Cognitive Load Theory:

Transcription

1 Cognitive Load Theory: Why using your EHR is so painful and how to fix it Michael Zimmerman, MD CHUG 2016 Oct 15th, 2016

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3 Risk Factors Family History Medications Diabetes Social History Patient Problem List CHF Asthma Surgical History Data Care Team

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5 Risk Factors Family History Medications Diabetes Social History Patient Problem List CHF Asthma Surgical History Data Care Team

6 Family History Social History Surgical History Risk Factors Medication Data Care Team Problem List

7 Got Cognitive Load? Do you feel Tired Overwhelmed Burned Out Disengaged Rushed Short Temper Lack of enthusiasm Ask you doctor

8 Cognitive Load is the aggregate mental effort required in problem solving and learning. Working Memory Working Memory is the space you have to do that work. It is finite and fixed.

9 Working Memory Working Memory 24 divided by 3 Problem Solving->Learning 1. Novel Information is Collected and Processed 1. Auditory 2. Visual The Problem or Task 24 divided by 3

10 Here s what I already know Working Memory Concepts of division and multiplication; 24/6 = 4 Working Memory 24 divided by 3 X 24/6 Problem Solving->Learning 1. Novel Information is Collected and Processed 1. Auditory 2. Visual The Problem or Task 2. Interpretation and consideration of information in context of existing knowledge schemas. (Long Term Memory) 24 divided by 3

11 24/3=8 X 24/6 Working Memory 24 divided by 3 24 divided by 3 24 /3 Problem Solving->Learning 1. Novel Information is Collected and Processed 1. Auditory 2. Visual The Problem or Task 2. Interpretation and consideration of information in context of existing knowledge schemas. (Long Term Memory) 3. Build and retention of new knowledge based on the problem solving experience. 24 divided by 3

12 Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load Intrinsic Germaine Extraneous Problem Solution

13 Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load Intrinsic Cognitive Load The inherent complexity of the task. Interactivity of elements Medical Problem Solving? Complexity 0- Interactivity 0- Intrinsic Cognitive Load Minimal Moderate Heavy

14 Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load Extraneous Cognitive Load manner in which information is presented to solver/learner it is imposed by mental activities that can have a negative effect on learning if not designed appropriately. Extraneous load can interfere with the construction or automation of schemas and complete complex tasks. a round plane figure whose boundary consists of points equidistant from a fixed point.

15 What s Missing?

16 Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load Germaine Cognitive Load- Learning Load imposed by constructing new schemas and automating them Learning and Problem Solving! This is germane cognitive load.

17 Intrinsic (Task) Extrinsic (presentation) Learning Aggregate Cognitive Load Working Memory Working Memory >= Cognitive Load Task Completed Learned some new things

18 Intrinsic (Task) Extrinsic (Presentation) Learning Intrinsic (Task) Working Memory Extrinsic (presentation) Learning Working Memory >= Cognitive Load Task Completed Learned some new things Working Memory < Cognitive Load Choices 1. Accept errors/ incomplete solutions 2. Decrease Extraneous Cognitive Load 3. Shrink the Task 4. Forgo new knowledge learning What now?

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20 Accept cognitive shortcuts and ultimately errors Working Memory Capacity Beyond Capacity Intellectual Performance Increase errors Suboptimal task completion Cognitive Load

21 Maladaptive Response to Cognitive Overload Mental shortcuts (Heuristics and Biases) Aggregate bias Anchoring Ascertainment bias Availability Base-rate Commission bias Confirmation bias Feedback sanction Framing effect Fundamental attribution error Gambler s fallacy Gender bias Hindsight bias Multiple alternatives bias Omission bias Order effects Outcome bias Overconfidence bias Playing the odds Posterior probability error Premature closure Psych-out error Representativeness restraint Search satisfying Sutton s slip Sunk costs Triage cueing Unpacking principle Vertical line failure Visceral bias Yin-Yang out

22 Lets assume we prefer not to accept errors or leave problems unsolved. Intrinsic Germaine Extraneous Choices 1.Decrease INTRINSIC LOAD 2.Decrease EXTRANEOUS LOAD 3.Limit Germaine Load during visit learning Problem Solution

23 Family History Risk Factors Meds Diabetes Social History Patient Problem List CHF Asthma Surgical History Care Team Data

24 Reduce Incidental Processing Basic layout Simple Structure Predictable, Consistent, Minimize scanning Colors/Symbols Meaningful, Consistent Content Increase Signal to Noise Ratio, Eliminate non essential information

25 Reduce Incidental Processing Basic layout Simple Presentation Consistent with the providers Mental Model/schema Flow Consistent with clinical thinking, Return me where I left off, Predict and make available 3 next most common actions *Make documentation a byproduct of the clinical work

26 Reducing Cognitive Load layout basics

27 Reducing Cognitive Load layout basics

28 Reducing Cognitive Load layout basics

29 Oh yeah, also 800x600 Resolution is so 1999

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32 Intrinsic (Task) Extrinsic (Presentation) Learning Reducing Intrinsic Cognitive Load Working Memory < Cognitive Load Choices Chunking - breaking up task Examples?

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34 Reducing Intrinsic Load - example Define and Support Medical Assistant Work Create Hand off to Provider within the Providers Context

35 Intrinsic (Task) Extrinsic (Presentation) Learning Reducing Extraneous Cognitive Load Working Memory < Cognitive Load Choices Presentation Offloading Facilitate Next Steps Examples?

36 Reducing Extraneous Cognitive Load Presentation of information in format and structure consistent with how providers see the world (schema). Remember our card game?

37 clk

38 Reducing Extrinsic Cognitive Load - Example Subjective What does the patient want to accomplish? What do I want to accomplish? Where did we leave off from Previous Visit? Where were we relative to other problems NOT on previous visit? Assessment and Plan In context of previous Last assessment date Surrounding data Instructions Communications

39 Reducing Extraneous Cognitive Load - example Structured documentation/data collection- Good templates, bad templates My office phone number (1)5 (2)1 (3)0 (4)2 (5)3 (6)0 (7)2 (8)3 (9)7 (10)2 (510) If you want discrete data captured, you must make it easy

40 Example- jumpstart

41 Reducing Extrinsic Cognitive Load Make it easy to offload working memory when appropriate Update in family hx, surgical hx. Refill medication Future reminder Flag task to MA eg get colonoscopy Right tool for the job- quick visit

42 examples

43 Intrinsic (Task) Extrinsic (Presentation) Learning Germaine Load- Learning Working Memory < Cognitive Load Best place for learning? Perhaps not the middle of an office visit

44 Cognitive Load is the aggregate mental effort required in problem solving and learning. Working Memory Working memory is finite and is the rate limiting step Help the doctor help the patient Shrink Intrinsic Load by breaking down tasks Shrink Extraneous Load by addressing presentation of information Limit Learning (Germaine) Load by avoiding education during visits

45 References Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003; 78: Groopman J. How doctors think. Boston: Houghton Mifflin Company; Mayer R. Nine Ways to Reduce Cognitive Load in Multimedia Learning EDUCATIONAL PSYCHOLOGIST 2003, 38(1), Daniel Kahneman. Thinking, fast and slow; New York : Farrar, Straus and Giroux, [2011]

46 I just want to thank everyone who made this day necessary. -Yogi Berra ( ) Jonathan Rodriguez, Sr. (774) Michael Zimmerman