How not to design the user experience in electronic health records

Two weeks ago, I summarised my own experience of using a research reporting system. I know (from subsequent communications) that many other researchers shared my pain. And Muki Haklay pointed me at another blog on usability of enterprise software, which discusses how widespread this kind of experience is with many different kinds of software system.

Today, I've had another experience that I think it's worth reporting briefly. I had a health screening appointment with a nurse (I'll call her Naomi, but that's not her real name). I had to wait 50 minutes beyond the appointment time before I was seen. Naomi was charming and apologetic: she was struggling with the new health record system, and every consultation was taking longer than scheduled. This was apparently only the second day that she had been using the health screening functions of the system. And she clearly thought that it was her own fault that she couldn't use it efficiently.

She was shifting between different screen displays more times than I could count. She had a hand-written checklist of all the items that needed to be covered in the screening, and was using a separate note (see right) to keep track of the measurements that she was taking. She kept apologising that this was only because the system was unfamiliar, and she was sure she'd be able to work without the checklist before long. But actually, checklists are widely considered helpful in healthcare. She was working systematically, but this was in spite of the user interactions with the health record system, which provided no support whatsoever for her tasks, and seemed positively obstructive at times. As far as I know, all the information Naomi entered into my health record was accurate, but I left her struggling with the final item: even though, as far as either of us could see, she had completed all the fields in the last form correctly, the system wasn't letting her save it, blocking it with a claim that a field (unspecified) had not been completed. Naomi was about to seek help from a colleague as I left. I don't know what the record will eventually contain about my smoking habits!

This is just one small snapshot of users' experience with another system that is not fit for purpose. Things like this are happening in healthcare facilities all over the world every day of the week. The clinical staff are expected to improvise and act as the 'glue' between systems that have clearly been implemented with minimal awareness of how they will actually be used. This detracts from both the clinicians' and the patients' experiences, and if all the wasted time were costed it would probably come to billions of £/$/€/ currency-of-your-choice. Electronic health records clearly have the potential to offer many capabilities that paper records could not, but they could be so, so much better than they are if only they were designed with their users and purposes in mind.

A mutual failure of discovery: DIB and DiCoT

Today, I have been doing literature searching for a paper on Distributed Cognition (DCog). By following a chain of references, I happened upon a paper on Determining Information Flow Breakdown (DIB). DIB is a method for applying the theory of DCog in a semi-structured way in complex settings. The example the authors use in the paper comes from healthcare.

The authors state that "distributed cognition is a theoretical approach without an accepted analytical method; there is no single 'correct way' of using it. [...] the DIB method is a practical application of the theory." At the time that work was published (2007), there were at least two other published methods for applying DCog: the Resources Model (2000) and DiCoT (Distributed Cognition for Teamwork; 2006). The developers of DIB were clearly unaware of this previous work. Conversely, it has taken me seven years from when the DIB paper was published to become aware of it and my team have been working on DCog in healthcare for most of that time. How could that happen?

I can think of several answers involving parallel universes, different literatures, too many different journals to keep track of, the fragility of search terms, needles in haystacks. You take your pick.

Whatever the answer actually is (and it's probably something to do with a needle in another universe), it's close to being anti-serendipity: a connection that is obvious and should have been expected. We clearly have some way to go in developing information discovery tools that work well.

Collaborative sensemaking under uncertainty: clinicians and patients

I've been discussing a couple of 'conceptual change' projects with clinicians, both of them in topic areas (pain management and contraception) where the clinical details aren't necessarily well understood, even by most clinicians. I have been struck by a few points that seem to me to be important when considering the design of new technologies to support people in managing their health:

1. Different people have different basic conceptual structures onto which they 'hang' their understanding. The most obvious differences are between health professionals (who have received formal training in the subject) and lay people (who have not), but there are also many individual differences. In the education literature, particularly building on the work of Vygotsky, we find ideas of the 'Zone of Proximal Development' and of 'scaffolding'. The key point is that people build on their existing understanding, and ideas that are too far from that understanding, or are expressed in unfamiliar terms, cannot be assimilated. In the sensemaking literature, Klein discusses this in terms of 'frames', while Pirolli, Card and Russell discuss the process of making sense of new information in terms of how people look for and integrate new information with existing understanding guided by the knowledge gaps of which they are aware. In all of these literatures, and others, it's clear that any individual starts from their current understanding and builds on it, and that significant conceptual change (throwing out existing ideas and effectively starting again from scratch) is difficult. This makes it particularly challenging to design new technologies that support sensemaking because it's necessary to understand where someone is starting from in order to design systems that support changing understanding.
2. One of the important roles of clinicians is to help people to make sense of their own health. In the usual consultation, this is a negotiative process, in which common ground is achieved – e.g., by the clinician having a repertoire of ways of assessing the patient's current understanding and building on it. The clinician's skills in this context are not well understood, as a far as I'm aware.
3. For many patients, the most important understanding is 'what to do about it': it's not to get the depth of understanding that the clinician has, but to know how to manage their condition and to make appropriately informed decisions. Designing systems to support people in obtaining different depths and types of understanding is an exciting challenge.
4. Health conditions can be understood at many different levels of abstraction (from basic chemistry and biology through to high-level causal relations), and we seem to employ metaphors and analogies to understand complex processes. Inevitably, these have great value, but also break down when pushed too far. There's probably great potential in exploring the use of different metaphors and explanations to support people in managing their health.
5. As people are being expected to take more responsibility for their own health, there's a greater onus on clinicians to support patients' understanding. Clinicians may have particular understanding that they want to get across to patients, but it needs to be communicated in different ways for different people. And we need to find ways of managing the uncertainty that still surrounds much understanding of health (e.g. risks and side-effects).

All these points make it essential to consider Human Factors in the design of technologies to support conceptual change, behavioural change and decision making in healthcare, so that we can close the gap between clinicians' and patients' understanding in ways that work well for both.

Different ways of interacting with an information resource

I'm at a workshop on how to evaluate information retrieval systems, and we are discussing the scope of concern. What is an IR system, and is the concept still useful in the 21st Century, where people engage with information resources in many different ways? The model of information seeking in sessions for a clear purpose still holds for some interactions, but it's certainly not the dominant practice any more.

I was struck when I first used the NHS Choices site that it encourages exploration above seeking: it invites visitors to consume health information that they hadn't realised that they might be interested in. This is possible with health in a way that it might not be in some other areas because most people have some inherent interest in better understanding their own health and wellbeing. At least some of the time! Such sites encourage unplanned consumption, hopefully leading to new understanding, without having a particular curriculum to impart.

On the way here, I read a paper by Natalya Godbold in which she describes the experiences of dialysis patients. One of the points she makes is that people on dialysis exploit a wide range of information resources in managing their condition – importantly, including how they feel at the time. This takes embodied interaction into a new space (or rather, into a space in which it has been occurring for a long time without being noticed as such): the interaction with the technology affects and is informed by the experienced effects that flow (literally as well as metaphorically) through the body. And information need, acquisition, interpretation and use are seamlessly integrated as the individual monitors, makes sense of and manages their own condition. The body, as well as the world around us, is part of the ecology of information resources we work with, often without noticing.

While many such resources can't be "designed", it's surely important to recognise their presence and value when designing explicit information resources and IR systems.

Cultural heritage: sense making and meaning making

Last week, I was presenting at the workshop on Supporting Users' Exploration of Digital Libraries in Malta. One of the themes that came up was the relationship between meaning making and sense making. These seem to be two literatures that have developed in parallel without either referencing the other. Sense making is studied in the broad context of purposeful work (e.g. studying intelligence analysts working with information, photocopier engineers diagnosing problems, or lawyers working on a legal matter). Meaning making is discussed largely within museum studies, where the focus is on how to support visitors in constructing meaning during their visit. Within a cultural heritage context (which was an important focus for the workshop), there is a tendency to consider both, but it is difficult to clearly articulate their relationship.

Paula Goodale suggested that it might be concerned with how personally relevant the understanding is. This is intuitively appealing. For example, when I was putting together a small family tree recently, using records available on the internet, I came across the name Anna Jones about 4 generations back, and immediately realized that that name features in our family Bible. She's "Anna Davies" on the cover, but "Anna Jones" in the family tree inside. I had not known exactly how Anna and I are related, and the act of constructing the family tree made her more real (more meaningful) to me.

The same can clearly be true for family history resources within a cultural heritage context. But does it apply more broadly in museum curation work?

Following the workshop, we visited St Paul’s Catacombs in Rabat (Malta). 

The audio guide was pretty good for helping to understand the construction of the different kinds of tombs and the ceremonies surrounding death and the commemoration of ancestors. But was this meaning making? I’d say probably not, because it remained impersonal – it has no particular personal meaning for me or my family – and also because although I was attentive and walked around and looked at things as directed, I did not actively construct new meaning beyond what the curatorial team had invested in the design of the tour. Similarly, it wasn’t sense making because I had no personal agenda to address and didn’t actively construct new understanding for myself. So – according to my understanding – sense making and meaning making both require very active participation, beyond the engagement that may be designed or intended by educationalists or curators. They can design to enhance engagement and understanding, but maybe not to deeply influence sense making or meaning making. That is much more personal.

Hidden in full view: the daft things you overlook when designing and conducting studies

Several years ago, when Anne Adams and I were studying how people engaged with health information, we came up with the notion of an "information journey", with three main stages: recognising an information need; gathering information and interpreting that information. The important point (to us) in that work was highlighting the important of interpretation: the dominant view of information seeking at that time was that if people could find information then that was job done. But we found that an important role for clinicians is in helping lay people to interpret clinical information in terms of what it means for that individual – hence our focus on interpretation.

In later studies of lawyers' information work, Simon Attfield  and I realised that there were two important elements missing from the information journey as we'd formulated it: information validation and information use. When we looked back at the health data, we didn't see a lot of evidence of validation (it might have been there, but it was largely implicit, and rolled up with interpretation) but – now sensitised to it – we found lots of evidence of information use. Doh! Of course people use the information – e.g. in subsequent health management – but we simply hadn't noticed it because people didn't talk explicitly about it as "using" the information. Extend the model.

Wind forwards to today, and I'm writing a chapter for InteractionDesign.org on semi-structured qualitative studies. Don't hold your breath on this appearing: it's taking longer than I'd expected.

I've (partly) structured it according to the PRETAR framework for planning and conducting studies:

• what's the Purpose of the study?
• what Resources are available?
• what Ethical considerations need to be taken into account?
• what Techniques for data gathering?
• how to Analyse data?
• how to Report results?

...and, having been working with that framework for several years now, I have just realised that there's an important element missing, somewhere between resources and techniques for data gathering. What's missing is the step of taking the resources (which define what is possible) and using them to shape the detailed design of the study – e.g., in terms of interventions.

I've tended to lump the details of participant recruitment in with Resources (even though it's really part of the detailed study design), and of informed consent in with Ethics. But what about interventions such as giving people specific tasks to do for a think-aloud study? Or giving people a new device to use? Or planning the details of a semi-structured interview script? Just because a resource is available, that doesn't mean it's automatically going to be used in the study, and all those decisions – which of course get made in designing a study – precede data gathering. I don't think this means a total re-write of the chapter, but a certain amount of cutting and pasting is about to happen ...

Parallel information universes

A few years ago, a raised white spot developed on my nose. It's not pretty, so I'm not going to post a picture of it. I didn't worry about it for a while; tried to do internet searching to work out what is was and whether I should do anything about it.

A search for "raised white spot on skin" suggested that "sebrrheic keratosis" was the most likely explanation. But I did an image search on that term and it was clearly wrong: wrong colour, wrong texture, wrong size...

"One should visit a doctor immediately when this signs arise": ignoring the grammatical problem in that advice, I booked an appointment with my doctor. She assured me that there is nothing to worry about -- that it is an "intradermal naevus", that there would be information about it on dermnetnz.org. Well, actually, no: information on Becker naevus (occurs mostly in men, has a dark pigment); on Sebaceous naevus (bright pink, like birth marks), Blue naevus (clue is in the colour)... and many other conditions that are all much more spectacular in appearance than a raised white spot. I find pages of information including words ending in "oma": melanoma, medulloblastoma, meningioma, carcinoma, lymphoma, fibroma. If the condition is serious, there is information out there about it. But the inconsequential? Not a lot, apparently. Contrary to my earlier belief, knowing the technical terms doesn't always unlock the desired information.

Look further. I find information on a patient site. But it's for healthcare professionals:  "This is a form of melanocytic naevus [...] The melanocytes do not impart their pigmentation to the lesion because they are located deep within the dermis, rather than at the dermo-epidermal junction (as is the case for junctional naevi/compound naevi)." I feel stupid: I have a PhD, but it's not in medicine or dermatology, and I have little idea what this means.

I eventually work out that naevus or nevi is another term for mole. I try searching for "white mole" and find general forums (as well as pictures of small furry creatures who dig). The forums describe something that sounds about right. But lacks clinical information, on causes or treatment or likely developments without treatment.

At that point, I give up. Lay people and clinicians apparently live in parallel universes when it comes to health information. All the challenges of interdisciplinary working that plague research projects also plague other interactions – at least when it comes to understanding white moles that are not cancerous and don't eat worms for breakfast.

The information journey and information ecosystems

Last year, I wrote a short piece for "Designing the search experience". But I didn't write it short enough (!) so it got edited down to a much more focused piece on serendipity. Which I won't reproduce here for copyright reasons (no, I don't get any royalties!). The theme that got cut was on information ecosystems: the recognition that people are encountering and working with information resources across multiple modalities the whole time. And that well designed information resources exploit that, rather than being stand-alone material. OK, so this blog is just digital, but it draws on and refers out to other information resources when relevant!

Here is the text from the cutting room floor...

The information journey presents an abstract view of information interaction from an individual’s perspective. We first developed this framework during work studying patients’ information seeking; the most important point that emerged from that study was the need for validation and interpretation. Finding information is not enough: people also need to be able to assess the reliability of the information (validation) and relate it to their personal situation and needs (interpretation).

This need for validation and interpretation had not been central to earlier information seeking models—possibly because earlier studies had not worked with user groups (such as patients) with limited domain knowledge, nor focused on the context surrounding information seeking. But we discerned these validation and interpretation steps in all of our studies: patients, journalists, lawyers and researchers alike.

The information journey starts when an individual either identifies a need (a gap in knowledge) or encounters information that addresses a latent need or interest. Once a need has been identified, a way to address that need must be determined and acted upon, such as asking the person at the next desk, going to a library, looking “in the world,” or accessing internet resources. On the web, that typically means searching, browsing, and follow trails of “information scent”. Often finding information involves several different resources and activities. These varied sources create an information ecosystem of digital, physical and social resources.

Information encountered during this journey needs to be validated and interpreted. Validation is often a loose assessment of the credibility of the information. Sillence and colleagues highlight important stages in the process: an early and rapid assessment—based on criteria such as the website’s design and whether it appears to be an advertising site—is typically followed by a more deliberate analysis of the information content, such as assessing whether it is consistent with other sources of information.
 
Interpretation is not usually straightforward. It often involves support from information intermediaries (an important part of the information ecosystem). This is one of the important roles of domain specialists (e.g. doctors and lawyers): working with lay people to interpret the “facts” in the context of the actual, situated needs. Even without help from intermediaries, Sillence & co. describe the lay users of health information in their study as acting like scientists, generating and testing hypotheses as they encountered new information resources, both online and offline. No one information resource is sufficient: online information fits in a broader ecology of information sources which are used together, albeit informally, to establish confidence and build understanding.
 
The interpretation of information can often highlight further gaps in understanding. So one information need often leads to others. For example, a colleague of mine was recently planning to buy a Bluetooth headset. His initial assumption was that there were only a few suitable headsets on the market, and his aim was simply to identify the cheapest; but it quickly became apparent that there were hundreds of possible headsets, and that he first needed to understand more about their technical specifications and performance characteristics to choose one that suited his needs. A simple information problem had turned into a complex, multi-faceted one. A known item search had turned into an exploratory search, and the activity had turned from fact-finding to sensemaking.

Information resources surround us. We are informavores, consuming and interpreting information across a range of channels. We are participants in huge information ecosystems, and new information interaction technologies need to be designed not just to work well on their own, but to be valuable components of those ecosystems.

Second-hand serendipity?

Doing research on serendipity enables me to reflect more than I would have done otherwise on experiences that I'd class as serendipity. Preparing for a recent workshop, I realised that it was a serendipitous encounter that led to all our work on serendipity, and transformed the careers of at least two members of my research team...

DSVIS 2004 was held at Tremsbuttel Castle in Germany. People from Lexis Nexis UK participated (i.e. the company paid for them to get out of the office and attend an academic conference that was frankly quite tangential to their core business). Over a beer, I mentioned that one of my post-docs had done his PhD on journalists' information seeking, and that Nexis had been an important product for them. The findings about how journalists used information (and particularly Nexis) was interesting to them, so they commissioned us to run a workshop for their staff on journalists' information seeking. This was followed by further consultancy projects on lawyers' information seeking, and collaboration on a research project on "making sense of information" (MaSI). These projects led to new Lexis Nexis products that are still going from strength to strength. All because Lexis Nexis supported their staff to go to a workshop in Germany in 2004 and we met there.

That same meeting enabled me to develop information interaction and sensemaking work that was foundational to the SerenA project studying serendipity. It also provided lots of opportunities for at least two members of my research team to study legal information seeking. So that one meeting, all starting with a beer (!), has been of immense value, to both us and Lexis Nexis. I suspect that my team have never realised quite how much all of our careers owe to that one serendipitous connection that they weren't even a direct part of!

Information detours

Recently, I did an online transaction. It started out superficially simple: to buy rail tickets from London to Salford. But then I had to check on a map of Salford to find out which station was appropriate. And the train operator wanted to know my loyalty card number, so I had to go and get that from my purse. Then my credit card supplier wanted me to add in additional security information, which of course I don't remember, so I had work to reconstruct what it might be. A superficially simple task had turned into a complicated one with lots of subtasks that comprise "invisible work".

It's a repeating pattern: that information tasks that are, at first sight, simple turn out to involve lots of detours like this, and sometimes the detours are longer than the original task.

Occasionally the detours are predictable; for example, I know that to complete my tax return I'm going to have to dig out a year's worth of records of income and expenditure that are filed in different places (some physical, some digital). There aren't actually a large number of relevant records, but I still dread this data collation task, which is why the relatively simple task of completing the form always gets put off until the last minute.

It's both hard to keep track of where one is amongst all these information detours and hard to keep focused on the main task through all the detours and distractions of our rich information environments. I'd like a supply of digital place-keeping widgets to help with progress-tracking amongst the clutter. If they could also link seamlessly to physical information resources, that would be even better...

Encountering information: serendipity or overload?

After my keynote at ISIC, one of the participants challenged me on my claim that information overload is a "bad thing" (not that I put it quite like that, but I certainly suggested it was something to be avoided). I framed it as a challenge when trying to design to support serendipity. We had an extended discussion about this later that day.

What Eva made me realise (thanks, Eva!) is that encountering exactly the same information can be regarded positively or negatively depending on the circumstances and the attitude of mind. If the attitude is one of exploring and of opportunity then the experience is typically positive. Eva consumes information enthusiastically on a wide variety of topics, and rarely if ever feels overloaded by the sheer volume of information available.

Whether or not information encountering is regarded as serendipitous is another question. A while ago, I gave a PechaKucha talk on the SerenA project; in the talk, I gave an example that I argue was serendipity: I encountered information that was unexpected, where I made a connection between my ambitions and an opportunity that was presenting itself, and from which the outcome was valuable. I also described the "sandpit" process that initiated SerenA – i.e., putting a bunch of academics together in a space that was conducive to ideas generation. Arguably, this experience was positive and creative, but not serendipitous, because it was designed to lead to positive outcomes. So although we could not have predicted the form of the outcome, we expected there to be an unanticipated outcome. So it wasn't serendipitous. Based on our empirical studies of serendipitous experiences, we have developed a process model of serendipity, namely that "a new connection is made that involves a mix of unexpectedness and insight and has the potential to lead to a valuable outcome. Projections are made on the potential value of the outcome and actions are taken to exploit the connection, leading to an (unanticipated) valuable outcome." From this, we also developed a classification framework
based on different mixes of unexpectedness, insight and value that define a “serendipity space” encompassing different “strengths” of serendipity.

So where does information overload fit? Well, as a busy academic, typical of many busy people, new information (however valuable) often represents new obligations:

•  to assimilate the information,
•  to assess its value, and
•  to act on it. 

I recognise the potential value of opportunities, and feel frustrated by my lack of capacity to exploit them all. And because of limited capacity, every opportunity taken means other opportunities that have to be passed over. In addition, limited memory means that even assimilating all the information I "should" know represents a substantial obligation that I can't hope to fulfill. So I feel under constant threat of information overload. And that seriously inhibits my openness to serendipitous encounters.

As recounted in the PechaKucha talk: twenty-something years ago, when my children were 2 years and 3 months old respectively, I came across an advert for a PhD studentship. It was my "dream" studentship, on an exciting topic and in the perfect location for me. Doing a PhD was not in my plans at the time, but was too good an opportunity to miss. And the outcome has been fantastic. It was unquestionably a serendipitous encounter. Apart from the unintended consequence that I now feel constantly under threat of total information overload!

Situated interaction from the system perspective: oops!

I am in Tokyo, to give a talk at Information Seeking In Context. Blogger infers that because a post is being composed in Tokyo, the author must understand Kanji. Result:

I have just experimented by pressing random buttons to enlarge the screen shot above from its default illegible size. It is quite gratifying to discover that it is still possible to compose a post, add a link, add a graphic, and maybe even publish it as intended. But believe me: it's taking a lot of effort. I am interacting with what appear to me to be squiggles (though of course those squiggles have meaning for readers of Kanji), and I can only guess the meaning from the graphical layout and positioning of the squiggles.

This is an amusing illustration of the dangers of computing technology being inappropriately "situated". The system has responded to the "place" aspect of the context while not adequately accounting for the "user" aspect. I fully accept that the physical environment presents information to me in Kanji, and that I sometimes fail to interpret it correctly. I don't expect the digital environment to put the same hurdles in my way!

Inarticulate? The challenges of health information seeking

Showing impeccable timing, three people I care about have fallen ill at the same time. To make sense of what it happening to each of them, I have been doing a lot of internet searching. And it has become really clear that – as a lay person – some health information needs are much easier to satisfy than others. Paradoxically, it's the more technical ones that are easier to work with. Or more precisely: the ones for which a key technical term is provided (e.g. by a clinician).

In one case, we were told that Bert (not his real name) needed an angioplasty. I had no idea what one of those was, but a quick search on the query term "angioplasty" gave several search results that were consistent with each other, comprehensible and credible. Following up on that and related terms has meant that I now (rightly or wrongly) feel that I understand fairly well what Bert has gone through and what implications it has for the future.

In a second case, Alf (also not real name) told me that the excruciating pain he had been experiencing had been diagnosed as gallstones, and in particular a stone that had lodged in the bile duct. The treatment was a procedure (not an operation) that involved putting a tube through his nose and down into his gall bladder and removing the stone. Any search that I tried with terms such as "gallstones", "removal", "nose" led to sites about "cholecystectomy" (i.e. either laparoscopic [keyhole] or open surgery). We both knew that Alf had not had an operation. It took hours of searching with different terms to find any information that even approximately matched what Alf and I knew. Eventually, I tried terms involving "camera" and "gallstones", which led to "endoscopy". As I type, I believe that Alf had a "endoscopic retrograde cholangiopancreatography". I can't even pronounce those terms, never mind spell them. But if you know the terms then there are pretty good descriptions of what they involve that really helps the lay person to make sense of the treatment.

In the third case, Clarissa (not real name) was incredibly tired. Her doctor had dismissed it as "a virus". I've seen a virus being defined as "a condition that the doctor can't diagnose in detail but isn't worried about". But this "virus" had been around for weeks. What is happening? Well most internet searches that involve the word "fatigue" and any other symptom seem to lead to results about "cancer". That's not what you want to find. And it's not what I believe. I'm still trying to make sense of what might be affecting Clarissa. I don't have a good search term, and I can't find one.

Health is an area that affects us all. We all want to make sense of conditions that affect us and our loved ones. But there is a huge terminological gulf between lay language for describing health experiences and the technical language of professionals. If you know the technical "keys" then it's easy to find lay explanations, but the opposite is not yet true: if you only have a lay way of talking about health experiences then there's no easy way to tap in to a sophisticated health information understanding. This isn't an easy challenge; I wonder whether anyone can rise to it.

"He's got dimples!": making sense of visualisations

Laura's baby is due in 2 months, so time to get a 3D scan... and the first thing that Laura told me after the scan was that "he's got dimples!" I'm sure that if there had been any problem detected, that would have been mentioned first, but no: the most important information is that he has dimples, just like her. But for the radiographer doing the scan, it's likely that dimples came way down the list of features to look out for (after formation of the spine, whether the cord is around his neck, how large his head is...). Conversely, when her uncle looked at pictures from the scan, his main comment was about the way it looked as if there was a light shining on the baby. And I wanted to know what the strange shape between chin and elbow was (I still don't know...).

People look at scenes and scans in different ways, and notice different features of them. They "make sense" of the visual information in different ways. Some are concerned with syntactic features such as aspects of the image quality. Some are more concerned with the semantics: what it means (in this case, for the health of the child, or what he will look like). Yet others may be more concerned with the pragmatics: how information from the scene can inform action – this might have been the case if the scan were being used by a surgeon to guide them during a live operation.

Scanning technology has come on in leaps and bounds over recent decades: the ultrasound scan I had before Laura was born was difficult to even recognise as a baby as a still image: a naive viewer could only make sense of the whole by seeing how the parts moved together. Advances in technology have meant that what used to be difficult interpretation tasks for the human have been made much easier. And they have made more information potentially available (I didn't even know whether Laura was a boy or a girl until she was born, never mind whether or not she had dimples).

New technologies create many new possibilities – for monitoring, diagnosis, treatment, and even for joy. In this case, they've made the user's interpretation task much easier and made more information available. The scan is for well defined purposes, and the value of the visualisation is that it takes a large volume of data and presents it in a form that really makes sense. There is lots of information about the baby that the 3D scan does not provide, but for its intended purpose it is delightful.

Making time for serendipity

Serendipity is about time and an attitude of mind. But it's not just about the individual: it also depends on the social context. Laura Dantonio proposed a Masters project that looked at the role of social media in facilitating serendipity. Her initial focus was on how people came across unexpected, but valuable, social media content, but it quickly embraced the idea that other people are intentionally creating this content and links to it. People are investing time in making opportunities for serendipity. This comes from both sides: both creating the opportunities and exploiting them. This is a gamble: there may be little pay-off for the time invested, because there's such a chance element in serendipity. The more we look at serendipity, the clearer it becomes that design is an important contributor to this experience, but that it is more about attitude: about openness to the opportunities that life presents (and recognizing unexpected connections between ideas), and the imagination to create opportunities for others. Laura's is the first work that we're aware of that really emphasises the social angle to serendipity: that people make opportunities for others to encounter interesting information.

Making sense of health information

A couple of people have asked me why I'm interested in patients' sensemaking, and what the problem is with all the health information that's available on the web. Surely there's something for everyone there? Well maybe there is (though it doesn't seem that way), but both our studies of patients' information seeking and personal experience suggest that it's far from straightforward.

Part of the challenge is in getting the language right: finding the right words to describe a set of symptoms can be difficult, and if you get the wrong words then you'll get inappropriate information. And as others have noted, the information available on the internet tends to be biased towards more serious conditions, leading to a rash of cyberchondria. But actually, diagnosis is only a tiny part of the engagement with and use of health information. People have all sorts of questions, such as "should I be worried?" or "how can I change my lifestyle?", and much more individual and personal issues, often not focusing on a single question but on trying to understand an experience, or a situation, or how to manage a condition. For example, there may be general information on migraines available, but any individual needs to relate that generic information to their own experiences, and probably experiment with trigger factors and ways of managing their own migraine attacks, gradually building up a personal understanding over time, using both external resources and individual experiences.

The literature describes sensemaking in different ways that share many common features. Key elements are that people:

• look for information to address recognised gaps in understanding (and there can be challenges in looking for information and in recognising relevant information when it is found).
• store information (whether in their heads or externally) for both immediate and future reference.
• integrate new information with their pre-existing understanding (so sensemaking never starts from a blank slate, and if pre-existing understanding is flawed then it may require a radical shift to correct that flawed understanding).

One important element that is often missing from the literature is the importance of interpretation of information: that people need to explicitly interpret information to relate to their own concerns. This is particularly true for subjects where there are professional and lay perspectives, languages and concerns for the same basic topic. Not only do professionals and lay people (clinicians and patients in this case) have different terminology; they also have different concerns, different engagement, different ways of thinking about the topic.

Sensemaking is about changing understanding, so it is highly individual. One challenge in designing any kind of resource that helps people make sense of health information is recognising the variety of audiences for information (prior knowledge, kinds of concerns, etc.) and making it easy for people to find information that is relevant to them, as an individual, right here and now. People will always need to invest effort in learning: I don't think there's any way around that (indeed, I hope there isn't!)... but patients' sensemaking seems particularly interesting because we're all patients sometimes, and because making sense of our health is important, but could surely be easier than it seems to be right now.

Serendipity: time, space and connections

Someone recently brought http://memex.naughtons.org/archives/2012/01/26/15216 to my attention. Quite apart from it being entertaining, it resonates well with our work on understanding serendipity (www.serena.ac.uk). Historically, work on serendipity has emphasised the encountering of information (often while looking for other information) and the importance of the "prepared mind" in recognising the value of the encountered information. This video (by Steven Johnson) emphasises the importance of "slow hunches" and connections. It highlights the dilemma that, with so many sources of information available to people, it can be difficult not to feel overwhelmed by information, and by demands to deliver results quickly -- and yet there are many more opportunities for identifying and exploiting new connections in our highly connected world. Our work on serendipity has highlighted the need to go beyond recognising the value of the connection to having the time and opportunity to exploit it. This requires "mental space" for reflecting on the nature and value of the connection, as well as the sense of freedom to follow up on it. Johnson claims that "chance favours the connected mind", but it also favours the mind that experiences the freedom to build on opportunities, that is not overwhelmed by demands.