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Boyle JG, Walters MR, Jamieson S, Durning SJ. Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159. MEDICAL TEACHER 2023; 45:1323-1333. [PMID: 37043405 DOI: 10.1080/0142159x.2023.2190479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthew R Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Susan Jamieson
- Health Professions Education Programme, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Steven J Durning
- Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Harrington L. The RaDonda Vaught Case: A Critical Conversation on Nursing Practice and Technology. AACN Adv Crit Care 2023; 34:11-15. [PMID: 36346434 DOI: 10.4037/aacnacc2023873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Linda Harrington
- Linda Harrington is an Independent Consultant, Health Informatics and Digital Strategy, and Adjunct Professor at Texas Christian University, 2800 South University Drive, Fort Worth, TX 76109
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Vatral C, Biswas G, Cohn C, Davalos E, Mohammed N. Using the DiCoT framework for integrated multimodal analysis in mixed-reality training environments. Front Artif Intell 2022; 5:941825. [PMID: 35937140 PMCID: PMC9353401 DOI: 10.3389/frai.2022.941825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Simulation-based training (SBT) programs are commonly employed by organizations to train individuals and teams for effective workplace cognitive and psychomotor skills in a broad range of applications. Distributed cognition has become a popular cognitive framework for the design and evaluation of these SBT environments, with structured methodologies such as Distributed Cognition for Teamwork (DiCoT) used for analysis. However, the analysis and evaluations generated by such distributed cognition frameworks require extensive domain-knowledge and manual coding and interpretation, and the analysis is primarily qualitative. In this work, we propose and develop the application of multimodal learning analysis techniques to SBT scenarios. Using these analysis methods, we can use the rich multimodal data collected in SBT environments to generate more automated interpretations of trainee performance that supplement and extend traditional DiCoT analysis. To demonstrate the use of these methods, we present a case study of nurses training in a mixed-reality manikin-based (MRMB) training environment. We show how the combined analysis of the video, speech, and eye-tracking data collected as the nurses train in the MRMB environment supports and enhances traditional qualitative DiCoT analysis. By applying such quantitative data-driven analysis methods, we can better analyze trainee activities online in SBT and MRMB environments. With continued development, these analysis methods could be used to provide targeted feedback to learners, a detailed review of training performance to the instructors, and data-driven evidence for improving the environment to simulation designers.
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Rosa E, Lyskov E, Grönkvist M, Kölegård R, Dahlström N, Knez I, Ljung R, Willander J. Cognitive performance, fatigue, emotional and physiological strains in simulated long-duration flight missions. MILITARY PSYCHOLOGY 2022. [DOI: 10.1080/08995605.2021.1989236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Eduardo Rosa
- Department of Psychology, University of Gävle, Gävle, Sweden
| | - Eugene Lyskov
- Centre for Musculoskeletal Research, Department of Occupational Health Sciences and Psychology, University of Gävle, Sweden
| | - Mikael Grönkvist
- Division of Environmental Physiology, Swedish Aerospace Physiology Center, Kth Royal Institute of Technology, Stockholm, Sweden
| | - Roger Kölegård
- Division of Environmental Physiology, Swedish Aerospace Physiology Center, Kth Royal Institute of Technology, Stockholm, Sweden
| | | | - Igor Knez
- Department of Psychology, University of Gävle, Gävle, Sweden
| | - Robert Ljung
- Department of Environmental Psychology, University of Gävle, Gävle, Sweden
| | - Johan Willander
- Department of Psychology, University of Gävle, Gävle, Sweden
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Keebler JR, Rosen MA, Sittig DF, Thomas E, Salas E. Human Factors and Ergonomics in Healthcare: Industry Demands and a Path Forward. HUMAN FACTORS 2022; 64:250-258. [PMID: 35000407 DOI: 10.1177/00187208211073623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This article reviews three industry demands that will impact the future of Human Factors and Ergonomics in Healthcare settings. These demands include the growing population of older adults, the increasing use of telemedicine, and a focus on patient-centered care. Following, we discuss a path forward through improved medical teams, error management, and safety testing of medical devices and tools. Future challenges are discussed.
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Affiliation(s)
- Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, 2830Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Michael A Rosen
- Department of Anesthesiology, Armstrong Institute for Patient Safety, Johns Hopkins University, Baltimore, MD, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Eric Thomas
- UT Health Memorial Center for Healthcare Quality and Safety, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Eduardo Salas
- Department of Psychological Sciences, Rice University, Houston, TX, USA
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Park J, Zhong X, Dong Y, Barwise A, Pickering BW. Investigating the cognitive capacity constraints of an ICU care team using a systems engineering approach. BMC Anesthesiol 2022; 22:10. [PMID: 34983402 PMCID: PMC8724599 DOI: 10.1186/s12871-021-01548-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
Background ICU operational conditions may contribute to cognitive overload and negatively impact on clinical decision making. We aimed to develop a quantitative model to investigate the association between the operational conditions and the quantity of medication orders as a measurable indicator of the multidisciplinary care team’s cognitive capacity. Methods The temporal data of patients at one medical ICU (MICU) of Mayo Clinic in Rochester, MN between February 2016 to March 2018 was used. This dataset includes a total of 4822 unique patients admitted to the MICU and a total of 6240 MICU admissions. Guided by the Systems Engineering Initiative for Patient Safety model, quantifiable measures attainable from electronic medical records were identified and a conceptual framework of distributed cognition in ICU was developed. Univariate piecewise Poisson regression models were built to investigate the relationship between system-level workload indicators, including patient census and patient characteristics (severity of illness, new admission, and mortality risk) and the quantity of medication orders, as the output of the care team’s decision making. Results Comparing the coefficients of different line segments obtained from the regression models using a generalized F-test, we identified that, when the ICU was more than 50% occupied (patient census > 18), the number of medication orders per patient per hour was significantly reduced (average = 0.74; standard deviation (SD) = 0.56 vs. average = 0.65; SD = 0.48; p < 0.001). The reduction was more pronounced (average = 0.81; SD = 0.59 vs. average = 0.63; SD = 0.47; p < 0.001), and the breakpoint shifted to a lower patient census (16 patients) when at a higher presence of severely-ill patients requiring invasive mechanical ventilation during their stay, which might be encountered in an ICU treating patients with COVID-19. Conclusions Our model suggests that ICU operational factors, such as admission rates and patient severity of illness may impact the critical care team’s cognitive function and result in changes in the production of medication orders. The results of this analysis heighten the importance of increasing situational awareness of the care team to detect and react to changing circumstances in the ICU that may contribute to cognitive overload. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01548-7.
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Affiliation(s)
- Jaeyoung Park
- Department of Industrial and Systems Engineering, University of Florida, 482 Weil Hall, P.O. Box 116595, Gainesville, FL, 32611-6595, USA
| | - Xiang Zhong
- Department of Industrial and Systems Engineering, University of Florida, 482 Weil Hall, P.O. Box 116595, Gainesville, FL, 32611-6595, USA.
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Mattioli DD, Thomas GW, Long SA, Tatum M, Anderson DD. Minimally Trained Analysts Can Perform Fast, Objective Assessment of Orthopedic Technical Skill from Fluoroscopic Images. IISE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2022; 12:212-220. [PMID: 36147899 PMCID: PMC9488091 DOI: 10.1080/24725579.2022.2035022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Skill assessment in orthopedics has traditionally relied on subjective impressions from a supervising surgeon. The feedback derived from these tools may be limited by bias and other practical issues. Objective analysis of intraoperative fluoroscopic images offers an inexpensive, repeatable, and precise assessment strategy without bias. Assessors generally refrain from using the scores of images obtained throughout the operation to evaluate skill for practical reasons. A new system was designed to facilitate rapid analysis of this fluoroscopy via minimally trained analysts. Four expert and four novice analysts independently measured one objective metric for skill using both a custom analysis software and a commercial alternative. Analysts were able to measure the objective metric three times faster when using the custom software, and without a practical difference in accuracy in comparison to the expert analysts using the commercial software. These results suggest that a well-designed fluoroscopy analysis system can facilitate inexpensive, reliable, and objective assessment of surgical skills.
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Affiliation(s)
- Dominik D. Mattioli
- Department of Industrial & Systems Engineering, University of Iowa, Iowa City, United States
| | - Geb W. Thomas
- Department of Industrial & Systems Engineering, University of Iowa, Iowa City, United States,Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, United States
| | - Steven A. Long
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, United States
| | - Marcus Tatum
- Department of Industrial & Systems Engineering, University of Iowa, Iowa City, United States
| | - Donald D. Anderson
- Department of Industrial & Systems Engineering, University of Iowa, Iowa City, United States,Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, United States
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Hussain MI, Figueiredo MC, Tran BD, Su Z, Molldrem S, Eikey EV, Chen Y. A scoping review of qualitative research in JAMIA: past contributions and opportunities for future work. J Am Med Inform Assoc 2021; 28:402-413. [PMID: 33225361 DOI: 10.1093/jamia/ocaa179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/07/2020] [Accepted: 07/17/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Qualitative methods are particularly well-suited to studying the complexities and contingencies that emerge in the development, preparation, and implementation of technological interventions in real-world clinical practice, and much remains to be done to use these methods to their full advantage. We aimed to analyze how qualitative methods have been used in health informatics research, focusing on objectives, populations studied, data collection, analysis methods, and fields of analytical origin. METHODS We conducted a scoping review of original, qualitative empirical research in JAMIA from its inception in 1994 to 2019. We queried PubMed to identify relevant articles, ultimately including and extracting data from 158 articles. RESULTS The proportion of qualitative studies increased over time, constituting 4.2% of articles published in JAMIA overall. Studies overwhelmingly used interviews, observations, grounded theory, and thematic analysis. These articles used qualitative methods to analyze health informatics systems before, after, and separate from deployment. Providers have typically been the main focus of studies, but there has been an upward trend of articles focusing on healthcare consumers. DISCUSSION While there has been a rich tradition of qualitative inquiry in JAMIA, its scope has been limited when compared with the range of qualitative methods used in other technology-oriented fields, such as human-computer interaction, computer-supported cooperative work, and science and technology studies. CONCLUSION We recommend increased public funding for and adoption of a broader variety of qualitative methods by scholars, practitioners, and policy makers and an expansion of the variety of participants studied. This should lead to systems that are more responsive to practical needs, improving usability, safety, and outcomes.
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Affiliation(s)
- Mustafa I Hussain
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
| | - Mayara Costa Figueiredo
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
| | - Brian D Tran
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA.,Medical Scientist Training Program, School of Medicine, University of California Irvine, Irvine, California, USA
| | - Zhaoyuan Su
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
| | - Stephen Molldrem
- Department of Anthropology, University of California Irvine, Irvine, California, USA
| | - Elizabeth V Eikey
- Department of Family Medicine and Public Health & Design Lab, University of California San Diego, San Diego, California, USA
| | - Yunan Chen
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
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Tools for Distributed Teamwork and Rapid Adaptation to Change: COVID-19 and Frontline Learning. Jt Comm J Qual Patient Saf 2021; 47:273-274. [PMID: 33785260 DOI: 10.1016/j.jcjq.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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10
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Pfaff MS, Eris O, Weir C, Anganes A, Crotty T, Rahman M, Ward M, Nebeker JR. Analysis of the cognitive demands of electronic health record use. J Biomed Inform 2020; 113:103633. [PMID: 33253896 DOI: 10.1016/j.jbi.2020.103633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/15/2020] [Accepted: 11/22/2020] [Indexed: 11/24/2022]
Abstract
The goal of this study was to elicit the cognitive demands facing clinicians when using an electronic health record (EHR) system and learn the cues and strategies expert clinicians rely on to manage those demands. This study differs from prior research by applying a joint cognitive systems perspective to examining the cognitive aspects of clinical work. We used a cognitive task analysis (CTA) method specifically tailored to elicit the cognitive demands of an EHR system from expert clinicians from different sites in a variety of inpatient and outpatient roles. The analysis of the interviews revealed 145 unique cognitive demands of using an EHR, which were organized into 22 distinct themes across seven broad categories. In addition to confirming previously published themes of cognitive demands, the main emergent themes of this study are: 1) The EHR does not help clinicians develop and maintain awareness of the big picture; 2) The EHR does not support clinicians' need to reason about patients' current and future states, including effects of potential treatments; and 3) The EHR limits agency of clinicians to work individually and collaboratively. Implications for theory and EHR design and evaluation are discussed.
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Affiliation(s)
- Mark S Pfaff
- The MITRE Corporation, Bedford, MA, McLean, VA, United States.
| | - Ozgur Eris
- The MITRE Corporation, Bedford, MA, McLean, VA, United States
| | - Charlene Weir
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Amanda Anganes
- The MITRE Corporation, Bedford, MA, McLean, VA, United States
| | - Tina Crotty
- The MITRE Corporation, Bedford, MA, McLean, VA, United States
| | - Mohammad Rahman
- The MITRE Corporation, Bedford, MA, McLean, VA, United States
| | - Merry Ward
- Office of Health Informatics, Department of Veterans Affairs, Washington, DC, United States
| | - Jonathan R Nebeker
- Office of Health Informatics, Department of Veterans Affairs, Washington, DC, United States; School of Medicine, University of Utah, Salt Lake City, UT, United States
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11
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Waller RG, Wright MC, Segall N, Nesbitt P, Reese T, Borbolla D, Del Fiol G. Novel displays of patient information in critical care settings: a systematic review. J Am Med Inform Assoc 2020; 26:479-489. [PMID: 30865769 DOI: 10.1093/jamia/ocy193] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/28/2018] [Accepted: 01/02/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Clinician information overload is prevalent in critical care settings. Improved visualization of patient information may help clinicians cope with information overload, increase efficiency, and improve quality. We compared the effect of information display interventions with usual care on patient care outcomes. MATERIALS AND METHODS We conducted a systematic review including experimental and quasi-experimental studies of information display interventions conducted in critical care and anesthesiology settings. Citations from January 1990 to June 2018 were searched in PubMed and IEEE Xplore. Reviewers worked independently to screen articles, evaluate quality, and abstract primary outcomes and display features. RESULTS Of 6742 studies identified, 22 studies evaluating 17 information displays met the study inclusion criteria. Information display categories included comprehensive integrated displays (3 displays), multipatient dashboards (7 displays), physiologic and laboratory monitoring (5 displays), and expert systems (2 displays). Significant improvement on primary outcomes over usual care was reported in 12 studies for 9 unique displays. Improvement was found mostly with comprehensive integrated displays (4 of 6 studies) and multipatient dashboards (5 of 7 studies). Only 1 of 5 randomized controlled trials had a positive effect in the primary outcome. CONCLUSION We found weak evidence suggesting comprehensive integrated displays improve provider efficiency and process outcomes, and multipatient dashboards improve compliance with care protocols and patient outcomes. Randomized controlled trials of physiologic and laboratory monitoring displays did not show improvement in primary outcomes, despite positive results in simulated settings. Important research translation gaps from laboratory to actual critical care settings exist.
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Affiliation(s)
- Rosalie G Waller
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Melanie C Wright
- Trinity Health and Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Noa Segall
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Paige Nesbitt
- Trinity Health and Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Damian Borbolla
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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Thate J, Rossetti SC, McDermott-Levy R, Moriarty H. Identifying best practices in electronic health record documentation to support interprofessional communication for the prevention of central line-associated bloodstream infections. Am J Infect Control 2020; 48:124-131. [PMID: 31606258 DOI: 10.1016/j.ajic.2019.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a paucity of research on best practices for communication through the electronic health record (EHR) to support shared decision-making and to prevent adverse events. To explore this issue, this study focused on interprofessional communication around a specific clinical issue, the prevention of central line-associated bloodstream infections. METHODS The Delphi technique was used to describe what information is needed to support decisions regarding central venous catheter (CVC) management, and best practices for communicating this information among the interprofessional team. RESULTS The expert panel, 4 physicians and 6 nurses, identified 12 information types necessary for decisions regarding CVC management and the removal of unnecessary lines. For each of the 12 information types, the panel reached agreement regarding the best channel to communicate this information, including asynchronous EHR formats and synchronous oral channels. CONCLUSIONS Findings address 2 important aspects of postinsertion CVC practices and a gap in the literature by moving beyond a description of current practices to a description of how the EHR ought to be used to support collaboration and interprofessional communication. Future research should examine how the communication practices identified in this study contribute to a reduction in central line-associated bloodstream infections.
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Affiliation(s)
| | - Sarah Collins Rossetti
- School of Nursing, Columbia University, New York, NY; Department of Biomedical Informatics, Columbia University, New York, NY
| | - Ruth McDermott-Levy
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA
| | - Helene Moriarty
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
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Dias RD, Zenati MA, Stevens R, Gabany JM, Yule SJ. Physiological synchronization and entropy as measures of team cognitive load. J Biomed Inform 2019; 96:103250. [PMID: 31295623 DOI: 10.1016/j.jbi.2019.103250] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 01/19/2023]
Abstract
The operating room (OR) is a high-risk and complex environment, where multiple specialized professionals work as a team to effectively care for patients in need of surgical interventions. Surgical tasks impose high cognitive demands on OR staff and cognitive overload may have deleterious effects on team performance and patient safety. The aim of the present study was to investigate the feasibility and describe a novel methodological approach to characterize dynamic changes in team cognitive load by measuring synchronization and entropy of heart rate variability parameters during real-life cardiac surgery. Cognitive load was measured by capturing interbeat intervals (IBI) from three team members (surgeon, anesthesiologist and perfusionist) using an unobtrusive wearable heart rate sensor and transmitted in real-time to a smartphone application. Clinical data and operating room audio/video recordings were also collected to provide behavioral and contextual information. We developed symbolic representations of the transient cognitive state of individual team members (Individual Cognitive State - ICS), and overall team (Team Cognitive State - TCS) by comparing IBI data from each team member with themselves and with others. The distribution of TCS symbols during surgery enabled us to display and analyze temporal states and dynamic changes of team cognitive load. Shannon's entropy was calculated to estimate the changing levels of team organization and to detect fluctuations resulting from a variety of cognitive demands and/or specific situations (e.g. medical error, emergency, flow disruptions). An illustrative example from a real cardiac surgery team shows how cognitive load patterns shifted rapidly after an actual near-miss medication event, leading the team to a more organized and synchronized state. The methodological approach described in this study provides a measurement technique for the assessment of team physiological synchronization, which can be applied to many other team-based environments. Future research should gather additional validity evidence to support the proposed methods for team cognitive load measurement.
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Affiliation(s)
- Roger D Dias
- STRATUS Center for Medical Simulation, Brigham and Women's Hospital, USA; Department of Emergency Medicine, Harvard Medical School, USA.
| | - Marco A Zenati
- Medical Robotics and Computer Assisted Surgery (MRCAS) Laboratory, Division of Cardiothoracic Surgery, Veterans Affairs Boston Healthcare System, USA; Department of Surgery, Harvard Medical School, USA
| | - Ronald Stevens
- Brain Research Institute, University of California, Los Angeles School of Medicine, USA
| | - Jennifer M Gabany
- Medical Robotics and Computer Assisted Surgery (MRCAS) Laboratory, Division of Cardiothoracic Surgery, Veterans Affairs Boston Healthcare System, USA
| | - Steven J Yule
- STRATUS Center for Medical Simulation, Brigham and Women's Hospital, USA; Department of Surgery, Harvard Medical School, USA
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Abstract
Cancer patients interact with clinicians who are distributed across locations and organizations. This makes it difficult to coordinate care and adds to the burden of cancer care delivery. Failures in care coordination can harm patients. The rapid growth in the number of cancer survivors and the increasing complexity of cancer care has kindled an interest in new care delivery models. Information technology (IT) is an important component of care delivery. While IT can potentially enhance collaborative work among people distributed across locations, organizations and time, the current design and implementation of health IT adds to the human burden and often makes it a part of the problem instead of the solution. A new paradigm is needed, therefore, to drive innovations that reframe health IT as an enabler (and a component) of a “thinking system,” in which patients, caregivers, and clinicians, even when distributed across locations and time, can collaborate to deliver high-quality care while decreasing the burden of care delivery. In a thinking system, the design of collaborative work in health care delivery is based on an understanding of complex interplay among social and technological components. We propose six core design properties for a thinking system: task coordination; information curation; creative and flexible organizing; establishing a common ground; continuity and connection; and co-production. A thinking system is needed to address the complexity of coordination, meet the rising expectation of personalized care, relieve the human burden in care delivery, and to deliver the best quality care that modern science can provide.
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Scott P, Nakkas H, Roderick P. Protocol for a scoping review to understand how interorganisational electronic health records affect hospital physician and pharmacist decisions. BMJ Open 2019; 9:e023712. [PMID: 30647036 PMCID: PMC6340433 DOI: 10.1136/bmjopen-2018-023712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Patient records are often fragmented across organisations and departments in UK health and care services, often due to substandard information technology. However, although government policy in the UK and internationally is strongly pushing 'digital transformation', the evidence for the positive impact of electronic information systems on cost, quality and safety of healthcare is far from clear. In particular, the mechanisms by which information availability is translated into better decision-making are not well understood. We do not know when a full interorganisational record is more useful than a key information summary or an institutional record. In this paper, we describe our scoping review of how interorganisational electronic health records affect decision-making by hospital physicians and pharmacists. METHODS AND ANALYSIS This scoping review will follow the Arksey and O'Malley (2005) methodology. The review has adopted sociotechnical systems thinking and the notion of distributed cognition as its guiding conceptual models. The UK National Institute for Health and Care Excellence Healthcare Databases Advanced Search will be used, as it incorporates key sources including PubMed, Medline, Embase, HMIC and Health Business Elite. A hand search will be conducted using the reference lists of included studies to identify additional relevant articles. A two-part study selection process will be used: (1) a title and abstract review and (2) full text review. During the first step, two researchers separately will review the citations yielded from the search to determine eligibility based on the defined inclusion and exclusion criteria. Related articles will be included if they are empirical studies that address how interorganisational records affect decision-making by hospital physicians and pharmacists. ETHICS AND DISSEMINATION The results will be disseminated through stakeholder meetings, conference presentations and peer-reviewed publication. The data used are from publicly available secondary sources, so this study does not require ethical review.
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Affiliation(s)
- Philip Scott
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Haythem Nakkas
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Roderick
- Public Health Sciences and Medical Statistics Group, University of Southampton, Southampton, UK
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Williamsson A, Dellve L, Karltun A. "Nurses' use of visual management in hospitals-A longitudinal, quantitative study on its implications on systems performance and working conditions". J Adv Nurs 2018; 75:760-771. [PMID: 30230003 DOI: 10.1111/jan.13855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/05/2018] [Accepted: 09/04/2018] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to examine potential benefits provided by daily visual management tool use and explore its association with systems performance and working conditions among hospital nurses. BACKGROUND Visual management tools used in everyday work and improvement work in health care theoretically contribute to shared understanding of complex work systems and provide certain user benefits. Cognitive load, miscommunication within and between professional groups, and pressure to engage in care process redesign add to nurses' strained working conditions. DESIGN Quantitative longitudinal. METHODS Questionnaires were distributed at T0, (N = 948, 66% response rate), T1 (N = 900, 70% response rate), and T2 (N = 621, 72% response rate) to nurses at five hospitals. Three groups of users (daily users, start users, and non-daily users) were compared by means T1-T2 (significance tested with Wilcoxon signed rank test) and by mixed model repeated measures T0, T1, T2. RESULTS Daily use associated to better overview of work, collaboration, social capital, and clinical engagement. Job resources were rated higher by daily users. Mental stress increased and development opportunities decreased over time among non-daily users. There were associations between use and perceptions of systems performance, though the differences between groups were small. CONCLUSION This study specifically explores visual management tool use in the hospital setting, which contributes to research by broadening the understanding of cognitive, social, and emotional benefits provided by visual management tool use. Daily use was associated to positive working conditions, small but positive differences in systems performance, and indicated a buffering effect on nurses' mental stress.
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Affiliation(s)
- Anna Williamsson
- Department of Biomedical Engineering and Health Systems, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Lotta Dellve
- Department of Sociology and Work Science, University of Gothenburg, Gothenburg, Sweden
| | - Anette Karltun
- Department of Industrial Engineering and Management, Jönköping University, Jönköping, Sweden
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Hansen SW, Gogan JL, Baxter RJ, Garfield MJ. Informed collaboration in health care: An embedded-cases study in geriatric telepsychiatry. INFORMATION SYSTEMS JOURNAL 2018. [DOI: 10.1111/isj.12218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Sean W. Hansen
- MIS, Marketing, and Digital Business Department; Rochester Institute of Technology; Rochester New York USA
| | - Janis L. Gogan
- Information and Process Management Department; Bentley University; Waltham Massachusetts USA
| | - Ryan J. Baxter
- Department of Accountancy; Boise State University; Boise Idaho USA
| | - Monica J. Garfield
- Computer Information Systems Department; Bentley University; Waltham Massachusetts USA
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18
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Smith MW, Hughes AM, Brown C, Russo E, Giardina TD, Mehta P, Singh H. Test results management and distributed cognition in electronic health record-enabled primary care. Health Informatics J 2018; 25:1549-1562. [PMID: 29905084 DOI: 10.1177/1460458218779114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.
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Affiliation(s)
| | | | | | | | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, USA
| | - Praveen Mehta
- VA Great Lakes Health Care System, USA; Loyola University Chicago Stritch School of Medicine, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, USA
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Avrunin GS, Clarke LA, Conboy HM, Osterweil LJ, Dias RD, Yule SJ, Goldman JM, Zenati MA. Toward Improving Surgical Outcomes by Incorporating Cognitive Load Measurement into Process-Driven Guidance. SOFTWARE ENGINEERING IN HEALTHCARE SYSTEMS (SEHS), IEEE/ACM INTERNATIONAL WORKSHOP ON 2018; 2018:2-9. [PMID: 30140792 PMCID: PMC6103223 DOI: 10.1145/3194696.3194705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This paper summarizes the accomplishments and recent directions of our medical safety project. Our process-based approach uses a detailed, rigorously-defined, and carefully validated process model to provide a dynamically updated, context-aware and thus, "Smart" Checklist to help process performers understand and manage their pending tasks [7]. This paper focuses on support for teams of performers, working independently as well as in close collaboration, in stressful situations that are life critical. Our recent work has three main thrusts: provide effective real-time guidance for closely collaborating teams; develop and evaluate techniques for measuring cognitive load based on biometric observations and human surveys; and, using these measurements plus analysis and discrete event process simulation, predict cognitive load throughout the process model and propose process modifications to help performers better manage high cognitive load situations. This project is a collaboration among software engineers, surgical team members, human factors researchers, and medical equipment instrumentation experts. Experimental prototype capabilities are being built and evaluated based upon process models of two cardiovascular surgery processes, Aortic Valve Replacement (AVR) and Coronary Artery Bypass Grafting (CABG). In this paper we describe our approach for each of the three research thrusts by illustrating our work for heparinization, a common subprocess of both AVR and CABG. Heparinization is a high-risk error-prone procedure that involves complex team interactions and thus highlights the importance of this work for improving patient outcomes.
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Affiliation(s)
| | - Lori A Clarke
- University of Massachusetts Amherst, Massachusetts, USA
| | | | | | - Roger D Dias
- Brigham and Women's Hospital Boston, Massachusetts, USA
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Mamykina L, Carter EJ, Sheehan B, Stanley Hum R, Twohig BC, Kaufman DR. Driven to distraction: The nature and apparent purpose of interruptions in critical care and implications for HIT. J Biomed Inform 2017; 69:43-54. [PMID: 28159645 DOI: 10.1016/j.jbi.2017.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 01/11/2017] [Accepted: 01/30/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To examine the apparent purpose of interruptions in a Pediatric Intensive Care Unit and opportunities to reduce their burden with informatics solutions. MATERIALS AND METHODS In this prospective observational study, researchers shadowed clinicians in the unit for one hour at a time, recording all interruptions participating clinicians experienced or initiated, their starting time, duration, and a short description that could help to infer their apparent purpose. All captured interruptions were classified inductively on their source and apparent purpose and on the optimal representational media for fulfilling their apparent purpose. RESULTS The researchers observed thirty-four one-hour sessions with clinicians in the unit, including 21 nurses and 13 residents and house physicians. The physicians were interrupted on average 11.9 times per hour and interrupted others 8.8 times per hour. Nurses were interrupted 8.6 times per hour and interrupted others 5.1 times per hour. The apparent purpose of interruptions included Information Seeking and Sharing (n=259, 46.3%), Directives and Requests (n=70, 12%), Shared Decision-Making (n=49, 8.8%), Direct Patient Care (n=36, 6.4%), Social (n=71, 12.7%), Device Alarms (n=28, 5%), and Non-Clinical (n=10, 1.8%); 6.6% were not classified due to insufficient description. Of all captured interruptions, 29.5% were classified as being better served with informational displays or computer-mediated communication. CONCLUSIONS Deeper understanding of the purpose of interruptions in critical care can help to distinguish between interruptions that require face-to-face conversation and those that can be eliminated with informatics solutions. The proposed taxonomy of interruptions and representational analysis can be used to further advance the science of interruptions in clinical care.
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Affiliation(s)
- Lena Mamykina
- Department of Biomedical Informatics, Columbia University, 622 W. 168th Street, VC-5, New York, NY 10032, United States.
| | - Eileen J Carter
- Columbia University School of Nursing, New York-Presbyterian Hospital, 617 West 168th Street, New York, NY 10032, United States
| | - Barbara Sheehan
- ColumbiaDoctors, Columbia University Medical Center, Faculty Practice Organization, 630 W 168th Street, New York, NY 10032, United States
| | - R Stanley Hum
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, 630 W 168th Street, New York, NY 10032, United States
| | - Bridget C Twohig
- Department of Biomedical Informatics, Columbia University, 622 W. 168th Street, VC-5, New York, NY 10032, United States
| | - David R Kaufman
- Department of Biomedical Informatics, Arizona State University, 13212 East Shea Boulevard, Scottsdale, AZ 85259, United States
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Banerjee A, Slagle JM, Mercaldo ND, Booker R, Miller A, France DJ, Rawn L, Weinger MB. A simulation-based curriculum to introduce key teamwork principles to entering medical students. BMC MEDICAL EDUCATION 2016; 16:295. [PMID: 27852293 PMCID: PMC5112730 DOI: 10.1186/s12909-016-0808-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 10/27/2016] [Indexed: 05/28/2023]
Abstract
BACKGROUND Failures of teamwork and interpersonal communication have been cited as a major patient safety issue. Although healthcare is increasingly being provided in interdisciplinary teams, medical school curricula have traditionally not explicitly included the specific knowledge, skills, attitudes, and behaviors required to function effectively as part of such teams. METHODS As part of a new "Foundations" core course for beginning medical students that provided a two-week introduction to the most important themes in modern healthcare, a multidisciplinary team, in collaboration with the Center for Experiential Learning and Assessment, was asked to create an experiential introduction to teamwork and interpersonal communication. We designed and implemented a novel, all-day course to teach second-week medical students basic teamwork and interpersonal principles and skills using immersive simulation methods. Students' anonymous comprehensive course evaluations were collected at the end of the day. Through four years of iterative refinement based on students' course evaluations, faculty reflection, and debriefing, the course changed and matured. RESULTS Four hundred twenty evaluations were collected. Course evaluations were positive with almost all questions having means and medians greater than 5 out of 7 across all 4 years. Sequential year comparisons were of greatest interest for examining the effects of year-to-year curricular improvements. Differences were not detected among any of the course evaluation questions between 2007 and 2008 except that more students in 2008 felt that the course further developed their "Decision Making Abilities" (OR 1.69, 95% CI 1.07-2.67). With extensive changes to the syllabus and debriefer selection/assignment, concomitant improvements were observed in these aspects between 2008 and 2009 (OR = 2.11, 95% CI: 1.28-3.50). Substantive improvements in specific exercises also yielded significant improvements in the evaluations of those exercises. CONCLUSIONS This curriculum could be valuable to other medical schools seeking to inculcate teamwork foundations in their medical school's preclinical curricula. Moreover, this curriculum can be used to facilitate teamwork principles important to inter-disciplinary, as well as uni-disciplinary, collaboration.
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Affiliation(s)
- Arna Banerjee
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue S, 526 MAB, Nashville, TN 37212 USA
- Department of Medical Education, Center for Experiential Learning and Assessment, Vanderbilt University Medical Center, Nashville, TN USA
| | - Jason M. Slagle
- Center for Research and Innovation in Systems Safety (CRISS), Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Nathaniel D. Mercaldo
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Ray Booker
- Department of Medical Education, Center for Experiential Learning and Assessment, Vanderbilt University Medical Center, Nashville, TN USA
| | - Anne Miller
- Center for Research and Innovation in Systems Safety (CRISS), Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN USA
- School of Nursing, Vanderbilt University Medical Center, Nashville, TN USA
- Present Address: Clinical and Rehabilitation Sciences Research Group, Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Daniel J. France
- Center for Research and Innovation in Systems Safety (CRISS), Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Lisa Rawn
- Department of Medical Education, Center for Experiential Learning and Assessment, Vanderbilt University Medical Center, Nashville, TN USA
- Present Address: Baptist Health Neurosurgery Arkansas, Little Rock, AR USA
| | - Matthew B. Weinger
- Department of Medical Education, Center for Experiential Learning and Assessment, Vanderbilt University Medical Center, Nashville, TN USA
- Center for Research and Innovation in Systems Safety (CRISS), Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
- Health Services Research Division and the Geriatrics Research Education and Clinical Center, Veterans Affairs (VA) Tennessee Valley Healthcare System – Nashville Campus, Nashville, TN USA
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Blaz JW, Doig AK, Cloyes KG, Staggers N. The Hidden Lives of Nurses' Cognitive Artifacts. Appl Clin Inform 2016; 7:832-49. [PMID: 27602412 PMCID: PMC5052553 DOI: 10.4338/aci-2016-01-ra-0007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 07/30/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Standardizing nursing handoffs at shift change is recommended to improve communication, with electronic tools as the primary approach. However, nurses continue to rely on personally created paper-based cognitive artifacts - their "paper brains" - to support handoffs, indicating a deficiency in available electronic versions. OBJECTIVE The purpose of this qualitative study was to develop a deep understanding of nurses' paper-based cognitive artifacts in the context of a cancer specialty hospital. METHODS After completing 73 hours of hospital unit field observations, 13 medical oncology nurses were purposively sampled, shadowed for a single shift and interviewed using a semi-structured technique. An interpretive descriptive study design guided analysis of the data corpus of field notes, transcribed interviews, images of nurses' paper-based cognitive artifacts, and analytic memos. RESULTS Findings suggest nurses' paper brains are personal, dynamic, living objects that undergo a life cycle during each shift and evolve over the course of a nurse's career. The life cycle has four phases: Creation, Application, Reproduction, and Destruction. Evolution in a nurse's individually styled, paper brain is triggered by a change in the nurse's environment that reshapes cognitive needs. If a paper brain no longer provides cognitive support in the new environment, it is modified into (adapted) or abandoned (made extinct) for a different format that will provide the necessary support. CONCLUSIONS The "hidden lives" - the life cycle and evolution - of paper brains have implications for the design of successful electronic tools to support nursing practice, including handoff. Nurses' paper brains provide cognitive support beyond the context of handoff. Information retrieval during handoff is undoubtedly an important function of nurses' paper brains, but tools designed to standardize handoff communication without accounting for cognitive needs during all phases of the paper brain life cycle or the ability to evolve with changes to those cognitive needs will be underutilized.
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Affiliation(s)
- Jacquelyn W Blaz
- Jacquelyn W. Blaz, PhD, MS, School of Nursing, University of Wisconsin-Madison, 701 Highland Ave, Madison, WI 53705,
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Senathirajah Y, Kaufman D, Bakken S. User-composable Electronic Health Record Improves Efficiency of Clinician Data Viewing for Patient Case Appraisal: A Mixed-Methods Study. EGEMS 2016; 4:1176. [PMID: 27195306 PMCID: PMC4862763 DOI: 10.13063/2327-9214.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Challenges in the design of electronic health records (EHRs) include designing usable systems that must meet the complex, rapidly changing, and high-stakes information needs of clinicians. The ability to move and assemble elements together on the same page has significant human-computer interaction (HCI) and efficiency advantages, and can mitigate the problems of negotiating multiple fixed screens and the associated cognitive burdens. Objective: We compare MedWISE—a novel EHR that supports user-composable displays—with a conventional EHR in terms of the number of repeat views of data elements for patient case appraisal. Design and Methods: The study used mixed-methods for examination of clinical data viewing in four patient cases. The study compared use of an experimental user-composable EHR with use of a conventional EHR, for case appraisal. Eleven clinicians used a user-composable EHR in a case appraisal task in the laboratory setting. This was compared with log file analysis of the same patient cases in the conventional EHR. We investigated the number of repeat views of the same clinical information during a session and across these two contexts, and compared them using Fisher’s exact test. Results: There was a significant difference (p<.0001) in proportion of cases with repeat data element viewing between the user-composable EHR (14.6 percent) and conventional EHR (72.6 percent). Discussion and Conclusion: Users of conventional EHRs repeatedly viewed the same information elements in the same session, as revealed by log files. Our findings are consistent with the hypothesis that conventional systems require that the user view many screens and remember information between screens, causing the user to forget information and to have to access the information a second time. Other mechanisms (such as reduction in navigation over a population of users due to interface sharing, and information selection) may also contribute to increased efficiency in the experimental system. Systems that allow a composable approach that enables the user to gather together on the same screen any desired information elements may confer cognitive support benefits that can increase productive use of systems by reducing fragmented information. By reducing cognitive overload, it can also enhance the user experience.
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Graumlich JF, Wang H, Madison A, Wolf MS, Kaiser D, Dahal K, Morrow DG. Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial. J Diabetes Res 2016; 2016:2129838. [PMID: 27699179 PMCID: PMC5028848 DOI: 10.1155/2016/2129838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/04/2016] [Indexed: 11/18/2022] Open
Abstract
Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™) implemented via an electronic medical record to improve patients' medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients' knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients' demonstrated medication use, regimen adherence, or glycemic control (HbA1c). Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.
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Affiliation(s)
- James F. Graumlich
- Department of Medicine, University of Illinois College of Medicine at Peoria, 530 Northeast Glen Oak Avenue, Peoria, IL 61637, USA
- *James F. Graumlich:
| | - Huaping Wang
- Department of Medicine, Division of Research Services, University of Illinois College of Medicine at Peoria, One Illini Drive, Peoria, IL 61605, USA
| | - Anna Madison
- Department of Psychology, University of Illinois at Urbana-Champaign, 603 E. Daniel, Champaign, IL 61820, USA
| | - Michael S. Wolf
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, 10th Floor, Chicago, IL 60611, USA
| | - Darren Kaiser
- Northwestern Medical Faculty Foundation, 675 North Saint Clair Street, Chicago, IL 60611, USA
| | - Kumud Dahal
- Department of Medicine, University of Illinois College of Medicine at Peoria, One Illini Drive, Peoria, IL 61605, USA
| | - Daniel G. Morrow
- Department of Educational Psychology, University of Illinois at Urbana-Champaign, Education Building, 1310 South 6th Street, Champaign, IL 61820, USA
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Technology-Based Support for Older Adult Communication in Safety-Critical Domains. PSYCHOLOGY OF LEARNING AND MOTIVATION 2016. [DOI: 10.1016/bs.plm.2015.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Review of crisis resource management (CRM) principles in the setting of intraoperative malignant hyperthermia. J Anesth 2015; 30:298-306. [DOI: 10.1007/s00540-015-2115-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 11/23/2015] [Indexed: 12/21/2022]
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Fioratou E, Chatzimichailidou MM, Grant S, Glavin R, Flin R, Trotter C. Beyond monitors: distributed situation awareness in anaesthesia management. THEORETICAL ISSUES IN ERGONOMICS SCIENCE 2015. [DOI: 10.1080/1463922x.2015.1106620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hazlehurst B. When I say … distributed cognition. MEDICAL EDUCATION 2015; 49:755-756. [PMID: 26152486 DOI: 10.1111/medu.12672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 10/16/2014] [Accepted: 12/01/2014] [Indexed: 06/04/2023]
Affiliation(s)
- Brian Hazlehurst
- Center for Health Research, Kasier Permanente Northwest, Portland, OR, USA
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Rajkomar A, Mayer A, Blandford A. Understanding safety-critical interactions with a home medical device through Distributed Cognition. J Biomed Inform 2015; 56:179-94. [PMID: 26056072 DOI: 10.1016/j.jbi.2015.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/23/2015] [Accepted: 06/02/2015] [Indexed: 11/19/2022]
Abstract
As healthcare shifts from the hospital to the home, it is becoming increasingly important to understand how patients interact with home medical devices, to inform the safe and patient-friendly design of these devices. Distributed Cognition (DCog) has been a useful theoretical framework for understanding situated interactions in the healthcare domain. However, it has not previously been applied to study interactions with home medical devices. In this study, DCog was applied to understand renal patients' interactions with Home Hemodialysis Technology (HHT), as an example of a home medical device. Data was gathered through ethnographic observations and interviews with 19 renal patients and interviews with seven professionals. Data was analyzed through the principles summarized in the Distributed Cognition for Teamwork methodology. In this paper we focus on the analysis of system activities, information flows, social structures, physical layouts, and artefacts. By explicitly considering different ways in which cognitive processes are distributed, the DCog approach helped to understand patients' interaction strategies, and pointed to design opportunities that could improve patients' experiences of using HHT. The findings highlight the need to design HHT taking into consideration likely scenarios of use in the home and of the broader home context. A setting such as home hemodialysis has the characteristics of a complex and safety-critical socio-technical system, and a DCog approach effectively helps to understand how safety is achieved or compromised in such a system.
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Affiliation(s)
- Atish Rajkomar
- UCL Interaction Centre, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - Astrid Mayer
- Department of Oncology, Royal Free NHS Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Ann Blandford
- UCL Interaction Centre, University College London, Gower Street, London WC1E 6BT, United Kingdom.
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Furniss D, Masci P, Curzon P, Mayer A, Blandford A. Exploring medical device design and use through layers of Distributed Cognition: How a glucometer is coupled with its context. J Biomed Inform 2015; 53:330-41. [DOI: 10.1016/j.jbi.2014.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 12/01/2014] [Accepted: 12/15/2014] [Indexed: 12/19/2022]
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Furniss D, Masci P, Curzon P, Mayer A, Blandford A. 7 Themes for guiding situated ergonomic assessments of medical devices: a case study of an inpatient glucometer. APPLIED ERGONOMICS 2014; 45:1668-1677. [PMID: 24953286 DOI: 10.1016/j.apergo.2014.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 05/15/2014] [Accepted: 05/26/2014] [Indexed: 06/03/2023]
Abstract
There is relatively little guidance on the situated ergonomic assessment of medical devices, and few case studies that detail this type of evaluation. This paper reports results of a detailed case study that focuses on the design and use of a modern blood glucose meter on an oncology ward. We spent approximately 150 h in-situ, over 11 days and 4 nights, performing observations and interviews with users. This was complemented by interviews with two staff with oversight and management responsibility related to the device. We identified 19 issues with the design and use of this device. These issues were grouped into 7 themes which can help guide the situated study of medical devices: usability, knowledge gaps and mental models, workarounds, wider tasks and equipment, the patient, connection between services, and policy.
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Affiliation(s)
- Dominic Furniss
- UCL Interaction Centre, MPEB 8th Floor, University College London, Gower Street, London WC1E 6BT, UK.
| | - Paolo Masci
- School of Electronic Engineering and Computer Science, Queen Mary University of London, E1 4NS, UK.
| | - Paul Curzon
- School of Electronic Engineering and Computer Science, Queen Mary University of London, E1 4NS, UK.
| | - Astrid Mayer
- Department of Oncology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK.
| | - Ann Blandford
- UCL Interaction Centre, MPEB 8th Floor, University College London, Gower Street, London WC1E 6BT, UK.
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The clinician in the driver's seat: part 2 - intelligent uses of space in a drag/drop user-composable electronic health record. J Biomed Inform 2014; 52:177-88. [PMID: 25445921 DOI: 10.1016/j.jbi.2014.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 09/12/2014] [Accepted: 09/30/2014] [Indexed: 11/23/2022]
Abstract
User-composable approaches provide clinicians with the control to design and assemble information elements on screen via drag/drop. They hold considerable promise for enhancing the electronic-health-records (EHRs) user experience. We previously described this novel approach to EHR design and our illustrative system, MedWISE. The purpose of this paper is to describe clinician users' intelligent uses of space during completion of real patient case studies in a laboratory setting using MedWISE. Thirteen clinicians at a quaternary academic medical center used the system to review four real patient cases. We analyzed clinician utterances, behaviors, screen layouts (i.e., interface designs), and their perceptions associated with completing patient case studies. Clinicians effectively used the system to review all cases. Two coding schemata pertaining to human-computer interaction and diagnostic reasoning were used to analyze the data. Users adopted three main interaction strategies: rapidly gathering items on screen and reviewing ('opportunistic selection' approach); creating highly structured screens ('structured' approach); and interacting with small groups of items in sequence as their case review progressed ('dynamic stage' approach). They also used spatial arrangement in ways predicted by theory and research on workplace spatial arrangement. This includes assignment of screen regions for particular purposes (24% of spatial codes), juxtaposition to facilitate calculation or other cognitive tasks ('epistemic action'), and grouping elements with common meanings or relevance to the diagnostic facets of the case (20.3%). A left-to-right progression of orienting materials, data, and action items or reflection space was a commonly observed pattern. Widget selection was based on user assessment of what information was useful or relevant. We developed and tested an illustrative system that gives clinicians greater control of the EHR, and demonstrated its feasibility for case review by typical clinicians. Producing the simplifying inventions, such as user-composable platforms that shift control to the user, may serve to promote productive EHR use and enhance its value as an instrument of patient care.
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Senathirajah Y, Bakken S, Kaufman D. The clinician in the Driver's Seat: part 1 - a drag/drop user-composable electronic health record platform. J Biomed Inform 2014; 52:165-76. [PMID: 25240253 DOI: 10.1016/j.jbi.2014.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 08/27/2014] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
Abstract
Creating electronic health records that support the uniquely complex and varied needs of healthcare presents formidable challenges. To address some of these challenges we created a new model for healthcare information systems, embodied in MedWISE,(2) a widget-based highly configurable electronic health record (EHR) platform. Founded on the idea that providing clinician users with greater control of the EHR may result in greater fit to user needs and preferences, MedWISE allows drag/drop user configurations and the sharing of user-created elements such as custom laboratory result panels and user-created interface tabs. After reviewing the current state of EHR configurability, we describe the philosophical, theoretical and practical rationales for our model, and the specific functionality of MedWISE. The alternative approach may have several advantages for human-computer interaction, efficiency, cognition, and fit of EHR tools to different contexts and tasks. We discuss potential issues raised by this approach.
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Affiliation(s)
- Yalini Senathirajah
- Dept. of Biomedical Informatics, Columbia University, 622 West 168th St. 5th Floor, New York, NY 10032, USA.
| | - Suzanne Bakken
- Dept. of Biomedical Informatics, Columbia University, 622 West 168th St. 5th Floor, New York, NY 10032, USA; Columbia University School of Nursing, 617 West 168th St. Room 225, New York, NY 10032, USA.
| | - David Kaufman
- Biomedical Informatics, Arizona State University, 13212 East Shea, Scottsdale, AZ, USA.
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Patel VL, Kannampallil TG. Human factors and health information technology: current challenges and future directions. Yearb Med Inform 2014; 9:58-66. [PMID: 25123724 DOI: 10.15265/iy-2014-0005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Recent federal mandates and incentives have spurred the rapid growth, development and adoption of health information technology (HIT). While providing significant benefits for better data integration, organization, and availability, recent reports have raised questions regarding their potential to cause medication errors, decreased clinician performance, and lowered efficiency. The goal of this survey article is to (a) examine the theoretical and foundational models of human factors and ergonomics (HFE) that are being advocated for achieving patient safety and quality, and their use in the evaluation of healthcare systems; (b) and the potential for macroergonomic HFE approaches within the context of current research in biomedical informatics. METHODS We reviewed literature (2007-2013) on the use of HFE approaches in healthcare settings, from databases such as Pubmed, CINAHL, and Cochran. RESULTS Based on the review, we discuss the systems-oriented models, their use in the evaluation of HIT, and examples of their use in the evaluation of EHR systems, clinical workflow processes, and medication errors. We also discuss the opportunities for better integrating HFE methods within biomedical informatics research and its potential advantages. CONCLUSIONS The use of HFE methods is still in its infancy - better integration of HFE within the design lifecycle, and quality improvement efforts can further the ability of informatics researchers to address the key concerns regarding the complexity in clinical settings and develop HIT solutions that are designed within the social fabric of the considered setting.
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Affiliation(s)
- V L Patel
- Vimla L. Patel, Center for Cognitive Studies, in Medicine and Public Health, The New York Academy of Medicine, 1216 5th Avenue, New York, NY, E-mail:
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Mickelson R, Holden R. Assessing the distributed nature of home-based heart failure medication management in older adults. ACTA ACUST UNITED AC 2013. [DOI: 10.1177/1541931213571165] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Non-adherence to medications in older adult chronic heart failure (CHF) patients suggests the difficulty these patients experience with medication management tasks. This qualitative study explored home-based medication management and how activities were distributed across persons, artifacts, time and space using a distributed cognition framework. Interviews with CHF patients (N = 27) and their informal caregivers (N=11) were content analyzed for cross-cutting themes about distributed task performance. Results illustrated problem areas within this distributed system such as representational discordance, communication difficulties, and lack of portability of information across environments. Implications for future design of interventions include the need for portability and exchange of information, portability of medications and reminder devices, and improved communication across the distributed system.
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Affiliation(s)
| | - Richard Holden
- Department of Medicine, Vanderbilt University, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN
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Abstract
Safety and quality of health care depend on collaborative efforts of multiprofessional and multidisciplinary teams of care providers. Team research in aviation and the military has produced a wealth of knowledge in terms of concepts and intervention strategies to improve team performance. Research on collaborative work in health care in the past 20 years has uncovered unique characteristics and requirements of teams in hospitals and other health care settings and has provided early assessment of the utility of the theoretical concepts, methodologies, and interventions developed outside health care. In this chapter, we review a set of concepts that have been used in characterizing teams in health care and in improving teamwork. These concepts include the organizational shell to capture the sociotechnical environment in which teams reside as well as nontechnical skills, team leadership, team mental models, and so on. We will review a number of leading interventions to enhance team performance, such as teamwork training (e.g., TeamSTEPPS) and structured communication (e.g., SBAR). Future directions are suggested on better understanding of the interdependencies between teams and their organizational shell, such as standardization of operating procedures and training, and to focus on the patient in terms of teamwork improvement.
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Tariq A, Georgiou A, Westbrook J. Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process. Int J Med Inform 2012; 82:299-312. [PMID: 23026393 DOI: 10.1016/j.ijmedinf.2012.08.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 08/16/2012] [Accepted: 08/17/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. METHODS The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. RESULTS The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. CONCLUSIONS Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety.
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Affiliation(s)
- Amina Tariq
- Centre for Health Systems and Safety Research, University of New South Wales, Sydney, Australia.
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Morrow DG, Conner-Garcia T, Graumlich JF, Wolf MS, McKeever S, Madison A, Davis K, Wilson EAH, Liao V, Chin CL, Kaiser D. An EMR-based tool to support collaborative planning for medication use among adults with diabetes: design of a multi-site randomized control trial. Contemp Clin Trials 2012; 33:1023-32. [PMID: 22664648 DOI: 10.1016/j.cct.2012.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 04/23/2012] [Accepted: 05/13/2012] [Indexed: 10/28/2022]
Abstract
Patients with type II diabetes often struggle with self-care, including adhering to complex medication regimens and managing their blood glucose levels. Medication nonadherence in this population reflects many factors, including a gap between the demands of taking medication and the limited literacy and cognitive resources that many patients bring to this task. This gap is exacerbated by a lack of health system support, such as inadequate patient-provider collaboration. The goal of our project is to improve self-management of medications and related health outcomes by providing system support. The Medtable™ is an Electronic Medical Record (EMR)-integrated tool designed to support patient-provider collaboration needed for medication management. It helps providers and patients work together to create effective medication schedules that are easy to implement. We describe the development and initial evaluation of the tool, as well as the process of integrating it with an EMR system in general internal medicine clinics. A planned evaluation study will investigate whether an intervention centered on the Medtable™ improves medication knowledge, adherence, and health outcomes relative to a usual care control condition among type II diabetic patients struggling to manage multiple medications.
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Affiliation(s)
- Daniel G Morrow
- Beckman Institute, University of Illinois, Urbana, IL 61801, USA.
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Rajkomar A, Blandford A. Understanding infusion administration in the ICU through Distributed Cognition. J Biomed Inform 2012; 45:580-90. [DOI: 10.1016/j.jbi.2012.02.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 02/14/2012] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
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Sheehan B, Kaufman D, Bakken S, Currie LM. Cognitive analysis of decision support for antibiotic ordering in a neonatal intensive care unit. Appl Clin Inform 2012; 3:105-23. [PMID: 23616903 DOI: 10.4338/aci-2011-10-ra-0060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 02/20/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Clinical decision support systems (CDSS) are a method used to support prescribing accuracy when deployed within a computerized provider order entry system (CPOE). Divergence from using CDSS is exemplified by high alert override rates. Excessive cognitive load imposed by the CDSS may help to explain such high rates. OBJECTIVES The aim of this study was to describe the cognitive impact of a CPOE-integrated CDSS by categorizing system use problems according to the type of mental processing required to resolve them. METHODS A qualitative, descriptive design was used employing two methods; a cognitive walkthrough and a think-aloud protocol. Data analysis was guided by Norman's Theory of Action and a theory of cognitive distances which is an extension to Norman's theory. RESULTS The most frequently occurring source of excess cognitive effort was poor information timing. Information presented by the CDSS was often presented after clinicians required the information for decision making. Additional sources of effort included use of language that was not clear to the user, vague icons, and lack of cues to guide users through tasks. CONCLUSIONS Lack of coordination between clinician's task-related thought processes and those presented by a CDSS results in excessive cognitive work required to use the system. This can lead to alert overrides and user errors. Close attention to user's cognitive processes as they carry out clinical tasks prior to CDSS development may provide key information for system design that supports clinical tasks and reduces cognitive effort.
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Affiliation(s)
- B Sheehan
- School of Nursing, Columbia University , NY NY
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Collins SA, Mamykina L, Jordan D, Stein DM, Shine A, Reyfman P, Kaufman D. In search of common ground in handoff documentation in an Intensive Care Unit. J Biomed Inform 2011; 45:307-15. [PMID: 22142947 DOI: 10.1016/j.jbi.2011.11.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 10/20/2011] [Accepted: 11/17/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Handoff is an intra-disciplinary process, yet the flow of critical handoff information spans multiple disciplines. Understanding this information flow is important for the development of computer-based tools that supports the communication and coordination of patient care in a multi-disciplinary and highly specialized critical care setting. We aimed to understand the structure, functionality, and content of nurses' and physicians' handoff artifacts. DESIGN We analyzed 22 nurses' and physicians' handoff artifacts from a Cardiothoracic Intensive Care Unit (CTICU) at a large urban medical center. We combined artifact analysis with semantic coding based on our published Interdisciplinary Handoff Information Coding (IHIC) framework for a novel two-step data analysis approach. RESULTS We found a high degree of structure and overlap in the content of nursing and physician artifacts. Our findings demonstrated a non-technical, yet sophisticated, system with a high degree of structure for the organization and communication of patient data that functions to coordinate the work of multiple disciplines in a highly specialized unit of patient care. LIMITATIONS This study took place in one CTICU. Further work is needed to determine the generalizability of the results. CONCLUSIONS Our findings indicate that the development of semi-structured patient-centered interdisciplinary handoff tools with discipline specific views customized for specialty settings may effectively support handoff communication and patient safety.
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Affiliation(s)
- Sarah A Collins
- Nurse Informatician, Clinical Informatics R&D, Partners Healthcare Systems, 93 Worcester St., Wellesley, MA 02481, USA.
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Singh H, Giardina TD, Petersen LA, Smith MW, Paul LW, Dismukes K, Bhagwath G, Thomas EJ. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf 2011; 21:30-8. [PMID: 21890757 DOI: 10.1136/bmjqs-2011-000310] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs), this study explored the use of the situational awareness (SA) framework from aviation human factors research. METHODS A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the USA. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process. RESULTS Of 254 cases meeting inclusion criteria, errors were found in 30 of 92 (32.6%) lung cancer cases and 56 of 167 (33.5%) colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, application of the SA framework provided insight into processes involved in attention management. CONCLUSIONS A framework of SA can help analyse and understand diagnostic errors in primary care settings that use EHRs.
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Affiliation(s)
- Hardeep Singh
- VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA.
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Collins SA, Bakken S, Vawdrey DK, Coiera E, Currie L. Clinician preferences for verbal communication compared to EHR documentation in the ICU. Appl Clin Inform 2011; 2:190-201. [PMID: 23616870 DOI: 10.4338/aci-2011-02-ra-0011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 04/22/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Effective communication is essential to safe and efficient patient care. Additionally, many health information technology (HIT) developments, innovations, and standards aim to implement processes to improve data quality and integrity of electronic health records (EHR) for the purpose of clinical information exchange and communication. OBJECTIVE We aimed to understand the current patterns and perceptions of communication of common goals in the ICU using the distributed cognition and clinical communication space theoretical frameworks. METHODS We conducted a focus group and 5 interviews with ICU clinicians and observed 59.5 hours of interdisciplinary ICU morning rounds. RESULTS Clinicians used an EHR system, which included electronic documentation and computerized provider order entry (CPOE), and paper artifacts for documentation; yet, preferred the verbal communication space as a method of information exchange because they perceived that the documentation was often not updated or efficient for information retrieval. These perceptions that the EHR is a "shift behind" may lead to a further reliance on verbal information exchange, which is a valuable clinical communication activity, yet, is subject to information loss. CONCLUSIONS Electronic documentation tools that, in real time, capture information that is currently verbally communicated may increase the effectiveness of communication.
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Affiliation(s)
- S A Collins
- Department of Biomedical Informatics , Columbia University
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Collins SA, Bakken S, Vawdrey DK, Coiera E, Currie LM. Agreement between common goals discussed and documented in the ICU. J Am Med Inform Assoc 2010; 18:45-50. [PMID: 21113075 DOI: 10.1136/jamia.2010.006437] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR. DESIGN Descriptive correlational study of common goals verbally stated during daily ICU interdisciplinary rounds compared with the presence of those goals, and actions related to those goals, documented in the EHR over the subsequent 24 h for 28 patients over 15 days. The study setting was a neurovascular ICU with a fully implemented electronic nursing and physician documentation system. MEASUREMENTS Descriptive statistics and χ(2) analyses were used to assess differences in EHR documentation of stated goals and goal-related actions. Inter-coder reliability was performed on 16 (13%) of the 127 stated goals. RESULTS One-quarter of the stated goals were not documented in the EHR. If a goal was not documented, actions related to that goal were 60% less likely to be documented. The attending physician note contained 81% of the stated ventilator weaning goals, but only 49% of the sedation weaning goals; additionally, sedation goals were not part of the structured nursing documentation. Inter-coder reliability (κ) was greater than 0.82. LIMITATIONS Observations in a single ICU setting at a large academic medical center using a commercial EHR. CONCLUSION The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.
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Affiliation(s)
- Sarah A Collins
- Department of Biomedical Informatics, Columbia University, New York, New York, USA.
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Fioratou E, Flin R, Glavin R, Patey R. Beyond monitoring: distributed situation awareness in anaesthesia. Br J Anaesth 2010; 105:83-90. [DOI: 10.1093/bja/aeq137] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Example of a Human Factors Engineering approach to a medication administration work system: Potential impact on patient safety. Int J Med Inform 2010; 79:e43-57. [DOI: 10.1016/j.ijmedinf.2009.07.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 06/25/2009] [Accepted: 07/18/2009] [Indexed: 11/17/2022]
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Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform 2008; 78:293-307. [PMID: 19081295 DOI: 10.1016/j.ijmedinf.2008.10.001] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 09/16/2008] [Accepted: 10/15/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Researchers in healthcare have begun to investigate interruptions extensively, given evidence for the adverse effects of work interruptions in other domains and given the highly interruptive hospital environment. In this paper, we reviewed literature on interruptions in critical care and medication dispensing settings in search of evidence for a relationship between interruptions and adverse events. METHODS The literature search included the databases MEDLINE, CINAHL+Pre CINHAL, Health Sources: Nursing Academic Edition, EMBASE, PsycINFO, ISI Web of Science and Ergonomics Abstracts. The paper titles and abstracts were subsequently reviewed. After the initial search, we reviewed paper titles and abstracts to define the subset for review. RESULTS We currently lack evidence in healthcare of the extent to which interruptions lead to adverse effects. The lack of evidence may be due to the descriptive rather than causal nature of most studies, the lack of theory motivating investigations of the relationship, the fact that healthcare is a complex and varied domain, and inadequate conceptualizations of accident aetiology. We identify two recent accident theories in which the relationship between activity and medical errors is complex, indicating that even when it is sought, causal evidence is hard to find. DISCUSSION Future research on interruptions in healthcare settings should focus on the following. First, prospective memory research and distributed cognition can provide a theoretical background for understanding the impact of interruptions and so could provide guidance for future empirical research on interruptions and the planning of actions in healthcare. Second, studying how interruptions are successfully rather than unsuccessfully overcome may better help us understand their effects. Third, because interruptions almost always have positive and adverse effects, more appropriate dependent variables could be chosen.
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Mastrian K, McGonigle D. Cognitive informatics: An essential component of nursing technology design. Nurs Outlook 2008; 56:332-3. [DOI: 10.1016/j.outlook.2008.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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