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Friday, March 7, 2014

Chuck Webster's "Pragmatic Interoperability," continued...

Continuing from my prior post. The importance of Chuck Webster's proffer (scroll down, or just click here) merits considerably more consideration and blog reflection.
"Interactions among EHR workflow systems, explicitly defined internal and cross-EHR workflows, hierarchies of automated and human handlers, and rules and schedules for escalation and expiration will be necessary to achieve seamless coordination among EHR workflow systems. In other words, we need workflow management system technology to enable self-repairing conversations among EHR and other health IT systems. This is pragmatic interoperability. By the way, some early workflow systems were explicitly based on speech act theory, an area of pragmatics."

Well, Chuck cited this text in support of his argument for "pragmatic interoperability," so let's start there. "Pragmatic," in this rather erudite ("graduate level") academic context, doesn't denote (nor connote) "pragmatism" in the casual conversational sense -- i.e., "practical, workable, expedient, etc." A specialty within "linguistics," it's about the importance of, well, uh -- context in communications for accuracy of information exchange and subsequent mutual understanding of "meaning."

A scene-setting sample:
Defining pragmatics
What did they mean by that? it’s a relatively common question, and it’s precisely the subject of the field of pragmatics. In order to know what someone meant by what they said, it’s not enough to know the meanings of the words (semantics)  and how they had been strung together into a sentence (syntax); we also need to know who uttered the sentence and in what context, and be able to make inferences regarding why they said it and what they intended us to understand. There's one piece of pizza left can be understood as an offer (“would you like it?”) Or a warning (“it’s mine!”) Or a scolding (“you didn’t finish your dinner”), depending on the situation, even if the follow-up comments in parenthesis are never uttered. People commonly mean quite a lot more than they say explicitly, and it’s up to their addressees to figure out what additional meaning they might have intended. A psychiatrist asking a patient can you express deep grief? Would not be taken to be asking the patient to engage in such a display immediately, but a movie director speaking to an actor might well mean exactly that. The literal meaning is a question about an ability (“are you able to do so?”); the additional meaning is a request (“please do so”) that may be inferred in some contexts but not others. The literal meaning is the domain of semantics; the “additional meaning” is the domain of pragmatics.

1. Pragmatics and natural language: 1.1.1 Introduction and preliminary definitions

Linguistics is the scientific study of language, and the study of linguistics typically includes, among other things, the study of our knowledge of sound systems (phonology), word structure (morphology), and sentence structure (syntax). It is also commonly pointed out that there is an important distinction to be made between our competence and our performance. Our competence is our (in principle flawless) knowledge of the rules of our own idiolect —  our own individual internalized system of language that has a great deal in common with the idiolects of other speakers in our community but almost certainly is not identical to any of them. (For example, it’s unlikely that any two speakers share the same set of lexical items.) Our performance, on the other hand, is what we actually do linguistically — including all of our hems and haws, false starts, interrupted sentences, and speech errors, as well as are frequently imperfect comprehension: linguists commonly point to sentences like the horse raced past the barn fell as cases in which our competence allows us — eventually — to recognize the sentence as grammatical (having the same structure as the men injured on the battlefield died), even though our imperfect performance in this instance initially caused us to mis-parse the sentence. (Such sentences are known as "garden path" sentences, since we are led "down the garden path” toward an incorrect interpretation and have to retrace our steps in order to get to the right one. [emphasis mine -BG])

Pragmatics may be roughly defined as the study of language use in context — as compared with semantics, which is the study of literal meaning independent of context ( although these definitions will be revised below). If I’m having a hard day, I may tell you that my day has been a nightmare — but of course I don’t intend you to take that literally; that is, the day hasn’t in fact been something I’ve had a bad dream about. In this case the mid-semantic meaning of “nightmare” (a bad dream) differs from its pragmatic meaning — that is, the meaning I intended in the context of my utterance. Given this difference, It might appear at first glance as those semantic meaning is a matter of competence, while pragmatic meaning is a matter of performance. However our knowledge of semantics, like all of our linguistic knowledge, is rule governed …  Because speakers within a language community share these pragmatic principles concerning language production and interpretation in context, they constitute part of our linguistic competence, not merely matters of performance. That is to say, pragmatic knowledge is part of our knowledge of how to use language appropriately. And as with other areas of linguistic competence are pragmatic  competence is generally implicit — known at some level but not usually available for explicit examination…

Pragmatics, then, has to do with it rather slippery type of meaning, one that isn’t found in dictionaries and which may vary from context to context. The same utterance will mean different things in different contexts, and will even mean different things to different people…
1.1.2 Situating pragmatics within the discipline of linguistics
Language use involves a relationship between form and meaning. As noted above, the study of linguistic form involves the study of a number of different levels of linguistic units: phonetics deals with individual speech sounds, phonology deals with how the sounds pattern systematically within a language, morphology deals with the structure of words, and syntax deals with the structure of sentences. At each level these forms may be correlated with meaning. At the phonetic/phonological level, individual sounds are not typically meaningful in themselves. However international contours are associated with certain meanings; these associations are the subject of the study of prosody.  At the morphological level, individual words and morphemes  are conventionally associated with meanings; this is the purview of the lexical semantics and lexical pragmatics. And at the sentence level, certain structures are conventionally associated with certain meanings (e.g.,  when two sentences are joined by and, as in I like pizza and I eat it frequently, we take the resulting conjunction to be true as well);  this is the purview of sentential semantics. Above the level of the sentence, we are dealing with pragmatics, including meaning that is inferred based on contextual factors rather than being conventionally associated with a particular utterance.

Pragmatics is closely related to the field of discourse analysis. Whereas morphology restricts its purview to the individual word, and syntax focuses on individual sentences, discourse analysis studies strings of sentences produced in a connected discourse. Because pragmatics concentrates on the use of language in context, and the surrounding discourse is part of the context, the concerns of the two fields overlap significantly. Broadly speaking, however, the two differ in focus: pragmatics uses discourse as data and seeks to draw generalizations that have predictive power concerning our linguistic competence, whereas discourse analysis focuses on the individual discourse, using the findings of pragmatic theory to shed light on how particular set of interlocutors use and interpret language in a specific context.
Got all that?

Right. Suzie, the primary care M.A. with the high school diploma, just got a catatonizing case of MEGO. (Q: will there be an ICD-10 code for that? dx "ATPIMC-IE"? Acute Transient Pragmatic Interoperability MEGO Catatonia, Initial Encounter.)

Looks like a great text. Way too expensive at $35.99 Kindle edition. Though, I may well buy it anyway at some point as a nicely-written refresher, after I digest a couple of other more important eBooks for me in the same price range. The Amazon 1-Click Cognitive Crack Pipe is killin' me.

I used my Mac Dragon Dictate to talk this stuff in, reading in split windows from the Amazon "Look Inside" preview, just for y'all.
"retrace our steps in order to get to the right [interpretation]."
Yeah. In ordinary Great Unwashed Lean-speak, we're simply talking about process errors, "defects," - MIS-communication. (More precisely, failures of intended communication.)

At its most banal, clinical miscommunication (failure of "communication") is merely an exasperating waste of resources. At its most consequential, patients die.

communication (n.)
late 14c., from Old French comunicacion (14c., Modern French communication), from Latin communicationem (nominative communicatio), noun of action from past participle stem of communicare "to share, divide out; communicate, impart, inform; join, unite, participate in," literally "to make common," from communis (see common (adj.)).
Again: if the meaning at the recipient end is not precisely what the sender intended, it's not "communication," it's error, it's defect, it's "miscommunication." (It may well be that the information proffered by the sender is erroneous as well and nonetheless taken at face value by the recipient, but that's a bit of another issue.)

My sub-Pragmatics, more fundamental (albeit still linguistically valid) rant on "Interop," specifically the argument for a metadata "Data Dictionary Standard" here.


My comment in response to THCB's latest post "
A New Model for Patient Safety"
Bobby Gladd says - March 9, 2014 at 10:23 am

“a lot of unhappy “stakeholders” who like the status quo.”

And a lot of that status quo goes to the chronic continuing prevalence of toxic psychosocial healthcare workplaces — e.g., the “Bully Culture,” also a topic long recognized as an identifiable component of patient safety, yet also an area short on systematic analytic study pointing to effective remedies.

People working on the front lines in healthcare are under increasing “productivity treadmill” time constraints, amid an increasingly complex technological and cognitive burden work environment. And, the “shame and blame culture” continues to hold material sway, notwithstanding all the tired Smiley Face Happy Talk regarding “fix the problem, not the blame.” The error rate / patient safety upshot of FUD environments should come as no surprise.

None of this is exactly news. We know that error rates are significantly correlated with workplace stress. People under duress make more mistakes, all other factors being equal. Until we pay systematic and prolonged attention to improving the psychosocial “health” of healthcare operations, all we’re likely to get — in addition to ineffective coercive “workplace wellness” programs — are more slick data reports pointing fingers in every direction.

Calls for “critical thinking” among workers fashionably abound. But, you simply cannot have a “critical thinking” CQI operation within a culture where one speaks truth to power at one’s peril. Dr. Toussaint of The ThedaCare Center added an 8th waste to the Lean model — the waste he calls “unused talent.” Part of that cannot but be the waste of the talents of people who might well be able to help improve things like patient safety but who are too often cowed by FUD. The first-rate talent moves on at the first opportunity. The ostensible “lesser lights” quickly learn that surviving in your job means keeping your head down and not making waves in the face of executive and managerial arrogance and the error-escalating subterranean hostility it invariably breeds.


In January 2013 I made note of Mary Mosquera's reporting on AHRQ's latest foray into revisiting clinical workflow. My take-away, as I commented at the time:
"4. Extract clinical data in logs and audit trails that have been time-stamped from the EHR to reconstruct clinical workflow related to the health IT system. This information validates and supplements the data recorded by human observers."
Better late than never, one supposes. I've been arguing this for years. An EHR audit log is essentially an information workflow record that should be mined to analyze routine tasks times-to-completion and variability. Analysis can also reveal the "pain points," i.e., iterative, recurrent "flow" barriers. You then couple these data with data taken regarding concomitant physical tasks to flesh out a more useful picture for systematic improvement activities
The very word 'workflow' has become a cliche. Rolls readily off the tongue with little thought given to what it entails. A more apt analogy might be a traffic copter shot of the jerky stop-&-go freeway traffic of rush hour. In most clinics, it's nearly ALWAYS rush hour.I joked in one jpeg I did for my blog that this was my Primary's office at 8:03 a.m.
See also (freely distributable)
A decade ago I was working in credit risk and portfolio management at a relatively small privately-held issuer of VISA/MC subprime credit cards (roughly a million active accounts). I had free run of most of the internal network. I got to looking at our in-house developed collections call center system (~1,000 collectors assiduously working the phones every day), and knew the source language and data tables architecture, so I started importing the data into SAS and mining them (it was basically a Collections "audit log," though I was the first to audit it, on my own initiative)
I was able to rather quickly show management that their staffing deployment and call volumes were egregiously misaligned. We were typically spending $1,000 to collect $50 (or less), hounding delinquent customers with sometimes up to 140 calls per month, at all hours of the day and night (the classic, hated subprime M.O.).
It was a lava flow of waste. I issued a snarky monthly report on these activities, dubbed "The Don Quixote Report."
On the basis of my rather simple call log analytics we were able to save the bank about $5 million a year in Collections Ops cost, dragging the VP of Collections kicking and screaming all the way (his annual bonus was tied in part to his budget, which was the largest in the company -- he did not become My Friend).
"Workflow" tactics deployed in healthcare remain stuck about 10-15 years behind the times, as they don't drill down into time consumed and error rates. Mining the EHR audit logs might be of great utility here -- though the datetime() stamps are gonna need to be more granular than just down to the second. SQL now supports time capture down to the microsecond, though tenths or hundreds might suffice.
Another barrier here in general might be "once you've seen one audit log data dictionary, you've seen one audit log data dictionary." Recall that we have at this point nearly 1,800 "complete Certified EHR systems." How many differing audit log architectures we have is probably unknown outside of ONC CHPL -- if they even bother to look.
Let's hope this AHRQ study will move us usefully ahead.
OK, my amended Workflow Triangle™(lol)

Lean / Six Sigma Process Improvement initiatives would likely focus principally (though not exclusively) on the "Physical Tasks" leg of clinical ops. Couple that with adroit analyses of HIT audit logs, and we might be able to better leverage significant improvement efforts. Time is, of course, the fundamental, inescapable constraint in any business. Saving time and reducing physical task and HIT inefficiencies and errors would leave more of it for improving the most important facet -- the cognitive.

So goes my theory, at any rate.

(The five million bucks I saved my bank was anything but "theoretical." Got a helluva bonus that year.)

The "cognitive." Chuck's "conversations."

Conversations go bad. All the time. They are by no means "self-repairing" at this point. By way of analogy, think of all the coding -- the various normative vocabularies, the "structured data" of MU (as well as the lack of a Data Dictionary Standard) as resulting in "lossy compression." Narrative "conversation" nuance gets erased.

Back to workflow. Riffing once again on my simple workflow model visualization:

Every time I go and play around in my Mac GarageBand app, I am struck by the similarity

That's a screen snip of the tracks to my silly July 2012 song "ObamaCare Free Rider." It's a workflow.
I was inspired to write and record this after the Supreme Court ruling narrowly upholding the PPACA, pejoratively known as "ObamaCare." Thanks to my bro' Lenny Lopez for the harmonies. Thanks to Apple for your awesome GarageBand app. The "Epistemic Hairball All Star Shoe Band" here is nothing but a multitrack sequence of Garageband library loops.
All I ever wanted to do was be a guitar player. :)

Stage 2 meaningful use off to slow start
Among the hurdles are vendor readiness, quality reporting, lack of interoperability
Neil Versel, March 10, 2014

Stage 2 of the federal Electronic Health Records Incentive Program is underway for providers who first reached Stage 1 in 2011. Although there will not be any official statistics available for several months, anecdotal evidence suggests that this new phase is off to a slow start.

Healthcare providers, EHR vendors and other health IT industry insiders have identified several pain points that seem to be hindering the migration from Stage 1 to Stage 2. Notably, providers have to juggle multiple healthcare reform efforts simultaneously and are struggling with Stage 2 requirements to engage and educate patients.

Vendors have tight timelines to bring their EHRs up to Stage 2 standards, and are unclear about new testing for usability. Any delay on the vendor side naturally makes achieving meaningful use more difficult for their customers.

And, of course, entities in all sectors of healthcare continue to lag when it comes to interoperability of electronic health information...
"...all sectors of healthcare continue to lag when it comes to interoperability of electronic health information"

Indeed. Chuck?

LOL. From my June 27th, 2013 post.

More to come...  

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