Mobile tech- rushing forward & standing still at the same time

We’re always reaching forward,  amazing ourselves about how quickly the mobile technology landscape is advancing. That’s a good thing,  but how about standing still for a moment to remember those who still live in environments not at the crest of the wave.

Back in 2009, The Economist published a series of articles about the evolving technology landscape. (Eureka Moments, Mobile Marvels) At that time basic and smart phones were referenced at “luxury” items, quickly evolving in the global landscape where the cost barriers were being broken. Much of this is due to the advances in device technology  and pre-paid  billing or “top up” options. This paved the way for those with limited cash to access these communication tools in more feasible ways.

Time and time again we amaze ourselves with evidence such as the total number of mobile subscriptions, or the increasing rate of global smart phone owners. And with this evidence we imagine and build tools with the aim to reshape the preparedness and response environment during disasters and humanitarian crisis.

 

Let’s stand still for a moment

who will be forgotten because they are not part of the cohort of emerging smart phone users because of illiteracy?

who will we rush by as we reach for new mobile technologies, leaving the older versions behind?

And might we leave our early users in the lurch as we surge forward with new versions but stumble with migration support systems?

Old smartphones and basic phones may just be transported to other parts of the developing world; sometimes for reuse.  Or better yet, just produced around the world to fit the needs of communities who can afford only the basics. And all of these devices will be part of a cohort of our “users”, especially in humanitarian environments. As protracted humanitarian crisis continue and more complex crisis emerge those most digitally vulnerable are likely to be a crucial part of the pulse of situation awareness, knowledge, and response in these environments.

So let’s not only rush to the next software, tool or app but support the slowdown efforts that may be less interesting. It may be hard to fund the less-than-shiny approaches, but it may reap the positive benefits we seek along the way. Let’s still put effort in building tools for the heterogeneity of users as they advance at the pace that is driven by the socio-political context that we live in.  Where sometimes technology just can’t transcend the drivers of war, conflict and poverty.

5 Cues- From Humanitarian Response to Emergency Care

A colleague in information management from the United Nations Office of Coordinating Humanitarian Affairs wrote a great blogpost a few weeks ago and I was inspired to reflect more about the cues that influence decision-making.

As an emergency medicine clinician of almost 12 years, I began my specialty career, head down –  learning a trade and practice – only to look up sometimes just to  eat and go to the bathroom. Over the years, I have been working and interacting with people in humanitarian assistance, information management, and technology. This has been an enlightening experience. And the trans-disciplinary environment has helped me also reflect on my career as an EM physician.

Interdisciplinary-Learning_Blog

I came to realize sitting in conferences, chatting with traditional and digital humanitarians colleagues, and lecturing across the country that my career as an emergency medicine physician (aka ER doc) was just as much about real time situational awareness, fast-cycle decision-making, and risk taking with innovation than I had ever realized.  I learn so much talking and thinking about these ideas with my humanitarian IM and crisis mapping colleagues. And when I walk into the Department (the ER as many say) I enact much of what we talk about. Traversing these two worlds has helped me work to bridge the struggles and successes we face in humanitarian technology and information management.  It also helps me see my work as a doctor in a busy urban ER in new ways.

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There are clear and stark differences between the dynamic and sometimes chaotic ER and humanitarian crisis that should not be overlooked. IMHO A bad night in the ER  is by no means a controlled disaster, or a humanitarian crisis, and should rarely be equated to these settings. But the often frequent information explosion, fragmentation of information streams (radio, the physical exam, electronic medical records, x-rays, rounds) , multiple stakeholders with varying agendas, politics (and more politics) are somewhat similar.  Both settings have varying degrees of uncertainly,  high risk and high acuity situations.

One of the first things we teach emerging physicians rotating in our Department is the “sick…not sick” skill set.  There is no recipe or checklist for this;  it’s a built and learned experience. It requires multiple senses, getting up, walking to the patient room, talking with paramedics and interacting with the patient.  There is no “code card” for determining if someone looks sick, they just do. And right before they “code” ER docs will frequently remember that moment, and collectively over the years, they build a body of experience of what that is and that collective experience of “sick”. ER physicians not only think about what decision to make from recognizing patterns in complex clinical environments but they also react and respond.

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I recall one of my cues in 2010— the sound of helicopters. And the heli sounds make me think of patient transfers at our field hospital in Haiti.  And it sets off a chain of learned activities, find the patient, let the medical team know, confirm that we have the patient record… oh well… chase down those patient records… find family, inform family, translate,  ensure the landing areas is safely clear.

Helicopter_Haiti_Blog

I was also an information user, collector, and provider.  Some people may have though that as a field practitioner in health one of my primary cues would be a map, or a sitrep.  For much of the day it was not.  It was primarily SMS, my two radios and the heli sounds.   Online and advanced digital products much much less so… except for excel and email which we used to created census lists and crunch numbers for the Flash Appeal. One exception during my second deployment was Humanitarian OpenStreetMap‘s online maps, that I printed for patient ground transport.

As a researcher and consultant for NGOs helping with rapid assessments, post emergency assessments and program evaluations, I’ve used a lot of sitreps, maps, and traditional information products. That was my primary cue at times. But for example in 2007 as I headed deeper into Sofala Province in Mozambique toward Chupanga my connectivity tailed off to only a BGAN… and not such a good one honestly. Just one email/day. And the challenges with limited connectivity were in similar in some ways for my Disaster Resilience Lab colleagues whom I supported remotely in the aftermath of the 2013 Typhoon Haiyan.  I lost SMS connectivity with them as they reached Tacloban and much of their time in Guiuan.

The route of information products to users becomes paramount when we think about “timely” information products that are being produced 50-100+/day or more in this age of disasters. 

The conversation continues about how humanitarian field staff make “decisions” often from those who may infrequently make them in similar contexts. This certainly adds to the conversation, but has always left a bit of tension within me. Some have stated that field humanitarians are not logical in their decisions and are just reactionary. While some of this may be true, it leaves me uncomfortable with discussions that imply that one can’t have that “gut feeling” along with thoughtful evidenced-based decision making.  In emergency medicine both the gut feeling and the evidence are powerful aspects of our work. We recognize and respect both.

In the ongoing exploration and understanding of how multiple stakeholders make decisions during humanitarian crisis, I agree we may not yet know enough yet to make such stark statements one way or another.

Medicine has been remarkably forward recently with reflecting upon errors.  Because we as an institution have made some grave and horrible mistakes, and have learned the hard way –  much like humanitarians. And a recent article in the British Medical Journal (BMJ) of Quality and Safety by two authors discusses a similar dichotomy that I think we are discussing in humanitarian IM. Both relate to improving the way we use information for decision-making. One end of the spectrum is behaviors and senses (cognition), the other is systems related.

“The putative distinction between ‘cognitive’ and ‘system’ becomes somewhat spurious when one considers the diagnostic work of a busy emergency department with its chaotic mix of system-based, cognitive, affective, perceptual, temporal and variable patient factors. Of course, both cognitive and system variables can be manipulated and tested separately, but with both types of variables interacting in the clinical setting, the interaction term in our analyses should be of just as much interest as the main effects.”

Henriksen, K., & Brady, J. (2013). The pursuit of better diagnostic performance: a human factors perspective. BMJ quality & safety, 22(Suppl 2), ii1-ii5. (open access)

I’d like to think that this may be true of humanitarian practitioners in the field, including those directly involved in last mile  humanitarian operations. This is no easy task, actually it’s a really really hard task. And I hope that these perspectives in the field of medicine will be shared and recognized across disciplines and communities of practice.

“The perils of embracing dichotomies too eagerly are ever present—no less for the learned than the uninitiated. Of course, they may serve as useful fictions or labels initially in helping to simplify complex phenomena. But dichotomies tend to assert too much, feeding delusions of understanding when their overuse impedes it. Instead of serving as convenient short-hand labels, they uncritically take on explanatory power, serving as causes rather than consequences. Parsing the world into imperfect humans and imperfect systems, into cognitive versus system-based research approaches, and into system 1 (intuitive) versus system 2 (analytical) modes of thinking,23,24 misses much of the human factors work on shared mental models and distributed cognition cited earlier.”

How the above reads to me is that we should pause to further consider this debate of “how field staff make no informed decisions” to “we just need a tech influenced decision support system on an iphone app”.  There is no correct camp that will solve this challenge in Emergency Medicine; nor in humanitarian crisis which is an exponential increase in acuity, uncertainty and chaos. The answer lies in a nuanced mix of the two, with a respect for each.

HermanMuch in a similar way the the current generation of EM clinicians use their senses and learned experiences to care for patients but trust and abide by studied protocols, diagnostics and tested interventions.  Cardiac arrest, acute stroke and sepsis are a few examples.  But among all of the patients who are affected by these grave clinical conditions, we still strongly respect the “sick… not sick” sense that we have in this specialty.

 

 

 

Understanding the influence of info products

In my last post, the work that we did in the aftermath of Typhoon Haiyan was briefly described from a design-side.  I’m excited to blog more with my good colleague Kenny Meesters about some details of our collaborative work with the Disaster Resilience Lab (DRL) team and “tracing information products” into the field.

“Tracing products into the field” can be a holistic process.

  • How far do these products reach “in the field”
  • How do practitioners come across these products? Was it coincidence (the right place, right time) or via a structured process?
  • Was their experience with specific products a “one off” or regular experience?
  • Who will actually remember they ever saw them? and if they can achieve the recall…. what does that spark in their memory?
  • And to what extent did they use specific products or rely on it?
  • What influence… and outcomes might it have on their decision-making

It is indeed these nuances, captured in the above questions that we hope will move beyond introductory metrics from an evaluative standpoint. The qualitative, conversational and observation evaluative methodologies help further explore “why are things they way they are? ” Through this exploratory research we aimed to not only capture if products were familiar but also ‘why’.

And this ‘why’ is the key to improving outcomes and impact, by changing what we deliver or the way it is disseminated or used. In many ways this is what makes field work and simulation environments so valuable. Difficult to accomplish, but amazingly insightful.

Our description in this post is only a fraction of the larger discussion on outcomes and impact. The discussions about what happens with crisis maps has been longstanding. Below is a brief selection of folks using these terms and sharing their thoughts on “impact”.

Open Cities and Crisis Mapping (2014) Shadrock Roberts, USAID.

The impact of our work with the Open Cities project continues to multiply. For example, the National Society for Earthquake Technology in Nepal has recently determined to share its own information, offering new data that will soon be available for public use on the Open Cities website.”

The [unexpected] Impact of  the Libya Crisis Map and the Standby Volunteer Task Force (2011) Ushahidi Bog

But what measured impact did the map have?”

Crisis Management: Understanding the Real Impact of ICTs, Social Media and Crisis Mapping (2004), Daniel Stauffacher, Digital Development Debates, Development Policy Forum

Real time or post-facto analytical tools are embryonic at best. Without analysis of correlation and causality, it is impossible to measure if and exactly how ICTs and social media impact crisis management. “

Kenny and Bartel Van de Walle co-authored a paper “Increasing Efficiency of Humanitarian Organizations with Volunteer Driven Information Products” describing “impact evaluation” from the perspective of evaluation design principles for information systems. The definition of impact evaluation is actually multi-tiered. (shown below).

Process

In general impact is the extent to which efforts supplied on one end reduce the efforts required on the ‘related’ entity (other side).  The questions is what two entities do we choose? This depends on the evaluation objective. However the further away these two points are, the harder it will be to attribute the impact to a provided effort.

The DRL project provided a great opportunity to further explore the influence of information products and their potential outcomes and impact. With the DRL Philippines team (Bartel Van de Walle, Tina Comes, Marc van den Homberg, and Bert Brugghemans) we had the opportunity to explore which entities could be considered. The exchange between the Digital Humanitarian Network (DHN) and their direct representative in the field, for example OCHA is known of course. The question remains what happens with the provided information after that exchange. In other words: what other (potential) entities are there, that could benefit from these products and do the products reach them?

For this exploratory research, Jennifer compiled traditional and digital humanitarian information products into 8 books of 83 information products. The DHN specific book was a collaborative curation of the DRL team.  There were 12 digital humanitarian information products  based on connections and previous work with the DHN (including the SBTF) and other communities involved in this work. All 12 products were “crisis maps” from various organizations, some which required online access; others in PDF format. Books existed both in paper and static digital format so the DRL field team could show screen shots of these maps if there was no accessible or reliable internet access.

DHN_Blog

For a select number of  interviews, books were incorporated into the semi-structured interviews. We asked which information products looked familiar, if and how they may have been used and how they were potentially integrated into the organization. Below are some audio clips from the field team in Cebu asking questions about the role of crisis maps in the field.

Asking about Online digital volunteers

Using the Information Product Books

Exploring field decision-makers view on what digital humanitarians can do for them

While not a comprehensive broad study, this approach provided an introductory understanding of how deep some information products penetrated into the field, as we held interviews from Manila (HQ) to Guiuan (one of the most severe disaster stricken area) and many ‘levels’ in between. More importantly, the interview setting, rather than ‘just tracing’ also provided a view into how these products were potentially used. These select interviews not only examined if information products were familiar or recognizable to some interviewees, but also to what extent they may have been integrated in the personal and/or organizational (decision making) processes.

This exploratory research is a first step towards a comprehensive outcomes and impact evaluation. In time the aim is to establish a more robust, comprehensive and thorough analysis of what information products ‘reach’ the field. And also further investigate the efforts ‘invested’ in creating the products and services by volunteers to determine the their outcomes and eventual impact. However,  our observations during this field project provide some preliminary thoughts on this subject. In due time we’ll be further analyzing our findings and hope to share them.

Below are initial observations.

  • Determining if these products provided added value was hard to determine, but our initial reflections suggest that value is potentially linked to time-sensitivity
  • Some interviewees recognized crisis maps through collaborations or connections with traditional organization (ex. The World Food Programme, WFP) when mapping contributions may also come from digital humanitarians.
  • Practitioners who were not directly connect to OCHA were less familiar with DHN information products
  • Some field practitioners interviewed wanted to learn more about digital humanitarians.