![References
• Croskerry P. The importance of cognitive errors in diagnosis and
strategies to minimize them. Acad Med 2003; 78: 775-780.
• Groopman J. How doctors think. Boston: Houghton Mifflin Company;
2007.
• Mayer R. Nine Ways to Reduce Cognitive Load in Multimedia Learning
EDUCATIONAL PSYCHOLOGIST 2003, 38(1), 43–52
• Daniel Kahneman. Thinking, fast and slow; New York : Farrar, Straus
and Giroux, [2011]](https://image.slidesharecdn.com/cognitiveloadtheory00000003-151005175424-lva1-app6892/85/Intrinsic-Encounter-Cognitive-Load-Theory-42-320.jpg)
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Intrinsic Encounter - Cognitive Load Theory
- 1. Cognitive Load Theory: Why using your EHR is so painful and how to fix it Michael Zimmerman, MD Temescal Creek Medicine
- 2. A moment of clarity S30.201A- Contusion of unspecified external genital organ, male, related to an altercation with a superhero, initial encounter
- 6. Family History Social History Surgical History Problem List Data Risk Factors Medication Care Team
- 7. Got Cognitive Load? Do you feel… Tired Overwhelmed Burned Out Disengaged Rushed Short Temper Lack of enthusiasm Ask you doctor…
- 8. •Cognitive Load is the aggregate mental effort required in problem solving and learning. Working Memory Working Memory is the space you have to do that work. It is finite and fixed.
- 9. Working Memory Working Memory Problem Solving->Learning The Problem or Task 1. Novel Information is Collected and Processed 1. Auditory 2. Visual 24 divided by 3 24 divided by 3
- 10. Working Memory Working Memory Problem Solving->Learning The Problem or Task 1. Novel Information is Collected and Processed 1. Auditory 2. Visual 24 divided by 3 2. Interpretation and consideration of information in context of existing knowledge schemas. (Long Term Memory) Concepts of division and multiplication; 24/6 = 4 Here’s what I already know… ÷ X 24/6 24 divided by 3
- 11. Working Memory Problem Solving->Learning The Problem or Task 1. Novel Information is Collected and Processed 1. Auditory 2. Visual 24 divided by 3 2. Interpretation and consideration of information in context of existing knowledge schemas. (Long Term Memory) 3. Build and retention of new knowledge based on the problem solving experience. ÷ X 24/6 24 /3 24 divided by 3 24/3=8 24 divided by 3
- 12. Cognitive Load is the aggregate mental effort required in problem solving and learning. Intrinsic Cognitive Load The inherent complexity of the task. Interactivity of elements. 2+2 18 + 37 879834+79275 Complexity 0- Interactivity 0- Intrinsic Cognitive Load Minimal Moderate Heavy Medical Problem Solving? = Intrinsic Load + Extraneous Load + Germaine Load
- 13. Extraneous Cognitive Load manner in which information is presented to solver/learner it is imposed by mental activities that can have a negative effect on learning if not designed appropriately. Extraneous load can interfere with the construction or automation of schemas. a round plane figure whose boundary consists of points equidistant from a fixed point. Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load
- 14. What’s Missing?
- 15. “Germaine” Cognitive Load- Learning Load imposed by constructing new schemas and automating them…Learning! This is germane cognitive load. Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load
- 16. Intrinsic(Task) Learning Extrinsic (presentation) Task Completed Learned some new things Working Memory >= Cognitive Load Working MemoryAggregate Cognitive Load
- 17. Intrinsic(Task) Learning Extrinsic (Presentation) Intrinsic(Task) Learning Extrinsic (presentation) Task Completed Learned some new things Working Memory >= Cognitive Load Working Memory < Cognitive Load Choices… 1. Accept errors/ incomplete solutions 2. Decrease Extrinsic Cognitive Load 3. “Shrink” the Task 4. Forgo new knowledge learning Working Memory What now?
- 19. Intrinsic(Task) Learning Extrinsic (Presentation) Working Memory < Cognitive Load Choices… 1. Accept errors/ incomplete solutions 2. Decrease Extrinsic Cognitive Load 3. “Shrink” the Task 4. Forgo new knowledge learning Working Memory
- 20. Accept cognitive shortcuts and ultimately errors Intellectual Performance Cognitive Load Working Memory Capacity Beyond Capacity Increase errors Suboptimal task completion
- 21. Maladaptive Response to Cognitive Overload Mental shortcuts (Heuristics and Biases) Aggregate bias Anchoring Ascertainment bias Availability Base-rate Commission bias Confirmation bias Feedback sanction Framing effect Fundamental attribution error Gambler’s fallacy Gender bias Hindsight bias Multiple alternatives bias Omission bias Order effects Outcome bias Overconfidence bias Playing the odds Posterior probability error Premature closure Psych-out error Representativeness restraint Search satisfying Sutton’s slip Sunk costs Triage cueing Unpacking principle Vertical line failure Visceral bias Yin-Yang out
- 22. Reducing Extrinsic Load Learning Extrinsic(Presentation) Working Memory < Cognitive Load Decrease Extrinsic Cognitive Load! Intrinsic(Task)
- 24. Getting started
- 25. Reduce Incidental Processing Basic layout – Simple • Structure • Predictable, Consistent, Minimize scanning • Colors/Symbols • Meaningful, Consistent • Content • Increase Signal to Noise Ratio, Eliminate non essential information
- 26. Reduce Incidental Processing Basic layout – Simple • Presentation • Consistent with the providers Mental Model/schema • Flow • Consistent with clinical thinking, Return me where I left off, Predict and make available 3 next most common actions • *Make documentation a byproduct of the clinical work
- 27. example
- 28. Oh yeah, also 800x600 Resolution is so 1999
- 31. Reducing Extrinsic Cognitive Load • Presentation of information in format and structure consistent with how providers see the world (schema). Remember our card game?
- 33. Examples • Problems • Last Assessment • Comments • Last Assessment Date • Previous HPI/Plan • Flowsheets-Clinical Clusters
- 34. Reducing Extrinsic Cognitive Load • Structured documentation/data collection- Good templates, bad templates • My office phone number • (1)5 (2)1 (3)0 (4)2 (5)3 (6)0 (7)2 (8)3 (9)7 (10)2 • (510) 230-2372 • If you want discrete data captured, you must make it easy
- 35. • example
- 36. Reducing Extrinsic Cognitive Load • Make it easy to offload working memory when appropriate • Update in family hx, surgical hx. • Refill medication • Future reminder • Flag task to MA • Right tool for the job- quick visit • Facilitate next steps
- 37. • examples
- 38. Reducing Intrinsic Load? Intrinsic(Task) Learning Extrinsic (Presentation) Working Memory < Cognitive Load Choices… “Chunking”- breaking up task Examples?
- 40. Germaine Load- Learning Intrinsic(Task) Learning Extrinsic (Presentation) Working Memory < Cognitive Load Best place for learning? Perhaps not the middle of an office visit
- 41. •Cognitive Load is the aggregate mental effort required in problem solving and learning. Working Memory Working memory is finite and is the rate limiting step Help the doctor help the patient Shrink Intrinsic Load by breaking down tasks Shrink Extrinsic Load by addressing presentation of information Limit Learning (Germaine) Load by avoiding “education” during visits
- 42. References • Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003; 78: 775-780. • Groopman J. How doctors think. Boston: Houghton Mifflin Company; 2007. • Mayer R. Nine Ways to Reduce Cognitive Load in Multimedia Learning EDUCATIONAL PSYCHOLOGIST 2003, 38(1), 43–52 • Daniel Kahneman. Thinking, fast and slow; New York : Farrar, Straus and Giroux, [2011]
- 43. Michael Zimmerman [email protected] Jonathan Rodriguez, Sr. (774) 226-9684 [email protected] I just want to thank everyone who made this day necessary. -Yogi Berra (1925-2015)
Editor's Notes
- #2: Welcome, Announcements, if you are here for the session entitled “Making Peace with your Dysfunctional EHR” you're in the wrong place. Practice manager started practice with six patients scheduled an hour the charts didn't have any chart dividers she said because the chart dividers take a room and not enough space in the records. Thought we were going to get electronic medical record and she said over my dead body. I Killed her.
- #4: They asked me to submit a picture for my bio. I found this one from about a year ago. Fortunately, since then I become much less stressed. What drives me crazy and always has is when inefficient and cumbersome processes get in the way of hard-working people trying to do their job. Continue working medical leadership positions but also has a practicing doc. you're not part of the problem. Note on the particularly difficult work in primary care broad nature. yes it's true that HER work better in focus specialized environments and I'm more difficult with the broad nature of primary care
- #5: This is the way I though about patients
- #6: This is the way my emr thought about patients. Everyday, every encounter, felt like a struggle, leaving me both physical and mentally tired.
- #7: List the game matching items concentration!
- #9: John Sweller (1946 — ) is Australian educational psychologist, Described TCL in late 1980s as he studied problem solving and learning. by J Sweller in late 1980s Working Memory – think of it like RAM, or your physical desktop space. It is fixed. The space you have to lay this out to figure them out and hopefully learn from the experience.
- #11: Think of using long term memory like opening a program. More LTR more powerful program or application. Pulling Files out of your File Cabinet
- #13: If the load is imposed by the nature of what is to be learned, including the number of information elements and their interactivity, it is known as intrinsic cognitive load. Sometimes we can change the nature of the learning task, but not that often. People need to learn what they need to learn
- #14: Added complexity healthcare encounter simultaneous auditory and visual (ehr)
- #15: Whats missing? The presentation of information increases or decrease cognitive load.
- #16: Review: as we saw in our example we Receive novel information auditory and or visual. We process that information in context of our LTM Solve the problem and hopefully learn something new that we retain.
- #18: Why is this important? What do you think happens now? What do we do in this situation naturally? Driving car daylight, straight road, familiar area, radio blasting tom petty, blabbing with our passenger? Detour, Night falls, pouring rain?
- #19: Well…in encounters we often cant turn down the radio… and we can slow down.. So What are the consequences…bad outcomes.
- #21: Just like bad outcomes if we don’t eliminate driving distractions, we have bad outcomes in thinking and inaccurate conclusions.
- #22: In psychology, heuristics are simple, efficient rules which people often use to form judgments and make decisions. They are mental shortcuts that usually involve focusing on one aspect of a complex problem and ignoring others These rules work well under most circumstances, but they can lead to systematic deviations from logic, probability or rational choice theory. The resulting errors are called "cognitive biases" and many different types have been documented. Jerome Groupman, Chair of Medicine Harvard University 2007 How Doctors Think Daniel Kahneman Nobel Laureate, Thinking Fast, Thinking Slow
- #23: Ltm. Muscle memory Know how to play golf. Ask u to hit 150 yard shot. Tell u to do it left handed The more interesting difficulties, however, arise when something presented on paper fails to fit into your schemas and/or level of automation. Uncommon or technical words such as 'einstellung' or 'xanthoma', or misspelt words such es thiis werrd may cause your attention to be directed to the individual word, perhaps even the individual letters.
- #24: Contacted developers from EHS I want to share some of our work to demonstrate some concepts applied to form elements Some of you may have amazing clinical and technical support and the support of larger systems for development. What we have done is in constant iteration by no means perfect. We also focused on getting the basics right.
- #25: Basic layout Simple. Minimize non essential information. Layout to minimize scanning Present information in blocks consistent with the providers Mental Model/schema. Reduce incidental processing Color schemes yellow button prompts for items valuable for review and documentation purposes. Orange – value added functions Access to key patient data, from everywhere. Font size, consistency Note on dual task of data intake and review AND documentation Make the documentation of work a byproduct of doing the work.
- #26: Basic layout - Simple Structure Predictable, Consistent, Minimize scanning, Flow consistent with clinical thinking Colors/Symbols Meaningful, Consistent Content Eliminate on essential information, Increase Signal to Noise Ratio Presentation Consistent with the providers Mental Model/schema. Make documentation a byproduct of the clinical work
- #30: 1366 x786
- #32: Presents information in blocks of elements consist with schema. Eg whole package of information regarding problems, this is how providers think And context of other problems. 2nd example flow sheets- clinical clusters
- #33: Remember our card game?
- #35: Patient talking not giving discrete data packages this doesn't mesh w templated hpi. Eg hpi upper respiratory. Yikes. .
- #37: On the other hand may have some info high priority to capture discretely eg family hx surgical hx update. Other. Need a place to off load this. Remind me, send a flag- make doing the right thing easy Programmers cant understand whats wrong with us. If the visit is scheduled for abdominal pain then load the abdominal pain encounter... Problem is reason for the visit has limited correlation with what actually happens in the visit. Improving the signal to noise ratio. Start with the basic allow deeper dive. Allow Providers to enter into the data how they want. Trust providers to the questions and help them get to the answers. Allow variation in data viewing, no fixed, complex. Use fixed prompts sparingly.
- #39: Intrinsic work is mostly fixed based on the complexity of the task. One strategy is breaking up the task or chunking Examples in healthcare? Clear delineation of MA work and Provider work. Patient Agenda, Clinical agenda