Vimla L. Patel

Position paper: The coming of age of artificial intelligence in medicine

This paper is based on a panel discussion held at the Artificial Intelligence in Medicine Europe (AIME) conference in Amsterdam, The Netherlands, in July 2007. It had been more than 15 years since Edward Shortliffe gave a talk at AIME in which he characterized artificial intelligence (AI) in medicine as being in its adolescence (Shortliffe EH. The adolescence of AI in medicine: will the field come of age in the 90s? Artificial Intelligence in Medicine 1993;5:93-106). In this article, the discussants reflect on medical AI research during the subsequent years and characterize the maturity and influence that has been achieved to date. Participants focus on their personal areas of expertise, ranging from clinical decision-making, reasoning under uncertainty, and knowledge representation to systems integration, translational bioinformatics, and cognitive issues in both the modeling of expertise and the creation of acceptable systems.

Interruptions in a Level One Trauma Center: A Case Study

BACKGROUNDnThe emergency department has been characterized as interrupt-driven. Government agencies and patient safety organizations recognize that interruptions contribute to medical errors. The purpose of this study was to observe, record, and contextualize activities and interruptions experienced by physicians and Registered Nurses (RNs) working in a Level One Trauma Center.nnnMETHODSnnnnDESIGNnA case study that relied on an ethnographic study design using the shadowing method.nnnSUBJECTSnA convenience sample of physicians and RNs, each with at least 6 months of experience in the Emergency Department (ED), were asked to participate. In these kinds of detailed qualitative investigations, it is quite common to have a small sample size. Ethical approval: Approval was obtained from institutional ethic committees prior to initiating the study. Community consent was obtained from the ED staff through in-service education.nnnSETTINGnAll observations were made in the trauma section of the ED of a tertiary teaching hospital. The hospital is situated in a major medical center in the Gulf Coast region of the United States of America (USA).nnnFINDINGSnFive attending ED physicians were observed for a total of 29h, 31min. Eight RNs were shadowed for a total of 40 h, 9min. Interruptions and activities were categorized using the Hybrid Method to Categorize Interruptions and Activities (HyMCIA). Registered Nurses received slightly more interruptions per hour than physicians. People, pagers, and telephones were identified as mediums through which interruptions were delivered. The physical environment was found to contribute to interruptions in workflow because of physical design and when supplies were not available. Physicians and RNs usually returned to the original, interrupted activity more often than leaving the activity unfinished.nnnCONCLUSIONnThis research provides an enhanced understanding of interruptions in workflow in the ED, the identification of work constraints, and the need to develop interventions to manage interruptions. It is crucial that interruptions be delivered in such a way that there is minimal negative impact on performance. The significance and importance of the interruption must always be weighed against the negative impact that it has on smooth, efficient workflow.

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

The dynamic and distributed work environment in critical care requires a high level of collaboration among clinical team members and a sophisticated task coordination system to deliver safe, timely and effective care. A complex cognitive system underlies the decision-making process in such cooperative workplaces. This methodological review paper addresses the issues of translating cognitive research to clinical practice with a specific focus on decision-making in critical care, and the role of information and communication technology to aid in such decisions. Examples are drawn from studies of critical care in our own research laboratories. Critical care, in this paper, includes both intensive (inpatient) and emergency (outpatient) care. We define translational cognition as the research on basic and applied cognitive issues that contribute to our understanding of how information is stored, retrieved and used for problem-solving and decision-making. The methods and findings are discussed in the context of constraints on decision-making in real-world complex environments and implications for supporting the design and evaluation of decision support tools for critical care health providers.

Methodological Review: 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.

Towards effective evaluation and reform in medical education: a cognitive and learning sciences perspective

Health professions education is dealing with major transformations in light of the changing nature of the health care delivery system, including the use of technology for “just in time” delivery of care, evidence-based practice, personalized medical care and learning, as health professionals strive to integrate biomedical advances and clinical practice. This has forced the medical education community to reassess the current teaching and learning practices and more importantly, the evaluation of the medical education process. There have been recent advances in cognitive and learning sciences theories, some of which can inform medical educators about best teaching and learning practices and their impact on the evaluation process. An understanding of these theories provides a sound rationale for choosing specific instructional strategies and choosing evaluation measures that assess the curricular objectives. The review begins with an overview of evaluation and assessment in education, followed by an overview of major theories from the cognitive and learning sciences. Next, the role of cognitive and learning sciences theories in informing the process of medical education evaluation is discussed, including its impact on student learning, performance and professional competence, as well as recommendations for reform of medical curricula based on such theories. The paper continues with the elaboration of current trends in health sciences education, particularly medical education, and available evidence for the impact on student learning and performance as well as areas where more research is needed.

Towards a hybrid method to categorize interruptions and activities in healthcare

OBJECTIVEnInterruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general.nnnMETHODnThe hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory.nnnRESULTSnThe categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case.nnnCONCLUSIONSnFindings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

New perspectives on error in critical care.

Purpose of reviewDespite unprecedented attention on the issue of medical error over the last 8 years, there is little evidence of widely available improvements in patient safety. The present review addresses some alternative approaches to the study of human error, and their implications for the characterization of medical error. Recent findingsThe complex nature of healthcare work has been proposed as a primary barrier to the implementation of effective safety measures. Approaches to error, based on individual accountability, cannot address this complexity. Strategies to eradicate error fail to appreciate that error detection and recovery are integral to the function of complex cognitive systems. Through investigation of the emergence of and recovery from error, one can identify new approaches for error management. SummaryThe present review discusses contemporary approaches to error that are able to address the complex nature of critical care work. Instead of producing situation-specific ‘quick fixes’, they are more likely to reveal generalizable mechanisms of error that can support widely applicable solutions.

Toward automated workflow analysis and visualization in clinical environments

Lapses in patient safety have been linked to unexpected perturbations in clinical workflow. The effectiveness of workflow analysis becomes critical to understanding the impact of these perturbations on patient outcome. The typical methods used for workflow analysis, such as ethnographic observations and interviewing, are limited in their ability to capture activities from different perspectives simultaneously. This limitation, coupled with the complexity and dynamic nature of clinical environments makes understanding the nuances of clinical workflow difficult. The methods proposed in this research aim to provide a quantitative means of capturing and analyzing workflow. The approach taken utilizes recordings of motion and location of clinical teams that are gathered using radio identification tags and observations. This data is used to model activities in critical care environments. The detected activities can then be replayed in 3D virtual reality environments for further analysis and training. Using this approach, the proposed system augments existing methods of workflow analysis, allowing for capture of workflow in complex and dynamic environments. The system was tested with a set of 15 simulated clinical activities that when combined represent workflow in trauma units. A mean recognition rate of 87.5% was obtained in automatically recognizing the activities.

The nature and occurrence of registration errors in the emergency department.

Research into the nature and occurrence of medical errors has shown that these often result from a combination of factors that lead to the breakdown of workflow. Nowhere is this more critical than in the emergency department (ED), where the focus of clinical decisions is on the timely evaluation and stabilization of patients. This paper reports on the nature of errors and their implications for patient safety in an adult ED, using methods of ethnographic observation, interviews, and think-aloud protocols. Data were analyzed using modified grounded theory, which refers to a theory developed inductively from a body of data. Analysis revealed four classes of errors, relating to errors of misidentification, ranging from multiple medical record numbers, wrong patient identification or address, and in one case, switching of one patients identification information with those of another. Further analysis traced the root of the errors to ED registration. These results indicate that the nature of errors in the emergency department are complex, multi-layered and result from an intertwined web of activity, in which stress in the work environment, high patient volume and the tendency to adopt shortcuts play a significant role. The need for information technology (IT) solutions to these problems as well as the impact of alternative policies is discussed.

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.