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 email@example.com 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 . 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 . 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 . 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 . 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 . According to Linden, working memory is closely linked to shortterm memory, but it functions at the interface of perception and action . 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 . 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 . 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 . 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 . 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 . 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 . 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 . 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 . 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. 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