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Mobile Computing in Healthcare:
The Dreams and Wishes of Clinicians
John Luo, M.D.
UCLA Department of Psychiatry
760 Westwood Plaza
Mailcode 175919
310-206-5448
jsluo@mednet.ucla.edu
ABSTRACT
Physicians and other health care providers are often slower to
adopt newer technologies in comparison to the other industries.
Reasons for slow adoption include the anxiety of learning how to
use new hardware, the frustration with constant technological
change, and hesitancy to get out of an established routine. This
talk will briefly review some of the psychology behind resistance
to change and adoption of new technologies, and highlight
strategies in encouraging the healthcare industry to quickly adapt
to the exciting and new technologies.
Categories and Subject Descriptors
K.6.1 [Project and People Management]: strategic information
systems planning
General Terms
Management, Human Factors
Keywords
Change management, biopsychoscial model
1. INTRODUCTION
In today’s digital age, new innovations almost arrive daily in our
lives, whether it is new electronic hardware such as mobile
phones and computers or web sites promoting a new service such
as social networking. The general public has adapted to these
new technologies quickly as evidenced by the high numbers of
iPhones sold and the rapid growth of Facebook users. In contrast,
physicians have been slow to adopt information technology tools
despite the obvious clinical benefits [1]. There are many different
reasons for slow adoption of technology, including financial
costs, resistance to change, and slow diffusion of innovation. In
the field of psychiatry, physicians are taught to use the
biospsychosocial formulation to assimilate the primary biological,
psychological, and social factors into an integrated understanding
of the patient [4]. This same approach can be applied to systems
planning both in assessment and deployment of new technologies
Permission to make digital or hard copies of all or part of this work for
personal or classroom use is granted without fee provided that copies are
not made or distributed for profit or commercial advantage and that
copies bear this notice and the full citation on the first page. To copy
otherwise, or republish, to post on servers or to redistribute to lists,
requires prior specific permission and/or a fee.
HealthNet’08, June 17, 2008, Breckenridge, CO, USA.
Copyright 2008 ACM ISBN 978-1-60558-199-6/08/06…$5.00.
in the healthcare arena.
2. BACKGROUND
2.1 Biological
One of the reasons for slow adoption of new technologies is that
learning requires the ability of the brain to store information.
There are three types of memory - immediate recall, short-term
memory, and long-term memory [15]. Immediate recall is the
phenomenon where people remember and are able to repeat
information shortly after reading or hearing it for up to 10
minutes. This type of memory is based in the auditory association
cortex. Short-term memory lasts up to an hour, and has been
associated with deep areas of the temporal lobe. Long-term
memory lasts for many years, and encoding of such memory is in
the hippocampus and adjacent cortex of the medial temporal
lobes.
The key to establishing new memory and create learning is the
ability of the brain to make new connections or pathways [7].
This process requires brain cells to create new connections with
one another, called synapses. The brain cell or neuron has a
central unit, the nucleus, with small connections known as
dendrites, and large interconnections that may travel long
distances known as axons. The speed of signal transmission is
dependent on the axon, which conducts signals faster when
covered in myelin, the white matter coating nerve fibers. This
speed increase is akin to faster local area network connections
with shielded cables that decrease interference.
Age is where these processes come to bear. Age related memory
impairment is a normal process, and it is distinct from
Alzheimer’s disease (AD), which is a neurodegenerative process.
Age related impairment (AAMI) impacts those who are at least 50
years of age, who complain of memory loss compared to early
adult life, and objective evidence exists that such memory loss is
one standard deviation below mean for young adults on a
standardized memory test [Kruse]. Animal studies suggest that
both AAMI and AD reflect vulnerability of the same neuronal
circuits, where in AD neuronal death dominates and in AAMI is
mediated by synaptic alterations in intact circuits [5].
According to Linden, working memory is closely linked to shortterm memory, but it functions at the interface of perception and
action [10]. It operates whenever information is retained and
manipulated over brief time periods to guide an immediate
response. Working memory has functional specialization into
‘visual’ and ‘spatial’ modules. Animal studies have demonstrated
that the age related decline in growth hormone contribute to the
decline in memory [14]. Thorton and collaborators administered
growth hormone releasing hormone in rats age 9 to 30 months and
compared them to rats age 6 months. The rats with long term that
GHRH exposure did not have the spatial memory decreases
associated with age.
will survive whatever comes next. Dr. Kübler-Ross writes that
anger is a necessary stage of the healing process because it helps
dissipate the multitude of emotions in grief. Anger is a stage that
must pace itself because it carries the pain of loss.
The exact biology inherent in learning and memory is still a
subject of significant research, but it indicates that from a
biological perspective, people undergo normal age related
declines in memory and processing. Myelin, which is central to
the speed of signal transduction through axons, has been
demonstrated to degrade in the fiber tracts of cortical, subcortical,
interhemispheric, and cerebellar systems in normal aging subjects
on quantitative imaging [13]. This functional degradation
correlated with poorer performance on cognitive or motor tests.
Hormonal influences, such as growth hormone, are also among
the biological changes with age that impact memory and learning.
Bargaining is the stage where one seeks in vain for a way out. It
is a place of mixed emotions where an alternate future provides
respite from grief. Bargaining helps the mind move from one
state of loss to another, and gives the psyche time to make
adjustments. It changes over time, and moves from the past to the
future.
2.2 Psychological
2.2.1 Attachment Theory
Attachment theory is the work of John Bowlby and Mary
Ainsworth. Although this theory focuses on the disruption of the
ties between the child and its mother in terms separation,
deprivation, and bereavement, it is a framework to understand
how people have difficulty adjusting to new technologies [2].
Bowlby’s attachment theory involves the relationship between
infants and their parents in the context of social development. In
this relationship, infants are completely dependent on the
behavior of their parents for survival, which is mutually activating
and stimulating relationship. Healthy development is a secure
attachment in which the children are confident that their parents
or parental figures will be available, responsive, and helpful in
times of need. This type of development provides the assurance
that children need to feel emboldened in their exploration of the
world as well as dealing with it. A second pattern is termed
anxious resistant attachment, where the child is unsure whether
the parents will be available, responsive, or helpful when needed.
In this pattern, the child is prone to separation anxiety, is very
clingy, and is anxious about exploring the world. In the third
pattern, anxious avoidant attachment, the child has no confidence
that the parents will be responsive, but in addition, expects to be
rebuked. This pattern stems from rejection, ill treatment, or
prolonged institutionalization of the child.
2.2.2 Grief and Grieving
Dr. Elisabeth Kübler-Ross is known for her work on grief and
grieving [9]. Her five stages of grief - denial, anger, bargaining,
depression, and acceptance – are part of a framework that helps
people learn to live with loss. A key element is that they are not
part of a linear timeline in grief, and not every stage is
implemented nor in any particular order.
Denial in grief means that the loss is too much for one’s psyche.
It does not mean that one denies that the loss has occurred and
operates as if nothing has happened, but that the mind does not
fully process the loss, an unconscious process to help manage the
feelings and survive the loss. Denial and shock is a way to cope
and make survival possible by helping pace the feelings of grief.
Anger presents itself in many different ways. Anger is not
necessarily logical or valid, but occurs once the feeling is that one
Depression is the final realization of the inevitable. This stage
feels as if it will last forever, but it is not to the extent of major
depression, a mental illness, where one loses the ability to
function in domains of work, school, or home. Depression is a
normal and appropriate response to grieving, a natural state of the
nervous system to shut down in order to adapt to something the
psyche cannot handle. Dr. Kübler-Ross writes that depression
will leave as soon as it has served its purpose in loss.
Acceptance is the stage where one finally finds the way forward.
It is where the psyche is able to accept that loss is the new reality
with which one must learn to live. Acceptance is where the final
healing and adjustment take place, a process of reintegration
towards healing.
2.3 Social
The social system is an important element of consideration for
change in Roger’s Diffusion of Innovation Theory [11]. Diffusion
is a kind of social change, defined as the process with which
change occurs in the structure and function of a social system. A
social system is defined as the set of interrelated units that are
engaged in joint problem solving to accomplish a common goal.
All members must cooperate to some extent to solve a common
problem in order to reach a mutual goal. Rogers defines structure
as the patterned arrangements of the system, which gives it
stability and regularity to individual behavior in the system. The
social structure of the system affects the innovation’s diffusion by
setting a boundary within which it diffuses.
Norms are the established behavior patterns of the units within a
social structure. Norms define a range of tolerable behavior and
serve as a guide for members of the system that tell them what
behavior they are expected to perform. A system’s norms can be a
barrier to change. These norms are usually exemplified in the
behavior of the opinion leaders in the system. Individuals within
the system who are the most innovative are often perceived as
deviant, and therefore have low credibility and status.
Opinion leadership is the degree to which an individual is able to
influence others attitudes or behavior informally in a desired
manner with relative frequency. This level is earned and
maintained by an individual’s technical competence, social
accessibility, and conformity to the system norm. This person
differs from a change agent, who is an individual who attempts to
influence others’ innovation-decisions in a desired direction. The
change agent seeks to obtain the adoption of new ideas but may
also slow down diffusion.
Change agents often use opinion
leaders within a social system to effect the desired change in
diffusion activities.
Social identity and self-categorization processes impact
organizations as well [6]. Hogg and Terry describe how selfcategorization is motivated by subjective uncertainty reduction.
Social categorization of self and others are into ingroup and
outgroups. Individuals seek to assimilate themselves into the
ingroup, hence depersonalization drives the social identity
process. Groups are structured in terms of perceived or actual
prototypes of members. Prototypes are all the attributes that
characterize the group and maximize the similarities and
differences from other groups, creating group identity.
3. STRATEGIES IN BIOPSYCHOSOCIAL
FORMULATION AND PLAN
3.1 Biological
In the context of the biopsychosocial formulation, any new
technology to be implemented should be assessed and
implemented according to these factors. In the biological
perspective, systems and networking support for healthcare and
assisted living environments must take into consideration that
learning may be slower by the older population due to age related
changes. Visual-spatial skills are often diminished, therefore
interfaces must be easier to manipulate. In the context of aging
and memory, it may be quite difficult for the elderly to learn to
navigate new surroundings, so maintaining them in their home or
assisted living environment as long as possible is ideal.
Strategies for maintaining brain health include stress reduction,
physical activity, healthy diet, and mental activity [12]. Stress
reduction works because animal studies show that prolonged
exposure to stress hormones have an adverse effect on the
hippocampus, the brain region involved with memory and
learning. Physical activity promotes new neuron growth in the
hippocampus of laboratory animals due to increase in cerebral
blood flow, which promotes nerve cell growth. A healthy diet is
important because factors related to obesity increase the risk of
cerebrovascular disease and hence memory decline with stroke
and vascular dementia. Antioxidants in foods such as vitamin E
and C help protect the brain. Mental activities such as mentally
stimulating jobs or educational experiences such as college
predict better cognitive function in later life. Sensor systems in
the home should not only track movements throughout the home,
but should also provide feedback and encouragement of motor
and mental activity to promote memory function.
3.2 Psychological
From the psychological construct, the older population may be
very attached to their home, and will experience separation
anxiety when placed in new settings. Those patients with good
attachments will adapt when moving to assisted living
environments because they are able to appreciate and believe that
staff and loved ones will address their needs. Their security
enables them to discover a sense of adventure with new activities
and new people. Patients with poor attachments may find that
they struggle with the concept of moving and therefore are better
maintained in their home setting. However, their lack of security
will drive them to be anxious with thoughts of how they will
manage on their own. In addition, their anxiety may make them
overly dependent on family, creating ‘burnout’.
New technologies should enable mobile communication
wirelessly to help create foster attachment and not dependency.
For example, a communication device such as a voice enabled
dialing phone that can work on both wireless networks at home
and away at the doctor’s office can provide physiological data to
healthcare providers while conveying location data to family.
This device should have algorithms to detect unusual inactivity,
perhaps an indication of an adverse event such as a fall or even
stroke, and thereby alert family and ambulance services if needed.
All too often, adaptation to new surroundings, new people, and
new devices require psychological processing of loss. Many
patients with health conditions may find it challenging to get
psychological services on a regular basis. Few physicians and
likely fewer psychiatrists make house calls. Perhaps the same
communication device that makes voice calls can provide real
time video messages from family or even health providers in
certain situations such as when the patient is crying and in need of
support.
3.3 Social
The social component of technological assessments and
innovations should include assessment of situation as well as
recommendations to improve aspects of living, financial, and
support network. The elderly and homebound population are at
risk for being unable to make changes, such as adjusting for
higher food prices on a fixed budget. In California, predatory
professional conservators who take on clients with the purported
goal of facilitating their livelihood have taken a law written to
help families legally manage the estate of their loved ones and
made it into a private business [3]. The writers found that more
than 500 seniors out of 2400 cases that they reviewed lost their
independence to for-profit conservators. Conservators made
money by charging processing fees, and have also wrecked havoc
by not following the wishes of their clients.
Now that smarphones can process bank transfers and can make
VISA payments using infrared communication, it may be
necessary to create social networks of seniors who pool their
collective needs such as grocery purchases to maximize their
fixed income. Facebook could transition into a potential platform
for senior socialization and applications could be developed that
are not frivolous and silly but actually mashup with Craigslist to
provide services and address needs of seniors. Seniors would be
less isolated in their home settings when they communicate with
others for support as well as share the financial cost of bulk
purchases and delivery.
4. CONCLUSION
The goal of the 2nd International HealthNet is to create new
technologies to provide support for the elderly and home bound
people by improving their quality of life without being instrusive
and disrespectful. The challenge of integrating sensors, wireless
networks, distributed intelligence, databases, and connectivity
requires more than integrating expertise from human computer
interface, middleware, and social networking. Psychiatry with its
rich experience in the biopsychosocial model for assessment and
planning as a tool for developing change can make the dreams
and wishes of clinicians, patients, and computing industry
professionals a reality.
5. REFERENCES
[1] Audet, A.M., Doty, M.M., Peugh, J., Shamasdin J., Zapert,
K., Schoenbaum, S. 2004. Information Technologies: When
Will They Make It Into Physicians’ Black Bags? MedGen
Med. 6, 4 (Dec. 2004), 2.
[2] Bowlby, J. 1988. Secure Base: Clinical Applications of
Attachment Theory. Brunner-Routledge, New York, NY.
[3] Fields, R., Larrubia E., and Leonard, J. 2005. When a Family
Matter turns Into a Business. Los Angeles Times (November
13, 2005),
[4] Hales, R.E., Yudofsky, S.C., and Gabbard, G.O. 2008. The
American Psychiatric Publishing Textbook of Psychiatry, 5th
Edition. American Psychiatric Publishing, Inc., Arlington,
VA.
[5] Hof, P.R., and Morrison, J.H. 2004. The Aging Brain:
Morphomolecular Senescence of Cortical Circuits. Trends.
Neurosci. 27, 10. (Oct. 2004), 607-613.
DOI=10.1016/j.tins.2004.07.013.
[6] Hogg, M.A., and Terry, D.J. 2000. Social Identity and SelfCategorization Processes in Organizational Contexts. Acad.
Manage. Rev. 25, 1, 121-140.
[7] Kandel, E.R., Schwartz, J.H., and Jessell, T.M. Principles of
Neural Science. 2000. McGraw-Hill Professional, New
York, NY.
[8] Kruse, C.G., Meltzer, H.Y., Semnef, C., and van de Witte,
S.V. 2006. Thinking About Cognition: Concepts, Targets,
and Therapeutics. IOS Press, Fairfax, VA, 15-18.
[9] Kübler-Ross, E. and Kessler, D. 2005. On Grief and
Grieving: Finding the Meaning of Grief Through the Five
Stages of Loss. Scribner, New York, NY.
[10] Linden, D.E.J. 2007. The Working Memory Networks of the
Human Brain. Neuroscientist. 13, 3, 257-267. DOI=
10.1177/1073858406298480.
[11] Rogers, E.M. 2003. Diffusion of Innovations. 5th ed. Free
Press, New York, NY.
[12] Small, G.W. 2002. What we Need to Know About Age
Related Memory Loss. Brit. Med. J., 324 (June 2002), 15021505.
[13] Sullivan, E.V., Rohlfing T., and Pfefferbaum A. 2008.
Quantitative fiber tracking of lateral and interhemisphreic
white matter systems in normal aging: relations to timed
performance. Neurobiol. Aging, 2008, in press.
DOI=10.1016/j.neurobiolaging.2008.04.007.
[14] Thornton, P.L., Ingram, R. L., and Sonntag, W.E. 2000.
Chronic [D-Ala2]-Growth Hormone-Releasing Hormone
Administration Attenuates Age-Related Deficits in Spatial
Memory. Journal of Gerontology Series A: Biological
Sciences and Medical Sciences. 55, 2, B106-B112.
[15] Waxman, S.G. 2003. Clinical Neuroanatomy, 25th Edition.
McGraw-Hill, New York, NY.
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