interest.  In addition I have set up RSS feeds on specific key words from PubMed.  As I scan through the articles, I tag and organize them by specialty.  I share some of these articles with colleagues on Twitter or Google+ which leads to some interesting discussions and helps ingrain the article in my memory.  

The part that really works is finding the article that you have scanned/read/shared.  Google reader has an excellent search function and quickly pulls up any article in your set of journals whether you have read it or not.  

If you can spend some time each week scanning through your journals of interest on Google reader, you can generally recall studies that got published and can retrieve the article very quickly.

To get him started, I gave him a link to a bundle of medicine journals I follow.  He was able to get started with these with 1 click!

3.  The last case prompted me to suggest something that I have just started using.  One of my medical students recommended Workflowy to me.  This tool is another case of things being so simple that they just work.  Workflowy lets you create a bulleted hierarchical list.  The web page can be opened in any browser including on mobile devices.  You start off by creating a high level list like

• Personal
• Family
• Work

and then create sub-items.  You can add notes to the items and strike through items that you have completed.  I am planning a trip to Peru and the amount of stuff that needed to be done e.g. flights, train tickets, forms for the consulate, Machu Picchu entrance tickets, hotels, SIM card etc. all needed to be completed.  Putting it together in one list and then adding notes of web sites, phone numbers, confirmation numbers etc made the whole process very organized.  I was able to share the list with my wife who could also complete and cross off certain items.  Being able to spend a few minutes to complete elective tasks takes a huge burden off ones shoulders and is very stress relieving.  If still need more help, you can use the Pomodoro extension on your browser (Chrome) to block off all distractions for a specified amount of time till you complete the task.

I will be first to admit that I am not the most organized of people and am constantly trying to find solutions for this.  Still these are tools I use regularly (except the Pomodoro) and they help immensely.  

What can the healthcare system learn from a car dealer?

The Car Salesman Becomes a Consumer Navigator

A friend just bought a new car and was raving about the experience.  This was not a luxury car, just a regular popular model.

I personally dread the car buying experience for many reasons but one thing that bothers me is the discontinuity.  You often see the sales person several times and to some extent the character of your relationship with him/her impacts the decision to purchase the vehicle.  But the moment you sign on the dotted line, you experience the HAND OFF!  If you have a question or problem with the car, and you try and reach the formerly very responsive sales person, you get shunted off to the voice mail of the service department.

Well, my friend was in a bit of shock because he experienced something quite unique.  The sales person spent and hour after the purchase describing every feature of the car and answering numerous questions.  In addition, he offered to stop by his home in a day or two to see if there were any questions that came up after he had used the vehicle.  But the real kicker came when he started driving out of the dealership. The sales person gave him his card with his cell phone number and e-mail address and said, "For any questions or problems you call me first and it is my job to ensure that they get resolved.  I will arrange for any service needs and for a loaner car."

Compare this experience with that of a hospitalized patient about to be discharged.  He gets a huge packet of papers including complicated discharge instructions, phone numbers to call for appointments, changed medication lists, etc and a message "If you have problems call your PCP".  The PCP in question often has no idea of what happened in the hospital; even with EHRs the discharge summaries and hospital notes are often unhelpful, with critical information lost in a flood of meaningless data.  Even if all the information is there, it cannot compare with the knowledge that is created from actually taking care of acutely sick patient in the hospital.  It is almost impossible to transfer this "knowledge" using a paper or electronic record.  To make matter worse, the next time the patient gets admitted, he ends up with a different provider and the whole process starts us again.

Have we, in the interest of efficiency and short lengths of stay created silos that are impacting on the patient experience?  This has led to the concept of the patient navigator which are being variable implemented/piloted.  Based on this anecdote, every hospital needs to have knowledgeable patient navigators.  Dare I say that the healthcare system should learn something from a car dealer who has already implemented this concept?

Brouhaha about social search in Google - Did Gizmodo miss the point?

As the amount of information on the Internet increases, it is not possible to keep up.  The ideal strategy to manage this information overload is to create filters that will increase the signal:noise ratio.  In addition the quality and usefulness of information is often related to the person creating or curating it.  Thus knowing who is the person/s behind the information can help appraise the information more critically.

Social search is a way to implement this. Thus you can for example when surfing the web, see what your Facebook friend thought of a particular article or post.  If you know this FB friend well enough, it gives you a special insight into how to appraise that article.  Here is a blog by the Bing team (almost a year back) about personalized search results based on FB "likes"

Recently Google announced that it will integrate their G+ information with Google Search.  The thought being that when you search for something, you can have the option of seeing posts and comments by people in your Google Plus circles show up in the search results.
This has raised a hue and cry re' Google contaminating the search results and possible anti-trust violations.

A post on Gizmodo titled "Google just made Bing the best search engine" is encouraging people to move to Bing. I had written earlier about how a sensational headline like "Sitting longer can make your bum bigger" can cause a ripple in the blogosphere with not many stopping to dig deep.  The post on a respected website like Gizmodo would be expected to have a bit more of the technical detail and ideally more balanced.  While the post does mention that with one click you can toggle the personal searches on/off (Fig 1) it could have mentioned that with 4 clicks anyone can disable the default setting of showing/not showing the personal searches.  Thus if you are bothered by the personal search option, just turn it off and you never need to toggle on/off again. Also if you are not signed into Google account, you don't get the personal search option. So why write such a "sensational" article about this?  

Very easy user control to toggle on/off the personal search results.

4 clicks change default preference for personal search

I am all for letting the user make an informed decision.  All Google has done is give the user an additional option.  Is this is potentially useful option?  Let me give you an example.

I have a large circle of educators on Google+ that I have spent time creating.  If I search for an education topic on Google, I would LOVE the ability to have an option to filter the search using this tool.  When I search for "ePortfolio" I get 90 excellent useful personal search results.

Depending on the topic, this is a feature that is incredibly helpful.  Imagine you search for a medication e.g. Viox.  If the future, you could have in your circle people like Eric Topol or Steve Nissen or the Cleveland Clinic.  You can have a choice of seeing their opinions about Viox in the search results.  Why is that an option that we would not give to consumers?

I would hope that at some point we could have an option to include similar personal search filters from FB and Twitter and Yelp or any other similar application on all search engines.  Thus when searching for a movie or a restaurant, I would toggle on the FB filter and when searching on an education technology topic, I could toggle on my Google+ filter.  Till that happens, maybe one can just use Bing for FB filter.
An option is to set up Bing as default search on Firefox and use it to search for movies, and use Google as default search engine on Chrome and use it to search for another areas of interest.  Its easy enough to keep a couple of different browsers running.  It's all about choice and creating smart filters.

As we look at the future, an ability to create such "smart" personalized filters will help you improve the signal:noise ratio and be more efficient in your searches.