Biomedical subjects

Vimla L Patel

Publications and source records attributed to Vimla L Patel.

At least 37 records · Page 2Linked to original sources

PubMed2005

Medical decision making: a selective review for child psychiatrists and psychologists.

Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent psychiatrists using theories and methods from cognitive and social sciences in order to design effective interventions to improve practice and education. This paper selectively reviews the decision-making literature, including recent studies on naturalistic decision making, novice-expert differences, and the role of technology on decision making and cognition. We also provide examples from other areas of medicine and discuss their implications for child psychiatry.

Adolescent↗

PubMed2005

Knowledge integration and reasoning as a function of instruction in a hybrid medical curriculum.

This study investigates the effect of curricular change on knowledge integration and reasoning processes during problem-solving by medical students. The curricular change involved the introduction of problem-based, small group tutorials into a conventional health science curriculum (CC). Students at three levels of training were asked to provide diagnostic explanations of two clinical cases, both before (spontaneous) and after (primed) being exposed to basic science information relevant to the clinical problems. Data were analyzed using techniques of propositional and semantic analysis. Based on theories of instruction and cognition, we expected that the instructional changes would facilitate knowledge integration and influence the reasoning patterns of the students. The results show that students generated fewer inferences and used more information from the basic science text (text-based) to explain the clinical problems. However, they generated a greater number of elaborations during explanations using a mixture of data-driven and hypothesis-driven strategies. The spontaneous and primed problem-solving conditions produced more hypothesis-driven and data-driven strategies, respectively, as would be expected in a hybrid curriculum. We conclude that a) problem-based, small group tutorials facilitate integration of clinical and biomedical knowledge through the use of elaborations and hypothesis-driven strategies, and b) aspects of problem-based learning can be successfully integrated into traditional curricula.

Clinical Competence↗

PubMed2005

When you come to a fork in the road, take it: strategy selection in order entry.

This study investigates how CPOE system users choose data input strategies for entering clinical orders. Complex systems often allow more than one way to complete a task. However, the appropriate entry strategy in the context of a specific clinical workflow situation may not be apparent to users. We have conducted a cognitive analysis of user interaction strategies for entering IV injection orders using a commercial CPOE system. We characterized the set of available information resources in the system interface and in the users' memory, and evaluated how effectively the application supported decision-making processes. Seven internal medicine residents participated in an experiment entering IV heparin orders to manage anticoagulation therapy. The analysis showed that efficiency was contingent upon high level of procedural and conceptual system knowledge. CPOE interface design needs to conform to decision-making and workflow processes if the technology is to become an effective clinical tool.

Anticoagulants↗

PubMed2005

Workflow modeling in critical care: piecing your own puzzle.

The intensive care unit (ICU) is an instance of a very dynamic health care setting where critically ill patients are being managed. It comprises of an extensive amount of communication amongst the role players, use of numerous information systems and operation of devices for monitoring and treatment purposes. The purpose of this research is to study error evolution and management within this environment. Ethnographic observation and semi-structured interview data were used to build individual pieces of the workflow dependent on the individual and the activity concerned. These pieces of the ICU workflow were used to develop a generalizable cognitive model to represent the intricate workflow in health care settings. The proposed model can be used to identify and characterize medical errors and also used for error prediction in practice.

Cognition↗

PubMed2005

Risky decisions despite counter evidence: modeling a culture of safer sexual practices.

To create a culture of safe practices, we need to understand how and under what conditions the public makes risky decisions about their health. Because risky sexual behaviors are known to be common in young adults, we investigated their decision making regarding sexual activities that could incur a high risk of HIV infection. Sixty young urban adults maintained journals for two weeks and were interviewed regarding condom use and sexual history. We characterized four patterns of condom use behavior: consistent (35.0%), inconsistent (16.7%), consistent to inconsistent (35.0%), and inconsistent to consistent (13.3%). Directionality of reasoning was analyzed in the explanations provided for condom use decisions. The consistent and inconsistent patterns were associated with data-driven heuristic reasoning, where behavior becomes automated and is associated with a high level of confidence in one's judgment. In the other two patterns, the shift in behavior was due to a significant event that influenced a change in directionality to explanation-based reasoning. We discuss these results within the framework of identifying potentially high-risk groups for whom customized intervention strategies (such as computer-based educational programs) can be used to reduce risk, thereby creating a culture of safer sexual practices.

Adult↗

PubMed2005

Cognitive neuroeconomics: new solutions to old problems.

The current models of decision-making are limited in their ability to provide a comprehensive understanding of the field. We propose the cognitive neuroeconomics model, which, we have used to better understand the process of decision-making in the domain of mental health, namely, young adults' risky sexual behavior. This model can have far reaching implications in developing adequate decision support tools.

Adult↗

PubMed2004

Decisions about critical events in device-related scenarios as a function of expertise.

This paper presents the perspectives of personnel involved in decision-making about devices in critical care. We use the concept of "sharp and blunt ends" of practice to describe the performance of health care professionals. The "sharp end" is physically and temporally close to the system; the "blunt end" is removed from the system in time and space and yet affects the system through indirect influence on the sharp end. In this study, the sharp end is represented by the clinicians (nurses and doctors) and the blunt end by the administrators and biomedical engineers. These subjects represent the professionals involved in the decision-making process for purchasing biomedical equipment for the hospital. They were asked to "think aloud" while evaluating three error scenarios based on real events. The responses were recorded and transcribed for analysis. The results show differences in interpretation of critical events as a function of professional expertise. The clinicians (sharp-end practitioners) focused on clinical and human aspect of errors while the biomedical engineers focused on device-related errors. The administrators focused on documentation and training. These different interpretations mean that the problems are represented differently by these groups of subjects, and these representations result in variable decisions about devices. These results are discussed within a systems approach framework to help us assess the completeness of the problem representations of the subjects, their awareness of critical events, and how these events would collectively contribute to the occurrence of error.

Decision Making↗

PubMed2004

Heuristic evaluation of infusion pumps: implications for patient safety in Intensive Care Units.

OBJECTIVE: The goal of this research was to use a heuristic evaluation methodology to uncover design and interface deficiencies of infusion pumps that are currently in use in Intensive Care Units (ICUs). Because these infusion systems cannot be readily replaced due to lease agreements and large-scale institutional purchasing procedures, we argue that it is essential to systematically identify the existing usability problems so that the possible causes of errors can be better understood, passed on to the end-users (e.g., critical care nurses), and used to make policy recommendations. DESIGN: Four raters conducted the heuristic evaluation of the three-channel infusion pump interface. Three raters had a cognitive science background as well as experience with the heuristic evaluation methodology. The fourth rater was a veteran critical care nurse who had extensive experience operating the pumps. The usability experts and the domain expert independently evaluated the user interface and physical design of the infusion pump and generated a list of heuristic violations based upon a set of 14 heuristics developed in previous research. The lists were compiled and then rated on the severity of the violation. RESULTS: From 14 usability heuristics considered in this evaluation of the Infusion Pump, there were 231 violations. Two heuristics, "Consistency" and "Language", were found to have the most violations. The one with fewest violations was "Document". While some heuristic evaluation categories had more violations than others, the most severe ones were not confined to one type. The Primary interface location (e.g., where loading the pump, changing doses, and confirming drug settings takes place) had the most occurrences of heuristic violations. CONCLUSION: We believe that the Heuristic Evaluation methodology provides a simple and cost-effective approach to discovering medical device deficiencies that affect a patient's general well being. While this methodology provides information for the infusion pump designs of the future, it also identifies important insights concerning equipment that is currently in use in critical care environments.

Humans↗

PubMed2004

Cognitive and usability engineering methods for the evaluation of clinical information systems.

Increasingly healthcare policy and decision makers are demanding evidence to justify investments in health information systems. This demand requires an adequate evaluation of these systems. A wide variety of approaches and methodologies have been applied in assessing the impact of information systems in health care, ranging from controlled clinical trials to use of questionnaires and interviews with users. In this paper we describe methodological approaches which we have applied and refined for the past 10 years for the evaluation of health information systems. The approaches are strongly rooted in theories and methods from cognitive science and the emerging field of usability engineering. The focus is on assessing human computer interaction and in particular, the usability of computer systems in both laboratory and naturalistic settings. The methods described can be a part of the formative evaluation of systems during their iterative development, and can also complement more traditional assessment methods used in summative system evaluation of completed systems. The paper provides a review of the general area of systems evaluation with the motivation and rationale for methodological approaches underlying usability engineering and cognitive task analysis as applied to health information systems. This is followed by a detailed description of the methods we have applied in a variety of settings in conducting usability testing and usability inspection of systems such as computer-based patient records. Emerging trends in the evaluation of complex information systems are discussed.

Biomedical Engineering↗

PubMed2004

GLIF3: a representation format for sharable computer-interpretable clinical practice guidelines.

The Guideline Interchange Format (GLIF) is a model for representation of sharable computer-interpretable guidelines. The current version of GLIF (GLIF3) is a substantial update and enhancement of the model since the previous version (GLIF2). GLIF3 enables encoding of a guideline at three levels: a conceptual flowchart, a computable specification that can be verified for logical consistency and completeness, and an implementable specification that is intended to be incorporated into particular institutional information systems. The representation has been tested on a wide variety of guidelines that are typical of the range of guidelines in clinical use. It builds upon GLIF2 by adding several constructs that enable interpretation of encoded guidelines in computer-based decision-support systems. GLIF3 leverages standards being developed in Health Level 7 in order to allow integration of guidelines with clinical information systems. The GLIF3 specification consists of an extensible object-oriented model and a structured syntax based on the resource description framework (RDF). Empirical validation of the ability to generate appropriate recommendations using GLIF3 has been tested by executing encoded guidelines against actual patient data. GLIF3 is accordingly ready for broader experimentation and prototype use by organizations that wish to evaluate its ability to capture the logic of clinical guidelines, to implement them in clinical systems, and thereby to provide integrated decision support to assist clinicians.

Artificial Intelligence↗

PubMed2004

A cognitive taxonomy of medical errors.

OBJECTIVE: Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology. DESIGN: Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems. MEASUREMENTS: Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error. RESULTS: The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level. CONCLUSION: Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies.

Cognition↗

PubMed2004

Design and implementation of the GLIF3 guideline execution engine.

We have developed the GLIF3 Guideline Execution Engine (GLEE) as a tool for executing guidelines encoded in the GLIF3 format. In addition to serving as an interface to the GLIF3 guideline representation model to support the specified functions, GLEE provides defined interfaces to electronic medical records (EMRs) and other clinical applications to facilitate its integration with the clinical information system at a local institution. The execution model of GLEE takes the "system suggests, user controls" approach. A tracing system is used to record an individual patient's state when a guideline is applied to that patient. GLEE can also support an event-driven execution model once it is linked to the clinical event monitor in a local environment. Evaluation has shown that GLEE can be used effectively for proper execution of guidelines encoded in the GLIF3 format. When using it to execute each guideline in the evaluation, GLEE's performance duplicated that of the reference systems implementing the same guideline but taking different approaches. The execution flexibility and generality provided by GLEE, and its integration with a local environment, need to be further evaluated in clinical settings. Integration of GLEE with a specific event-monitoring and order-entry environment is the next step of our work to demonstrate its use for clinical decision support. Potential uses of GLEE also include quality assurance, guideline development, and medical education.

Database Management Systems↗

PubMed2004

Public awareness about depression: the effectiveness of a patient guideline.

OBJECTIVE: To evaluate the effectiveness of a patient guideline for educating the public in the recognition and treatment of depression. METHOD: Lay subjects were interviewed regarding their knowledge and beliefs about depression through the use of a semi-structured questionnaire. They were asked to "think aloud" while evaluating two clinical scenarios about depression, both with and without the use of a patient guideline. All interviews were audio taped, transcribed, and analyzed for subjects' thought processes and accuracy of responses in the presence and absence of the guideline. RESULTS: Subjects with no prior history of depression identified fewer symptoms of depression listed in the patient guideline than did subjects with a history of depression. In the absence of the guideline, only 50% and 38% of subjects provided accurate diagnosis of depression for the simple and complex problems respectively. In the presence of the guideline, 92% and 83% of subjects provided an accurate diagnosis of depression for the simple and complex problems respectively. CONCLUSIONS: Lay people have a limited knowledge of depression and its treatment, and are less able to recognize symptoms of depression without the help of patient guideline. The guideline primes lay people to better recognize these symptoms and their relationship to diagnosis. This level of understanding about depression by lay people will facilitate improved communication between physicians and their patients.

Adult↗

PubMed2004

Practical considerations for exploiting the World Wide Web to create infobuttons.

BACKGROUND: We are studying ways to provide automated, context-specific links (called "infobuttons") between clinical information systems (CIS) and other information resources available on the World Wide Web. As part of this work, we observed the information needs that arose when clinicians used a CIS and we classified those needs into generic questions. We then sought general methods for accessing information resources to answer the questions. METHODS: For each generic question, we identified a satisfactory resource and then developed a method for retrieving from it the information relevant to the question. We then studied these methods to characterize them into general approaches. RESULTS: We identified six general approaches and describe them in detail. These approaches range in complexity from simple, hard-coded links to intelligent agents and calculators. CONCLUSION: Web-based information resources can be exploited using a relatively small number of methods, although the specific methods require custom solutions. Standard methods for accessing Web-based resources would simplify the task of linking to CISs.

Decision Support Systems, Clinical↗

PubMed2004

Computer-based drug ordering: evaluation of interaction with a decision-support system.

Provider order entry systems (POE) often incorporate active decision-support component for drug dosing. The efficacy of automated alerts that suggest dose amounts to the clinician in real time depends in part on how well they are timed to fit into the decision process and on their representational structure. We have conducted a cognitive evaluation of an interaction with a POE system that offered active decision support for heparin dosing with the goal of characterizing its effectiveness and opportunities for error. Two researchers completed a cognitive walk-through of an ordering task based on a clinical scenario. In addition, seven clinicians were asked to enter a set of orders in an experiment using the same scenario. The analysis revealed that users without a solid conceptual knowledge of the ordering system followed patterns of inefficient interactive behavior resulting in delays and some errors. Physicians often did not take full advantage of automatic dose computation provided by a decision support component and used it largely as reference. The calculated dose was not perceptually salient in the generated alert and required users to engage in meaning interpretation of the displayed information. Better visual presentation of the alert message would likely result in faster and less cognitively demanding interaction.

Anticoagulants↗

PubMed2004

Institutional decision-making for medical device purchasing: evaluating patient safety.

Many medical devices that are currently on the market are sub-optimal for human use, thus contributing to medical errors. This places significant responsibility for device selection on purchasers. This paper describes a retrospective analysis of decision making processes for infusion pump selection in three large hospitals and focuses on patient safety. Through a series of detailed interviews and a study of relevant documentation we characterized the nature of the decision-making, patterns of communication, and the roles of different participants. Findings suggest that success of the process is related to effective communication among participants with different expertise and adequate device usability assessment during the process. The paper discusses how information technology could provide support to distributed institutional decision making.

Communication↗

PubMed2004

Relationship between small group problem-solving activity and lectures in health science curricula.

Components of problem-based education, such as small group teaching, are being implemented in diverse health curricula. Implementation, however, is often motivated by the intuitive appeal of many problem-based learning components, when what is needed is the detailed examination of how these components support students' integration of knowledge as well as continuity of their learning experiences. This study presents an investigation of the relationship between lecture and small group teaching (SGT) in a medical curriculum. Four problem-oriented SGT sessions representing diverse topics in the first-year curriculum and their corresponding lectures were videotaped and analyzed using techniques of concept mapping, where the broad concepts from the lectures were identified and matched to the case-specific concepts in the small group sessions. The results show that lectures function as an anchor for the students' discussion of issues relevant to clinical problem-solving and interventions in small group sessions. These discussions extended to contextual aspects of clinical practice that were not dealt with in the lectures, such as ethical/cultural issues around the treatment of patients. Furthermore, small group environments were found to promote discussions that allowed the integration of information from different sources and encompassed concepts across a number of disciplines. These results suggest that carefully designed small group sessions serve the purposes of 1) illustrating broader concepts in lectures to case-specific, clinically relevant problem-solving and 2) promoting knowledge integration from diverse sources of information. The implications of these results for learning and reasoning in health science curricula are discussed.

Cardiology↗

PubMed2003

The InterMed approach to sharable computer-interpretable guidelines: a review.

InterMed is a collaboration among research groups from Stanford, Harvard, and Columbia Universities. The primary goal of InterMed has been to develop a sharable language that could serve as a standard for modeling computer-interpretable guidelines (CIGs). This language, called GuideLine Interchange Format (GLIF), has been developed in a collaborative manner and in an open process that has welcomed input from the larger community. The goals and experiences of the InterMed project and lessons that the authors have learned may contribute to the work of other researchers who are developing medical knowledge-based tools. The lessons described include (1) a work process for multi-institutional research and development that considers different viewpoints, (2) an evolutionary lifecycle process for developing medical knowledge representation formats, (3) the role of cognitive methodology to evaluate and assist in the evolutionary development process, (4) development of an architecture and (5) design principles for sharable medical knowledge representation formats, and (6) a process for standardization of a CIG modeling language.

Computer Systems↗