Emerging Paradigms of Cognition in Medical Decision-Making

Transcription

1 Emerging Paradigms of Cognition in Medical Decision-Making Vimla L. Patel, PhD, DSc, FRSC Laboratory of Decision Making and Cognition Department of Biomedical Informatics Columbia University New York, NY Workshop on Medical Thinking: What We Know University College, London June 22-23, 2006

2 Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, et al. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors JAMA 2005;293: CPOE system facilitated 22 types of medication errors Fragmented displays prevent coherent medications view Pharmacy inventory mistaken for dosage guidelines Separation of functions that facilitate double dosing and incompatible orders Inflexible ordering formats generating wrong orders Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often

3 Another Case Potassium chloride (KCl) ordered as IV injection and as IV fluid additive using Eclipsys CPOE system 85-year-old patient, admitted to the medical ICU with septic shock and respiratory failure Patient received 316 meq KCl over 42 hrs in setting of acute and chronic kidney failure High dose delivered due to errors and misperceptions by several care providers Compounded errors propagated through the system over three days Horsky J, Kuperman GJ, Patel VL. Comprehensive analysis of a medication dosing error related to CPOE: A case report. J Am Med Inform Assoc 2005;12:

4 Analysis of Failure Misconceptions about the relation between IV volume (humans) and time duration (system) Misconception of latest and dated laboratory results Lack of Alerts when potassium value reached a dangerous level Inadequate clinical user training regarding safe and efficient ordering practices

5 Why should we be concerned about cognitive and social sciences? Human behavior is influenced by our thoughts and our social values Cognitive / Social sciences provide theoretical & methodological foundations for the study of human behavior Problems of changing behavior has always been an issue, but now we have better methods for investigation It isn t sufficient to use the methods without understanding the rationale

6 What is Cognitive Science? Multidisciplinary field incorporating theories and methods from psychology, linguistics, philosophy, anthropology, and computer science in the investigation of cognitive processes in humans and machines Patel, V.L., Arocha, J.F. & Kaufman, D.R (2001) A Primer on Aspects of Cognition for Medical Informatics.Journal of the American Medical Informatics Association. 8;

7 Cognitive Research Investigates psychological processes underlying performance via an in-depth analysis of cognitive steps that lead to observable behavior Methodology: focus on understanding knowledge structures and mental processes in cognitive activity

8 Typical Methods Naturalistic Field Studies: Ethnography Participant Observation Use of think aloud protocols Study of Naturally Occurring Discourse: Discourse analyses Interviews: semi-structured questionnaires Case Studies Video recordings

9 Methods of Analysis Task and activity analysis Representations of ideas and concepts (Propositional) Meaningful relations between ideas and concepts (Semantic), higher level understanding (conceptual), and context sensitive (pragmatic) representations Dialogue analysis for team communication Protocol analysis Usability analyses

10 From Cognitive Science to Medical Cognition Cognitive Science Theory Memory Knowledge Organization Problem Solving Heuristics/Strategies Computational Theory of Mind Medical Cognition Conceptual Frameworks Medical Problem Solving Organization of Clinical and Basic-Science Knowledge Diagnostic Reasoning Strategies Medical Decision Making

11 From Medical Cognition to Biomedical Informatics Medical Cognition Medical Problem Solving Organization of Knowledge Diagnostic Reasoning Strategies Medical Decision Making Text Comprehension and Problem Representation Development of Medical Expertise Medical Discourse Biomedical Informatics Knowledge and Data Representation Management of Medical Information Human-Computer Interaction Cognitive Models for Enhancing Decision Support Cognitive Assessment of Usability and Interfaces Targeted Training

12 Clinical Applications and Cognition Nature of Expertise and Heuristic Reasoning Effects of technology on Reasoning Clinical decision making and medical errors

13 Reference Patel, V.L., Arocha, J.F. & Kaufman, D.R. (1994) Diagnostic Reasoning and Expertise. The Psychology of Learning and Motivation: Advances in Research and Theory, 31,

14 Forward-Directed Reasoning: An Example Unemployed young male presents with fever, rigor, and chills. A puncture wound is observed on his arm. Unemployed Young Male Puncture Wound Intravenous Drug User Contaminated Needle Infection Data Hypothesis

15 Backward-Directed Reasoning: An Example Elderly woman presents with signs of myxedema. She also presents with respiratory failure, which is unexplained for by myxedema. Myxedema Respiratory Failure Hypoventilation Hypometabolic State Data Hypothesis

16 Case Interpretation by a Novice Myocardial Infarction Other Diagnosis 45 yr.-old male 4-hour hx of chest pain central, crushing chest pain faintness sweating mild cough

17 Case Interpretation by an Intermediate 45 yr.-old male Myocardial Infarction Other Diagnoses 4-hour hx of chest pain central, crushing chest pain faintness sweating mild cough

18 Case Interpretation by an Advanced Subject 45 yr.-old male Myocardial Infarction Other Diagnoses 4-hour hx of chest pain central, crushing chest pain faintness sweating Aortic Dissection mild cough asymmetric BP

19 Constraints on Decision Making Cognitive Memory Knowledge Inferences Strategies Socio-Cultural Group norms Policies and Practices Organizational/Situational Environmental Team and Resources

20 Clinical Applications and Cognition Nature of Expertise and Heuristic Reasoning Effects of technology on Reasoning Clinical decision making and medical errors

21 Effect of an EMR System on Human Cognition Transition from paper records to EMR and back to paper record Impact on knowledge organization, reasoning Information and other technologies are not merely tools to expedite, facilitate and enable the execution of task Patel V, Kushniruk A,Yang S,Yale J-F, Impact of a computerbased patient record system on data collection,knowledge organization and reasoning. JAMIA,7(6)569-85,2001

22 Information in EMR and Hand-Written Records Category of Information Hand-Written Patient Record Computer-Based Patient Record 1. Chief Complaint Past Medical History Life Style Psychological Profile Family History History of Present Illness Review of Systems Physical Examination Diagnosis Investigation Treatment TOTAL ENTRIES

23 First section from paper-based record (Pre-EMR) 74 year old woman, whose diagnosis was made in February, as she complained of polyuria/nocturia and fatigue for a few years. She was told her sugar was very high and she was sent to Dr. K., who started her on Diabeta 5 mg/d and sent her to Dr. S. in ophthalmology who reported normal retina. She lost weight, her polyuria improved, her bladder urgency got better, and her glucose values improved dramatically. She does no monitoring at home. She had to be hospitalized for an ankle fracture after falling on ice, for 3 months. At follow-up, Dr. K. seemed pleased with the results.

24 First Section from Electronic Medical Record (EMR) CHIEF COMPLAINT: Type II diabetes mellitus PERSONAL HISTORY SURGICAL: cholecystectomy: Age 60 years old MEDICAL: hypothyroidism: asymptomatic since 25 years LIFE STYLE MEDICATION DIABETA (Tab 2.5 MG) Sig: 1 tab(s) Oral before breakfast SYNTHROID (Tab MG) Sig: 1 tab(s) Oral before breakfast HABITS: smoking: 0 alcohol: 0

25 First Section from Paper-Based Record (Post-EMR) Diabetes type I X age 4 Currently on N54 - N28 R6 - R2 Measure with OT II Glucose levels: < >180 AM IIIIIII IIIIIIIIIIIIIII Lunch Supper Bedtime IIIIIIIIII IIIIIIIII IIIIIIIIIIII Last HbA 1C since April 96: 7.4/7.2/6.7/6.6/8.9 - higher values in log book Retinopathy: NIL March 97 Nephropathy: NIL Oct. 96

26 Diagnostic Reasoning Paper Record Patient Data Multiple Hypotheses Electronic Medical Record Return to Paper Record Patient Data Hypotheses Same as EMR!

27 SYSTEMS LEVEL DIAGNOSTIC LEVEL INTERMEDIATE CONSTRUCT C1 C2 D1 D2 D3 FA1 FA2 FA3 FA4 FA5 Structure of Medical Knowledge in Problem Solving FINDING LEVEL F1 F2 F3 F4 F5 F6 F7 F8 F OBSERVATION LEVEL O 7 O 1 O 8 O 2 O 9 O 3 O 10 O 4 O1 1 O 5 O1 2 O 6

28 Influence of Technology on Human Cognition Information and other technologies are not merely tools to expedite, facilitate and enable the execution of tasks They have profound and enduring consequences Optimal design requires sensitivity to internal organization of concepts by human beings Utility and acceptance depend on designer s recognition that the system is a mediator of cognition (re-organizes cognition)

29 Clinical Applications and Cognition Nature of Expertise and Heuristic Reasoning Effects of technology on Reasoning Clinical decision making and medical errors

30 Some References Patel, V.L., Kaufman, D.A., Arocha, J.F. (2002) Emerging Paradigms of Cognition and Medical Decision Making, Journal of Biomedical Informatics, 35, Patel, V.L., Arocha, J.F., & Zhang, J. (2005). Thinking and reasoning in medicine. In K.J. Holyoak & R.G. Morrison (Eds.), Handbook of thinking and reasoning (pp ). Cambridge: Cambridge University Press.

31 Studying Decision Making Classical Approach: Adopts normative or rational decision models Models tend to be prescriptive Any systematic deviations from normative standards are seen as decision biases

32 New Framework: Expanding the Scope of Decision Making More descriptively adequate account of decision making Explain adaptive as well as suboptimal characteristics of decision makers Decisions embedded in a broader social and technological context

33 Progress and Occurrence of Medical Error Death Normal Routine Boundary Near Miss Boundary Adverse Event Report

34 Clinical Cognition: Implications for Informatics Need a better understanding of cognitive and situational demands on competent performance of clinicians in team work Must recognize that acquiring expertise implies developing an ability to adapt flexibly to ever changing complex situations Need baseline information on how clinicians make decisions in their everyday tasks

35 Cognition in the Wild Distributed cognition External and Internal resourses Cohen, T., Blatter, B., Almeida, C., Shortliffe, E., & Patel, V. (in press). Distributed cognition in the Psychiatric Emergency Department: A cognitive blueprint of a collaboration in context. Artificial Intelligence in Medicine.

36 Specific Methods Shadowing of medical team personnel during Crucial Periods pertinent to the individual. Mapping the activities to the ICU/ER layout and timestamping each interaction or event. Conducting brief interviews to gain insight on infrastructure, roles, shifts, timings. Obtaining log files of the clinical information systems and attempting correlation with observational data.

37 Distributed Cognition Cockpits, navigation Shift in focus A solitary individual Groups of individuals in context

38 Collaborative Cognition DATA 1. Team members 2. Representation 3. Data sources Multiple DATA DATA

39 Intellectual Partnership Distributed cognition Human-computer interaction analysis paradigm PDA Knowledge resides partly in the environment

40 Intellectual Partnership PDA Coordinating internal (user s s mind) and external (interface, environment) resources

41 Cognition Distributed Across Time Attending 1 Attending 2 Attending 1 Resident 1 Resident 2 Night Resident Resident 4 Social worker Social worker Nurse Night Nurse Nurse DURATION OF STAY

42 Cognition Distributed Across Teams Inpatient Admission Attending core mini-team Area B Security Resident Mobile Crisis Nurse SW/PSAC Patient NYPD Managed Care Liaison Homeless Outreach Family OPD

43 Bridging by External Representation Attending 1 Attending 2 Attending 1 Resident 1 Night Resident Resident 3 Social worker Nurse Night Nurse chart chart chart Nurse DURATION OF STAY

44 Limitations of Naturalistic Decision Making Massive amount of data Labor intensive analysis No specific standard to evaluate against Limited generalizability Bench to Bedside needs also to include Bedside to Bench

45 Conclusions Normative models, despite grand contributions, cannot accurately describe the complexity of real-life decision making. A more descriptive naturalistic approaches contribute significantly to overcome this limitation A broader framework to include both the approaches is proposed

46 Some Lessons It is human to make errors, but we also learn from errors Challenge is to reduce errors while improving our ability to recognize and correct errors before they do irreparable harm Technology can help but also introduce new opportunities for errors We need a better understanding of cognitive and situational demands on competent performance We must recognize that acquiring expertise implies developing an ability to adapt flexibly to ever changing situations

47 Chapter 4: Cognitive Science in Biomedical Informatics VL Patel and DR Kaufman Bio Biomedical Informatics Textbook (3rd edition) Springer Verlag

48 Thank You