Translational cognition for decision support in critical care environments: A review

Journal of Biomedical Informatics

Volumn 41, Issue 3, 2008, Pages 413-431

  Patel, Vimla L ^a,b   Zhang, Jiajie ^c   Yoskowitz, Nicole A ^b   Green, Robert ^d   Sayan, Osman R ^d  

^a ARIZONA STATE UNIVERSITY   (United States)

^b Howard Hughes Medical Institute   (United States)

^c UNIVERSITY OF TEXAS   (United States)

^d New York Presbyterian Morgan Stanley Children's Hospital   (United States)

Author keywords

Clinical workflow; Cognitive task analysis; Critical care; Decision support; Distributed cognition; Emergency triage; Ethnographic analysis; Intensive care; Medical errors; Naturalistic decision making; Technological design; Translational cognition

Indexed keywords

DECISION MAKING; DECISION SUPPORT SYSTEMS; HEALTH CARE; INFORMATION TECHNOLOGY; PROBLEM SOLVING;

CLINICAL WORKFLOW; COGNITIVE TASK ANALYSIS; CRITICAL CARE; DISTRIBUTED COGNITION; EMERGENCY TRIAGE; ETHNOGRAPHIC ANALYSIS; INTENSIVE CARE; MEDICAL ERRORS; TECHNOLOGICAL DESIGN; TRANSLATIONAL COGNITION;

COGNITIVE SYSTEMS;

APPLIED RESEARCH; BASIC RESEARCH; CLINICAL PRACTICE; DECISION SUPPORT SYSTEM; EMERGENCY CARE; HOSPITAL CARE; INTENSIVE CARE; OUTPATIENT CARE; PRIORITY JOURNAL; PROBLEM SOLVING; REVIEW;

ARTIFICIAL INTELLIGENCE; COGNITION; CRITICAL CARE; DECISION SUPPORT SYSTEMS, CLINICAL; EMERGENCY MEDICAL SERVICES;

EID: 44649142577     PISSN: 15320464     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.jbi.2008.01.013     Document Type: Review

References (117)

1. Plsek P.E., and Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ 323 (2001) 625-628
2. Plsek P.E., and T W. Complexity, leadership, and management in healthcare organisations. BMJ 323 (2001) 746-749
3. Wilson T., Holt T., and Greenhalgh T. Complexity science: complexity and clinical care. BMJ 323 (2001) 685-688
4. The emergency department as a complex system. Available from: http://necsi.org/cxworld/healthcare.html.
5. Patel V.L., Kaufman D.R., and Arocha J.F. Emerging paradigms of cognition in medical decision-making. J Biomed Inform 35 (2002) 52-75
6. Carlson J.M., and Doyle J. Complexity and robustness. Proc Natl Acad Sci USA 99 (2002) 2538-2545
7. Rasmussen J. Information processing and human-machine interaction: an approach to cognitive engineering (1986), North-Holland, New York
8. Rasmussen J. Risk management in a dynamic society: a modelling problem. Saf Sci 27 (1997) 183-213
9. Cook R.I., and Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care 14 (2005) 130-134
10. Holland J. Hidden order: how adaptation builds complexity (1995), Addison-Wesley, Reading, MA
11. Levin S. Ecosystems and the biosphere as complex adaptive systems. Ecosystems 1 (1998) 431-436
12. In: Greenes R.A. (Ed). Clinical decision support: the road ahead (2007), Elsevier-Academic Press
13. Salas E., and Klein G.A. Linking expertise and naturalistic decision making (2001), Lawrence Erlbaum, Mahwah, NJ
14. Klein G.A., Orasanu J., and Calderwood R. Decision making in action: models and methods (1993), Ablex Publishing, Westport, USA
15. Klein G.A., and Calderwood R. Decision models: some lessons from the field. IEEE Trans Syst Man Cybern B Cybern 21 (1991) 1018-1026
16. Hutchins E. Cognition in the wild (1995), MIT Press, Cambridge, MA
17. Flor N.V., and Hutchins E.L. Analyzing distributed cognition in software teams: a case study of team programming during perfective software maintenance. In: Joenemann-Belliveau J., Moher T.G., and Robertson S.P. (Eds). Empirical studies of programmers (1992), Ablex Publishing
18. Hutchins E. How a cockpit remembers its speed. Cogn Sci 19 (1995) 265-288
19. Hutchins E, Norman DA. Distributed cognition in aviation: a concept paper for NASA (Contract No. NCC 2-591), Department of Cognitive Science, San Diego, University of California; 1988.
20. Norman D.A. Cognition in the head and in the world: an introduction to the special issue on situated action. Cogn Sci 17 (1993) 1-6
21. Norman D.A. Things that make us smart (1993), Addision-Wesley, Reading, MA
22. Zhang J. A distributed representation approach to group problem solving. J Am Soc Inform Sci 49 (1998) 801-809
23. Zhang J., and Norman D.A. Representations in distributed cognitive tasks. Cogn Sci 18 (1994) 87-122
24. Salomon G. No distribution without individuals' cognition: a dynamic interactional view. In: Salomon G. (Ed). Distributed cognition: psychological and educational considerations (1997), Cambridge University Press, Cambridge, MA 111-138
25. Zhang J. The nature of external representations in problem solving. Cogn Sci 21 (1997) 179-217
26. Zhang J. Distributed representation as a principle for the analysis of cockpit information displays. Int J Aviat Psychol 7 (1997) 105-121
27. Norman D.A. Cognitive artifacts. In: Carroll J.M. (Ed). Designing interaction: psychology at the human-computer interface (1991), Cambridge University Press, New York
28. Patel V.L. Individual to collaborative cognition: a paradigm shift?. Artif Intell Med 12 (1998) 93-96
29. Patel V.L., and Arocha J.F. The nature of constraints on collaborative decision-making in health care settings. In: Salas E., and Klein G. (Eds). Linking expertise and naturalistic decision-making (2000), Lawrence Erlbaum, Mahwah, NJ 78-91
30. Wright P.C., Fields R.E., and Harrison M.D. Analyzing human-computer interaction as distributed cognition: the resources model. Hum Comput Interact 15 (2000) 1-41
31. Suchman L.A. Plans and situated action: the problem of human-machine communication (1985), Cambridge University Press, Cambridge
32. Clancey W.J. Situated cognition: on human knowledge and computer representations (1997), Erlbaum, Hillsdale, NJ
33. George J.M. Personality, affect, and behavior in groups. J Appl Psychol 75 (1990) 107-116
34. Bandura A. Social foundations of thoughts and actions: a social cognitive theory (1986), Prentice-Hall, Englewood Cliffs, NJ
35. Wegner D.M. Transactive memory: a contemporary analysis of the group mind. In: Mullen B., and Goethals G.R. (Eds). Theories of group behavior (1987), Springer, New York
36. Woods D.D., and Hollnagel E. Joint cognitive systems: patterns in cognitive systems engineering (2006), CRC Press, Boca Raton, FL
37. Hollnagel E., and Woods D.D. Joint cognitive systems: foundations of cognitive systems engineering (2006), CRC Press, Boca Raton, FL
38. Albolino S., Cook R.I., and O'Conor M. Sensemaking, safety, and cooperative work in the intensive care unit. Cogn Technol Work 9 (2007) 131-137
39. Albolino S., and Cook R. Making sense of risks: a field study in an intensive care unit. In: Tartaglia R., Bagnara S., Bellandi T., and Albolino S. (Eds). Healthcare systems ergonomics and patient safety (2005), Bell, London 208-214
40. Alvarez G., and Coiera E. Interruptive communication patterns in the intensive care unit ward round. Int J Med Inform 74 (2005) 791-796
41. Chisholm C.D., Collison E.K., Nelson D.R., and Cordell W.H. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"?. Acad Emerg Med 7 (2000) 1239-1243
42. Randell R. Medicine and aviation: a review of the comparison. Methods Inf Med 42 (2003) 433-436
43. France D.J., Levin S., Hemphill R., Chen K., Rickard D., Makowski R., et al. Emergency physicians' behaviors and workload in the presence of an electronic whiteboard. Int J Med Inform 74 (2005) 827-837
44. Coiera E. Clinical communication-a new informatics paradigm. In: Proc AMIA Annu Fall Symp; 1996. pp. 17-21.
45. Coiera E., Jayasuria R.A., Hardy J., Bannan A., and Thorpe M. Communication loads on clinical staff in the emergency department. MJA 176 (2002) 415-418
46. Coiera E., and Tombs V. Communication behaviours in a hospital setting: an observational study. BMJ 7132 (1998) 673-676
47. Spencer R, Logan P. Role-based communication patterns within an emergency department setting. In: Proceedings HIC, Melbourne; 2002.
48. Harvey R., Jarrett P.G.P., and K M. Patterns of paging medical interns during night calls at two teaching hospitals. Can Med Assoc J 151 (1994) 307-311
49. Blum N.J., and Lieu T.A. Interrupted care. The effects of paging on pediatric resident activities. Am J Dis Child 146 (1992) 806-808
50. Xiao Y., Lasome C., Moss J., Mackenzie C.F., and Farsi S. Cognitive properties of a whiteboard. In: Prinz W., Jarke M., Rogers Y., Schmidt K., and Wulf V. (Eds). Proceedings of the seventh european conference on computer-supported cooperative work (2001), Kluwer Academic Publishers, Bonn 16-20
51. Xiao Y., Schenkel S., Faraj S., Mackenzie C.F., and Moss J. What whiteboards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med 50 (2007) 387-395
52. Wears R., Perry S., and Wilson S. Emergency department status boards: user-evolved artefacts for inter- and intra-group coordination. Cogn Technol Work 9 (2007) 163-170
53. Coiera E. When conversation is better than computation. J Am Med Inform Assoc 7 (2000) 277-286
54. Parker J., and Coiera E. Improving clinical communication: a view from psychology. J Am Med Inform Assoc 7 (2000) 453-461
55. Toussaint P.J., and Coiera E. Supporting communication in health care. Int J Med Inf 74 (2005) 779-781
56. Patel V.L., Arocha J.F., and Zhang J. Thinking and reasoning in medicine. In: Holyoak K. (Ed). Thinking and reasoning (2005), Cambridge University Press, MA 727-750
57. Patel V.L., Kushniuruk A.W., Yang S., and Yale J.F. Impact of a computerized patient record system on medical data collection, organization and reasoning. J Am Med Inform Assoc 7 (2000) 569-585
58. Gawande A.A., and Bates D.W. The use of information technology in improving medical performance. Part III. Patient-support tools. Med Gen Med 2 (2000) E12
59. Vicente K.J. Ecological interface design: Progress and challenges. Hum Factors 44 (2002) 62-78
60. Vicente K.J., Moray N., Lee J.D., and Rasmussen J. Evaluation of a Rankine cycle display for nuclear power plant monitoring and diagnosis. Hum Factors 38 (1996) 506-521
61. Wilson J.R., and Corlett E.N. Evaluation of human work: a practical ergonomics methodology (1995), Taylor & Francis, Bristol, PA
62. Bates D.W., Cohen M., Leape L.L., Overhage J.M., Shabot M.M., and Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 8 (2001) 299-308
63. Cook R.I., and Woods D.D. Operating at the 'sharp end': the complexity of human error. In: Bogner S. (Ed). Human error in medicine (1994), Erlbaum, Mahwah, NJ 255-310
64. Kuperman G., Bobb A., Payne T., Avery A.J., Gandhi T.K., Burns G., et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc 14 (2007) 29-40
65. Weir C.R., Hicken B., Nebeker J., Campo R., Drews F., and LeBar B. Cognitive task analysis of information management strategies in a computerized provider order entry environment. J Am Med Inform Assoc 14 (2007) 65-75
66. Cook R.I., Potter S.S., Woods D.D., and McDonald J.S. Evaluating the human engineering of microprocessor-controlled operating room devices. J Clin Monit 7 (1991) 217-226
67. Gray W.D. The nature and processing of errors in interactive behavior. Cogn Sci 24 (2000) 205-248
68. Adams M.J., Tenney Y.J., and Pew R.W. Situation awareness and the cognitive management of complex systems. Hum Factors 37 (1995) 85-104
69. Wachter S.B., Agutter J., Syroid N., Drews F., Weinger M.B., and Westenskow D. The employment of an iterative design process to develop a pulmonary graphical display. J Am Med Inform Assoc 10 (2003) 363-372
70. Horsky J., Kaufman D.R., Oppenheim M.I., and Patel V.L. A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. J Biomed Inform 36 (2003) 4-22
71. MEDWATCH-the FDA safety information and adverse event reporting program. Available from: http://www.accessdata.fda.gov/scripts/medwatch.
72. Dovey S.M., Meyers D.S., Phillips Jr. R.L., Green L.A., Fryer G.E., Galliher J.M., et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care 11 (2002) 233-238
73. Battles J.B., and Shea C.E. A system of analyzing medical errors to improve GME curricula and programs. Acad Med 76 (2001) 125-133
74. Runciman W.B., Helps S.C., Sexton E.J., and Malpass A. A classification for incidents and accidents in the health-care system. J Qual Clin Pract 18 (1998) 199-211
75. Benner P., Sheets V., Uris P., Malloch K., Schwed K., and Jamison D. Individual, practice, and system causes of errors in nursing: a taxonomy. J Nurs Adm 32 (2002) 509-523
76. Chang A., Schyve P.M., Croteau R.J., O'Leary D.S., and Loeb J.M. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care 17 (2005) 95-105
77. Elder N.C., and Dovey S.M. Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract 51 (2002) 927-932
78. Sentinel event statistics, March 31, 2005. Available from: http://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+ev ent+statistics.htm.
79. Taxonomy of medication errors. Available from: http://www.nccmerp.org/pdf/taxo2001-07-31.pdf.
80. Zhang J., Patel V.L., Johnson T.R., and Shortliffe E.H. A cognitive taxonomy of medical errors. J Biomed Inform 37 (2004) 193-204
81. Norman D.A. The psychology of everyday things (1988), Basic Books, New York, NY
82. Norman D.A., and Draper S.W. User centered system design: new perspectives on human-computer interaction (1986), Lawrence Erlbaum, Hillsdale, NJ
83. Reason J. Human error (1990), Cambridge University Press, Cambridge, England
84. Zhang J., and Norman D.A. Representations in distributed cognitive tasks. Cogn Sci 18 (1994) 87-122
85. Zhang J., and Patel V.L. Distributed cognition, representation, and affordance. Cogn Pragmatics 14 (2006) 333-341
86. Ackerman M.S., and Halverson C.A. Organizational memory as objects, processes, and trajectories: an examination of organizational memory in use. Comput Support Coop Work 13 (2004) 155-189
87. Nunamaker J., Dennis A., Valacich J., Vogel D., and George J. Electronic meeting systems to support group work. Commun ACM 34 (1991) 40-61
88. Patel V., Arocha J., and Kaufman D. Diagnostic reasoning and medical expertise. Psychol Learn Motiv: Adv Res Theory 31 (1994) 187-252
89. Te'eni D. Review: a cognitive-affective model of organizational communication for designing IT. MIS Quarter 25 (2001) 251-312
90. Patel V.L., Kaufman D.R., and Magder S.A. The acquisition of medical expertise in complex dynamic environments. In: Ericsson A. (Ed). The road to excellence: the acquisition of expert performance in the arts and sciences, sports, and games (1996), Lawrence Erlbaum Associates, Mahwah, NJ 369
91. Patel V.L., Kaufman D.R., Allen V.G., Shortliffe E.H., Cimino J.J., and Greenes R.A. Toward a framework for computer-mediated collaborative design in medical informatics. Methods Inf Med 38 (1999) 158-176
92. Malhotra S., Jordan D., Shortliffe E., and Patel V.L. Workflow modeling in critical care: piecing together your own puzzle. J Biomed Inform 40 (2007) 81-92
93. Hollnagel E., Woods D., and Levenson N. Resilience engineering: concepts and precepts (2006), Ashgate, England
94. Ball L.J., and Ormerod T.C. Putting ethnography to work: the case for a cognitive ethnography of design. Int J Hum Comput Stud 53 (2000) 147-168
95. Ericsson K.A., and Simon H.A. Protocol analysis: verbal reports as data (1993), MIT Press, Cambridge, MA
96. Shortliffe E., and Patel V. Generation and formulation of knowledge: human-intensive techniques. In: Greenes R.A. (Ed). Clinical decision support (2007), Elsevier, The Road Ahead 207-226
97. Schraagen J.M., Chipman S.F., and Shalin V.L. Cognitive task analysis (2000), Lawrence Erlbaum Associates, Mahwah, NJ
98. Patel V.L., Arocha J.F., and Kaufman D.R. A primer on aspects of cognition for medical informatics. J Am Med Inform Assoc 8 (2001) 324-343
99. Patel V.L., and Kaufman D.R. Cognitive science and biomedical informatics. In: Shortliffe E.H., and Cimino J.J. (Eds). Biomedical informatics: computer applications in health care and biomedicine. 3rd ed. (2006), Springer-Verlag, New York 133-185
100. Card S.K., Moran T.P., and Newell A. The psychology of human-computer interaction (1983), Erlbaum, Hillsdale, NJ
101. Kieras D.E. GOMS models for task analysis. In: Diaper D., and Stanton N. (Eds). Handbook of task analysis for human-computer interaction (2003), Lawrence Erlbaum, London 83-116
102. Mokkarala P, Brixey JJ, Johnson TR, Patel VL, Zhang J, Turley JP. Development of comprehensive medical error ontology. In: AHRQ: advances in patient safety: new directions and alternative approaches, in press.
103. Gong Y, Zhu M, Li J, Turley JP, Zhang J. Communication ontology for medical errors. In: Proceedings of MedInfo; 2007.
104. Horsky J, Gutnik L, Patel VL. Technology for emergency care: cognitive and workflow considerations. In: Proc AMIA Annu Fall Symp; 2006. pp. 344-48.
105. Hakimzada A.F., Green R.A., Sayan O.R., Zhang J., and Patel V.L. The nature and occurrence of registration errors in the emergency department. Int J Med Inform 77 (2008) 169-175
106. Laxmisan A., Hakimzada F., Sayan O.R., Green R.A., Zhang J., and Patel V.L. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform 40 (2007) 801-811
107. Brixey J.J., Robinson D.J., Johnson C.W., Johnson T.R., Turley J.P., Patel V.L., et al. Towards a hybrid method to categorize interruptions and activities in healthcare. Int J Med Inform 40 (2007) 812-820
108. Brixey JJ, Tang Z, Robinson DJ, Johnson CW, Johnson TR, Turley JP, et al. Interruptions in a level one trauma center: a case study. Int J Med Inform 2007. doi:10.1016/j.ijmedinf.2007.04.006.
109. Brixey J.J., Robinson D.J., Johnson C.W., Johnson T.R., Turley J.P., and Zhang J. A concept analysis of the phenomenon interruption. Adv Nurs Sci 30 (2007) E26-E42
110. Cohen T., Blatter B., Almeida C., Shortliffe E., and Patel V. Distributed cognition in the psychiatric emergency department: a cognitive blueprint of a collaboration in context. Artif Intell Med 37 (2006) 73-83
111. Horsky J., Kuperman G.J., and Patel V.L. Comprehensive analysis of a medication dosing error related to CPOE. J Am Med Inform Assoc 12 (2005) 377-382
112. Ash J.S., Berg M., and Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 11 (2004) 104-112
113. Sharda P., Das A.K., Cohen T.A., and Patel V. Customizing clinical narratives for the electronic medical record interface using cognitive methods. Int J Med Inform 75 (2006) 346-368
114. Kintsch W. The representation of meaning in memory (1974), Lawrence Erlbaum, Hillsdale, NJ
115. van Dijk T., and Kintsch W. Strategies of discourse comprehension (1983), Academic Press, New York
116. Arocha J.F., Wang D., and Patel V.L. Identifying reasoning strategies in medical decision making: a methodological guide. J Biomed Inform 38 (2005) 154-171
117. Kushniruk A.W., and Patel V.L. Cognitive and usability engineering methods for the evaluation of clinical information systems. J Biomed Inform 37 (2004) 56-76