Clinical cognition and biomedical informatics: issues of patient safety

Recent developments in biomedical informatics research have afforded possibilities for great advances in health care delivery. These exciting opportunities also present a number of challenges to the implementation and integration of technologies in the workplace. As in most domains, there is a gulf between technologic artifacts and end users, which compromises the culture of safety in the workplace. Because clinical practice is a human endeavor, there is a need for bridging disciplines to enable clinicians to benefit from rapid technologic advances. This, in turn, necessitates a broadening of disciplinary boundaries to consider cognitive and social factors related to the design and use of technology. The authors argue for a place of prominence for cognitive science in understanding nursing factors associated with patient safety. Cognitive science provides a framework for the analysis and modeling of complex human performance. Studies of clinical cognition can meaningfully inform and shape design, development and assessment of information systems. Furthermore, they have a decisive impact on whether information technology has a positive influence on human performance and are especially important in understanding and promoting safe practices. These issues are discussed in the context of clinical informatics with a focus on nursing practice.     

Cognitive informatics in biomedicine and healthcare

Cognitive Informatics (CI) is a burgeoning interdisciplinary domain comprising of the cognitive and information sciences that focuses on human information processing, mechanisms and processes within the context of computing and computer applications. Based on a review of articles published in the Journal of Biomedical Informatics (JBI) between January 2001 and March 2014, we identified 57 articles that focused on topics related to cognitive informatics. We found that while the acceptance of CI into the mainstream informatics research literature is relatively recent, its impact has been significant – from characterizing the limits of clinician problem-solving and reasoning behavior, to describing coordination and communication patterns of distributed clinical teams, to developing sustainable and cognitively-plausible interventions for supporting clinician activities. Additionally, we found that most research contributions fell under the topics of decision-making, usability and distributed team activities with a focus on studying behavioral and cognitive aspects of clinical personnel, as they performed their activities or interacted with health information systems. We summarize our findings within the context of the current areas of CI research, future research directions and current and future challenges for CI researchers.     

Distributed cognition: an alternative model of cognition for medical informatics

BACKGROUND: Medical informatics has been guided by an individual-centered model of human cognition, inherited from classical theory of mind, in which knowledge, problem-solving, and information-processing responsible for intelligent behavior all derive from the inner workings of an individual agent. OBJECTIVES AND RESULTS: In this paper we argue that medical informatics commitment to the classical model of cognition conflates the processing performed by the minds of individual agents with the processing performed by the larger distributed activity systems within which individuals operate. We review trends in cognitive science that seek to close the gap between general-purpose models of cognition and applied considerations of real-world human performance. One outcome is the theory of distributed cognition, in which the unit of analysis for understanding performance is the activity system which comprises a group of human actors, their tools and environment, and is organized by a particular history of goal-directed action and interaction. CONCLUSION: We describe and argue for the relevance of distributed cognition to medical informatics, both for the study of human performance in healthcare and for the design of technologies meant to enhance this performance.     

Methods of cognitive analysis to support the design and evaluation of biomedical systems: the case of clinical practice guidelines

This article provides a theoretical and methodological framework for the use of cognitive analysis to support the representation of biomedical knowledge and the design of clinical systems, using clinical-practice guidelines (CPGs) as an example. We propose that propositional and semantic analyses, when used as part of the system-development process, can improve the validity, usability, and comprehension of the resulting biomedical applications. The framework we propose is based on a large body of research on the study of how people mentally represent information and subsequently use it for problem solving. This research encompasses many areas of psychology, but the more important ones are the study of memory and the study of comprehension. Of particular relevance is research devoted to investigating the comprehension and memory of language, expressed verbally or in text. In addition, research on how contextual variables affect performance is informative because these psychological processes are influenced by situational variables (e.g., setting, culture). One important factor limiting the acceptance and use of clinical-practice guidelines (CPGs) may be the mismatch between a guideline's recommended actions and the physician-user's mental models of what seems appropriate in a given case. Furthermore, CPGs can be semantically complex, often composed of elaborate collections of prescribed procedures with logical gaps or contradictions that can promote ambiguity and hence frustration on the part of those who attempt to use them. An improved understanding of the semantics and structure of CPGs may help to improve such matching, and ultimately the comprehensibility and usability of CPGs. Cognitive methods of analysis can help guideline designers and system builders throughout the development process, from the conceptual design of a computer-based system to its implementation phases. By studying how guideline creators and developers represent guidelines, both mentally and in text, and how end-users understand and make decisions with such guidelines, we can inform the development of technologies that seek to improve the match between the representations of experts and practitioners. We urge informaticians to recognize the potential relevance of cognitive analysis methods and to begin more extensive experimentation with the their use in biomedical informatics research.     

The think aloud method: a guide to user interface design

OBJECTIVES: Clinical use of computer systems has been hampered by their poorly designed user interfaces. The objective of this study was to design a user interface for a pediatric oncologists' computerized patient record with great consideration of their working behavior and of human computer interfacing principles so as to contribute to oncologists' efficiency and satisfaction in interaction with the system. METHODS: The think aloud method was used in combination with video recording to get a deep understanding of the way in which four pediatric oncologists searched through the paper-based patient record in preparing a patient visit. Protocol and video analyses was used to develop a cognitive task model reflecting pediatric oncologists' task behavior. This model was input for a prototype user interface, which was subsequently evaluated by eight other pediatric oncologists. RESULTS: The resulting computerized medical record system proved to meet pediatric oncologists' information needs and task behavior patterns. The design of the user interface minimized pediatric oncologists' work load and was highly efficient in supporting the pediatric oncologists in preparing their patient visits. The pediatric oncologists were very much satisfied with the computer system. CONCLUSIONS: It is argued that early involvement of cognitive engineering methods in the system design process may be of great help in designing systems that fully support health care professionals' work practices. The think aloud method, if applied under prescribed conditions, is a valuable information source of human task-behavior and as such a useful technique for requirements analysis in designing clinical computer systems.     

Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education

Theoretical and methodological advances in the cognitive and learning sciences can greatly inform curriculum and instruction in biomedicine and also educational programs in biomedical informatics. It does so by addressing issues such as the processes related to comprehension of medical information, clinical problem-solving and decision-making, and the role of technology. This paper reviews these theories and methods from the cognitive and learning sciences and their role in addressing current and future needs in designing curricula, largely using illustrative examples drawn from medical education. The lessons of this past work are also applicable, however, to biomedical and health professional curricula in general, and to biomedical informatics training, in particular. We summarize empirical studies conducted over two decades on the role of memory, knowledge organization and reasoning as well as studies of problem-solving and decision-making in medical areas that inform curricular design. The results of this research contribute to the design of more informed curricula based on empirical findings about how people learn and think, and more specifically, how expertise is developed. Similarly, the study of practice can also help to shape theories of human performance, technology-based learning, and scientific and professional collaboration that extend beyond the domain of medicine. Just as biomedical science has revolutionized health care practice, research in the cognitive and learning sciences provides a scientific foundation for education in biomedicine, the health professions, and biomedical informatics.     

Third generation participatory design in health informatics--making user participation applicable to large-scale information system projects

Participatory Design (PD) methods in the field of health informatics have mainly been applied to the development of small-scale systems with homogeneous user groups in local settings. Meanwhile, health service organizations are becoming increasingly large and complex in character, making it necessary to extend the scope of the systems that are used for managing data, information and knowledge. This study reports participatory action research on the development of a PD framework for large-scale system design. The research was conducted in a public health informatics project aimed at developing a system for 175,000 users. A renewed PD framework was developed in response to six major limitations experienced to be associated with the existing methods. The resulting framework preserves the theoretical grounding, but extends the toolbox to suit applications in networked health service organizations. Future research should involve evaluations of the framework in other health service settings where comprehensive HISs are developed.     

Teaching the fundamentals of information systems management in health care. Lecture and practical training for students of medical informatics

For the management of information systems in health care, it is important that projects are systematically planned and carried out. This is a major task for medical informatics professionals which should be taught in a medical informatics curriculum. In the respective lecture in the Heidelberg/Heilbronn medical informatics curriculum, we teach fundamentals of the management of information systems and of projects. The examples of the lecture are taken from hospital information systems. Furthermore, we have developed a 5-step method for the systematic, goal-oriented planning of projects. The lecture is complemented by a comprehensive practical training, so that the methods taught can be applied to a particular, relevant problem of the Heidelberg University Hospital.     

Methodological framework for evaluating clinical processes: A cognitive informatics perspective

We propose a methodological framework for evaluating clinical cognitive activities in complex real-world environments that provides a guiding framework for characterizing the patterns of activities. This approach, which we refer to as a process-based approach, is particularly relevant to cognitive informatics (CI) research—an interdisciplinary domain utilizing cognitive approaches in the study of computing systems and applications—as it provides new ways for understanding human information processing, interactions, and behaviors. Using this approach involves the identification of a process of interest (e.g., a clinical workflow), and the contributing sequences of activities in that process (e.g., medication ordering). A variety of analytical approaches can then be used to characterize the inherent dependencies and relations within the contributing activities within the considered process. Using examples drawn from our own research and the extant research literature, we describe the theoretical foundations of the process-based approach, relevant practical and pragmatic considerations for using such an approach, and a generic framework for applying this approach for evaluation studies in clinical settings. We also discuss the potential for this approach in future evaluations of interactive clinical systems, given the need for new approaches for evaluation, and significant opportunities for automated, unobtrusive data collection.     

Cognitive neuropsychology and its vicissitudes: The fate of Caramazza's axioms

ABSTRACT

Cognitive neuropsychology is characterized as the discipline in which one draws conclusions about the organization of the normal cognitive systems from the behaviour of brain-damaged individuals. In a series of papers, Caramazza, later in collaboration with McCloskey, put forward four assumptions as the bridge principles for making such inferences. Four potential pitfalls, one for each axiom, are discussed with respect to the use of single-case methods. Two of the pitfalls also apply to case series and group study procedures, and the other two are held to be indirectly testable or avoidable. Moreover, four other pitfalls are held to apply to case series or group study methods. It is held that inferences from single-case procedures may profitably be supported or rejected using case series/group study methods, but also that analogous support needs to be given in the other direction for functionally based case series or group studies. It is argued that at least six types of neuropsychological method are valuable for extrapolation to theories of the normal cognitive system but that the single- or multiple-case study remains a critical part of cognitive neuropsychology's methods.     

Health informatics and the delivery of care to older people

In the light of an aging society, effective delivery of healthcare will be more dependent on different technological solutions supporting the decentralisation of healthcare, higher patient involvement and increased societal demands. The aim of this article is therefore, to describe the role of health informatics in the care of elderly people and to give an overview of the state of the art in this field. Based on a review of the existing scientific literature, 29 review articles from the last 15 years and 119 original articles from the last 5 years were selected and further analysed. Results show that review articles cover the fields of information technology in the home environment, integrated health information systems, public health systems, consumer health informatics and non-technology oriented topics such as nutrition, physical behaviour, medication and the aging process in general. Articles presenting original data can be divided into 5 major clusters: information systems and decision support, consumer health informatics, emerging technologies, home telehealth, and informatics methods. Results show that health informatics in elderly care is an expanding field of interest but we still do lack knowledge about the elderly person's needs of technology and how it should best be designed. Surprisingly, few studies cover gender differences related to technology use. Further cross-disciplinary research is needed that relates informatics and technology to different stages of the aging process and that evaluates the effects of technical solutions.     

Advancing cognitive engineering methods to support user interface design for electronic health records

BackgroundDespite many decades of research on the effective development of clinical systems in medicine, the adoption of health information technology to improve patient care continues to be slow, especially in ambulatory settings. This applies to dentistry as well, a primary care discipline with approximately 137,000 practitioners in the United States. A critical reason for slow adoption is the poor usability of clinical systems, which makes it difficult for providers to navigate through the information and obtain an integrated view of patient data.ObjectiveIn this study, we documented the cognitive processes and information management strategies used by dentists during a typical patient examination. The results will inform the design of a novel electronic dental record interface.MethodsWe conducted a cognitive task analysis (CTA) study to observe ten general dentists (five general dentists and five general dental faculty members, each with more than two years of clinical experience) examining three simulated patient cases using a think-aloud protocol.ResultsDentists first reviewed the patient's demographics, chief complaint, medical history and dental history to determine the general status of the patient. Subsequently, they proceeded to examine the patient's intraoral status using radiographs, intraoral images, hard tissue and periodontal tissue information. The results also identified dentists’ patterns of navigation through patient's information and additional information needs during a typical clinician–patient encounter.ConclusionThis study reinforced the significance of applying cognitive engineering methods to inform the design of a clinical system. Second, applying CTA to a scenario closely simulating an actual patient encounter helped with capturing participants’ knowledge states and decision-making when diagnosing and treating a patient. The resultant knowledge of dentists’ patterns of information retrieval and review will significantly contribute to designing flexible and task-appropriate information presentation in electronic dental records.     

Cooperation and communication challenges in small-scale eHealth development projects

AimIn eHealth development there is an increasing focus on user participation inspired by the information systems field of practice and research. There are, however, many other challenges in developing information systems that fit healthcare practices. One of these is the challenge of cooperation and communication in development projects that are initiated and managed by clinicians e.g. cooperating with IT professionals in ‘bottom up’ health informatics projects that have been initiated and are managed by healthcare professional project managers.MethodThe analysis and results are drawn from a qualitative case study on a systems development project that was managed by a local, non-technical, healthcare professional and the complex blend and interactions with the IT professionals in the phases of ideas, design, development, implementation, maintenance and distribution.ResultsWe analyze the challenges of cooperation and communication using perspectives from information systems research and the concepts of ‘language-games’ and ‘shared design spaces’, and thereby exploring the boundaries between the different communication, practice and culture of the IT professionals and the healthcare professionals.ConclusionThere is a need to (a) develop a better understanding of the development process from the point of view of the ‘user’ and (b) tools for making technical knowledge explicit in the development process. Cooperative and communicative methods are needed that support and develop the shared design spaces between IT professionals and the clinical context in order to strengthen small-scale health information systems projects.     

The association between health literacy and indicators of cognitive impairment in a diverse sample of primary care patients

Objectives

To confirm the association of health literacy scores as measured by Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT) with cognitive ability and education. To determine whether this association differs by cognitive task.

Methods

Cognitive impairment was measured using the Mini-Cog, which combines a delayed word recall task (WRT) and a clock drawing task (CDT) to yield an overall classification of normal versus cognitively impaired. Participants were recruited from primary care clinics that provide care to underserved patients.

Results

Participants (n = 574) were predominantly non-Hispanic black (67%) with a mean age of 46 years, 50% did not have health insurance, 56% had a high school education or less and 21% screened positive for cognitive impairment. Overall cognitive ability and education were significantly associated with health literacy after adjusting for other variables, including race/ethnicity and physical health. We observed a stronger association between the CDT and health literacy than between the WRT and health literacy.

Conclusion

By confirming hypothesized associations, this study provides additional support of the validity of Health LiTT.

Practice implications

Health LiTT is a reliable and valid tool that researchers and clinicians can use to identify individuals who might have difficulty understanding health information.     

Expanding multi-disciplinary approaches to healthcare information technologies: what does information systems offer medical informatics?

The effective use of information technology (IT) is a crucial component for the delivery of effective services in health care. Current approaches to medical informatics (MI) research have significantly contributed to the success of IT use in health care but important challenges remain to be addressed. We believe that expanding the multi-disciplinary basis for MI research is important to meeting these research challenges. In this paper, we outline theories and methods used in information systems (IS) research that we believe can inform our understanding of health care IT applications and outcomes. To do so, we discuss some general differences in the focus and methods of MI and IS research to identify broad opportunities. We then review conceptual and methodological approaches in IS that have been applied in health care IT research. These include: technology-use mediation, collaborative work, genre theory, interpretive research, action research, and modeling. Examples of these theories and methods in healthcare IS research are illustrated.     

Illusory Reduplication of One's Own Body: Phenomenology and Classification of Autoscopic Phenomena

Introduction. Cognitive deficits are commonly reported in schizophrenia and have a significant impact on the daily life of patients and on their social and work inclusion. Cognitive remediation therapies (CRT) may enhance the capabilities of schizophrenia patients. Although social and work integration is the ultimate goal of CRT, previous studies have failed to carry out a detailed assessment of the effects on everyday life.

Methods. Fifty-nine schizophrenia patients were randomised into two groups (remediation or usual treatment) to test the effects of a new remediation programme, which included both rehearsal and strategy learning, on cognitive functions. An ecological test was used to evaluate its transfer to daily living skills.

Results. Cognitive improvements are revealed in CRT patients, mainly in memory and executive functions. Patients showing some deficiencies to perform the ecological test had better scores after the CRT. Moreover, they significantly improve their social activity scores.

Conclusions. CRT would facilitate mental load monitoring by enhancing or reallocating cognitive resources, facilitating the patient's organisation and autonomy. The rehearsal learning approach improves the ability to carry out automatic operations that are less demanding in terms of cognitive resources, thereby increasing the resources available for acquisition and efficient use of strategies provided during the strategy learning approach.     

Longitudinal imaging pattern analysis (SPARE-CD index) detects early structural and functional changes before cognitive decline in healthy older adults

This article investigates longitudinal imaging characteristics of early cognitive decline during normal aging, leveraging on high-dimensional imaging pattern classification methods for the development of early biomarkers of cognitive decline. By combining magnetic resonance imaging (MRI) and resting positron emission tomography (PET) cerebral blood flow (CBF) images, an individualized score is generated using high-dimensional pattern classification, which predicts subsequent cognitive decline in cognitively normal older adults of the Baltimore Longitudinal Study of Aging. The resulting score, termed SPARE-CD (Spatial Pattern of Abnormality for Recognition of Early Cognitive Decline), analyzed longitudinally for 143 cognitively normal subjects over 8 years, shows functional and structural changes well before (2.3-2.9 years) changes in neurocognitive testing (California Verbal Learning Test [CVLT] scores) can be measured. Additionally, this score is found to be correlated to the [(11)C] Pittsburgh compound B (PiB) PET mean distribution volume ratio at a later time. This work indicates that MRI and PET images, combined with advanced pattern recognition methods, may be useful for very early detection of cognitive decline.