Informatics at NIH.
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Biomedical Engineering↗
Biomedical subjects
V L Patel
Publications and source records attributed to V L Patel.
Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning.
OBJECTIVE: To assess the effects of a computer-based patient record system on human cognition. Computer-based patient record systems can be considered "cognitive artifacts," which shape the way in which health care workers obtain, organize, and reason with knowledge. DESIGN: Study 1 compared physicians' organization of clinical information in paper-based and computer-based patient records in a diabetes clinic. Study 2 extended the first study to include analysis of doctor-patient-computer interactions, which were recorded on video in their entirety. In Study 3, physicians' interactions with computer-based records were followed through interviews and automatic logging of cases entered in the computer-based patient record. RESULTS: Results indicate that exposure to the computer-based patient record was associated with changes in physicians' information gathering and reasoning strategies. Differences were found in the content and organization of information, with paper records having a narrative structure, while the computer-based records were organized into discrete items of information. The differences in knowledge organization had an effect on data gathering strategies, where the nature of doctor-patient dialogue was influenced by the structure of the computer-based patient record system. CONCLUSION: Technology has a profound influence in shaping cognitive behavior, and the potential effects of cognition on technology design needs to be explored.
Cognition↗
Studying the human-computer-terminology interface.
OBJECTIVE: To explore the use of an observational, cognitive-based approach for differentiating between successful, suboptimal, and failed entry of coded data by clinicians in actual practice, and to detect whether causes for unsuccessful attempts to capture true intended meaning were due to terminology content, terminology representation, or user interface problems. DESIGN: Observational study with videotaping and subsequent coding of data entry events in an outpatient clinic at New York Presbyterian Hospital. PARTICIPANTS: Eight attending physicians, 18 resident physicians, and 1 nurse practitioner, using the Medical Entities Dictionary (MED) to record patient problems, medications, and adverse reactions in an outpatient medical record system. MEASUREMENTS: Classification of data entry events as successful, suboptimal, or failed, and estimation of cause; recording of system response time and total event time. RESULTS: Two hundred thirty-eight data entry events were analyzed; 71.0 percent were successful, 6.3 percent suboptimal, and 22.7 percent failed; unsuccessful entries were due to problems with content in 13.0 percent of events, representation problems in 10.1 percent of events, and usability problems in 5.9 percent of events. Response time averaged 0.74 sec, and total event time averaged 40.4 sec. Of an additional 209 tasks related to drug dose and frequency terms, 94 percent were successful, 0.5 percent were suboptimal, and 6 percent failed, for an overall success rate of 82 percent. CONCLUSIONS: Data entry by clinicians using the outpatient system and the MED was generally successful and efficient. The cognitive-based observational approach permitted detection of false-positive (suboptimal) and false-negative (failed due to user interface) data entry.
Ambulatory Care Information Systems↗
A primer on aspects of cognition for medical informatics.
As a multidisciplinary field, medical informatics draws on a range of disciplines, such as computer science, information science, and the social and cognitive sciences. The cognitive sciences can provide important insights into the nature of the processes involved in human- computer interaction and help improve the design of medical information systems by providing insight into the roles that knowledge, memory, and strategies play in a variety of cognitive activities. In this paper, the authors survey literature on aspects of medical cognition and provide a set of claims that they consider to be important in medical informatics.
Cognition↗
Domain knowledge and hypothesis generation in diagnostic reasoning.
The role of domain knowledge in the process of hypothesis generation during diagnostic reasoning was examined. Subjects were given a clinical case presented one segment at a time on a microcomputer. They were prompted to think aloud after presentation of each segment of the clinical case. A combination of discourse and protocol analysis techniques was used to investigate the problem solving process in two groups of experts working on an endocrine problem. The groups consisted of high-domain-knowledge subjects (HDK), endocrinologists, and low-domain-knowledge subjects (LDK), cardiologists. The results showed no significant differences between the groups in terms of selection of relevant and critical cues from the case. However, specific differences were found in the links or relations between the cues, with the HDK subjects using more relations to connect important information. The HDK subjects generated accurate diagnostic hypotheses early in the problem encounter and spent the rest of the time confirming the hypotheses by explaining the given cues. The LDK subjects also generated accurate diagnostic hypotheses but were unable to discriminate between and eliminate alternative hypotheses. A two-stage problem solving process and its relationship to domain specific knowledge are proposed.
Clinical Competence↗
Reanalysis: recalibration versus replication.
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Clinical Protocols↗
Hypothesis generation and the coordination of theory and evidence in novice diagnostic reasoning.
This study investigates hypothesis generation and evaluation in clinical problem solving by medical trainees. The study focuses on 1) directionality of reasoning and 2) use of confirmation and disconfirmation strategies in generating and evaluating hypotheses. Two clinical problems were divided into segments of information containing presenting complaint, past history, and physical examination. The initial information indicated a typical myocardial infarct but subsequent information contradicted it. The results showed that the participating students predominantly used forward reasoning and confirmation strategies. When faced with contradictory evidence: 1) second-year students ignored cues in the problem or reinterpreted them to fit the hypothesis; 2) third-year students generated concurrent hypotheses to account for different sets of data; and 3) fourth-year students generated several initial hypotheses and subsequently narrowed the hypothesis space by generating a single coherent diagnostic explanation. The results are discussed in terms of coordination of clinical evidence and its relationship to scientific reasoning.
Aortic Dissection↗
Decision-making strategies for telephone triage in emergency medical services.
Decision-making strategies used by nurses in telephone triage involving public emergency calls for medical help were investigated as a function of task urgency and complexity in the real-world dynamic environment. The sample included 34 nurses as call receivers. Transcripts of 50 nurse-client dialogues and 50 explanations of the decision-making process, elicited immediately after completion of the calls, were analyzed using methods of discourse and protocol analyses. In high-urgency situations, heuristic rules based on symptoms were used, and the decisions were mostly accurate. With the increase in problem complexity, more causal explanations were found, and the decisions were more often inaccurate. Furthermore, the explanations supporting the accurate decisions were often inaccurate, showing a decoupling of knowledge and action. Alternate strategies were used in moderate- to low-urgency conditions, where contextual knowledge of the situations was exploited to identify the needs of the clients and to negotiate the best plan of action to meet these needs, resulting in more accurate decisions.
Decision Support Techniques↗
Assessment of a computerized patient record system: a cognitive approach to evaluating medical technology.
Numerous research and development projects have been aimed at implementing computerized patient record (CPR) systems. Yet little emphasis has been placed on physicians' ability to learn and use these systems or on their effects on physicians' reasoning. This article describes an innovative approach to assessing these aspects of a CPR system. The method involves observing physicians' use of a CPR under various clinical conditions and analyzing the CPR system with a technique called the cognitive walkthrough. We will show how learning to use a CPR system can change a physician's performance, with accompanying effects on information gathering and reasoning.
Cognitive Science↗
Cognition and technology in health education research.
There is an explicit relationship between knowledge generation, transmission (dissemination and diffusion), knowledge acquisition, and utilization. In order to disseminate and diffuse information for health promotion and disease prevention, there is an assumption that we just need to change the behaviours of people. This paper challenges this notion and suggests that the thinking behind the behaviours (cognition) also needs to be addressed for successful acquisition and utilization of information. Studies focusing on cognition or thought processes and how sociocultural factors influence or interact with cognitive factors is a high priority area of research. This area of research becomes more important if we include technology in the health care delivery system.
Cognition↗