intrinsic encounter - cognitive load theory
TRANSCRIPT
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Cognitive Load Theory:Why using your EHR is so painful and
how to fix it
Michael Zimmerman, MD
Temescal Creek Medicine
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A moment of clarityS30.201A- Contusion of unspecified external genital
organ, male, related to an altercation with a superhero,
initial encounter
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Patient
Risk Factors
Medications
Problem List
Data
Care Team
Surgical History
Social History
Family History
Diabetes
CHF
Asthma
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Family History
Social History
Surgical History
Problem List
Data
Risk Factors
Medication
Care Team
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Got Cognitive Load?
Do you feel…TiredOverwhelmedBurned OutDisengagedRushedShort TemperLack of enthusiasm
Ask you doctor…
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•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.
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Working Memory
Working MemoryProblem Solving->Learning
The Problem or
Task
1. Novel Information is Collected and Processed1. Auditory2. Visual
24 divided by 3
24 divided by 3
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Working Memory
Working Memory Problem Solving->Learning
The Problem or
Task
1. Novel Information is Collected and Processed
1. Auditory2. 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
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Working Memory Problem Solving->Learning
The Problem or
Task
1. Novel Information is Collected and Processed
1. Auditory2. 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
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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-
IntrinsicCognitive Load
Minimal Moderate Heavy
Medical Problem Solving?
= Intrinsic Load + Extraneous Load + Germaine Load
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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
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What’s Missing?
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“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
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Intr
insi
c (T
ask)
Lear
nin
g
Extr
insi
c (p
rese
nta
tio
n)
Task Completed Learned some new things
Working Memory >= Cognitive Load
Working MemoryAggregate Cognitive Load
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Intr
insi
c (T
ask)
Lear
nin
g
Extr
insi
c (P
rese
nta
tio
n)
Intr
insi
c (T
ask)
Lear
nin
g
Extr
insi
c (p
rese
nta
tio
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Task Completed Learned some new things
Working Memory >= Cognitive Load
Working Memory < Cognitive Load
Choices…1. Accept errors/ incomplete solutions2. Decrease Extrinsic Cognitive Load3. “Shrink” the Task4. Forgo new knowledge learning
Working Memory
What now?
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Intr
insi
c (T
ask)
Lear
nin
g
Extr
insi
c (P
rese
nta
tio
n)
Working Memory < Cognitive Load
Choices…1. Accept errors/ incomplete solutions2. Decrease Extrinsic Cognitive Load3. “Shrink” the Task4. Forgo new knowledge learning
Working Memory
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Accept cognitive shortcuts and ultimately errors
Intellectual Performance
Cognitive Load
Working Memory Capacity Beyond Capacity
Increase errorsSuboptimal task completion
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Maladaptive Response to Cognitive Overload Mental shortcuts (Heuristics and Biases)
Aggregate biasAnchoringAscertainment biasAvailabilityBase-rateCommission biasConfirmation biasFeedback sanctionFraming effectFundamental attribution errorGambler’s fallacyGender bias
Hindsight biasMultiple alternatives biasOmission biasOrder effectsOutcome biasOverconfidence biasPlaying the oddsPosterior probability errorPremature closurePsych-out errorRepresentativeness restraint
Search satisfying Sutton’s slipSunk costsTriage cueingUnpacking principle Vertical line failureVisceral biasYin-Yang out
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Reducing Extrinsic Load
Lear
nin
g
Extr
insi
c (P
rese
nta
tio
n)
Working Memory < Cognitive Load
Decrease Extrinsic Cognitive Load!
Intr
insi
c (T
ask)
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Patient
Risk Factors
Meds
Problem List
Data
Care Team
Surgical History
Social History
Family History
Diabetes
CHF
Asthma
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Getting started
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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
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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
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example
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Oh yeah, also 800x600 Resolution is so 1999
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Reducing Extrinsic Cognitive Load
• Presentation of information in format and structure consistent with how providers see the world (schema).
Remember our card game?
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Examples
• Problems• Last Assessment
• Comments
• Last Assessment Date
• Previous HPI/Plan
• Flowsheets-Clinical Clusters
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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
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• example
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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
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• examples
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Reducing Intrinsic Load?
Intr
insi
c (T
ask)
Lear
nin
g
Extr
insi
c (P
rese
nta
tio
n)
Working Memory < Cognitive Load
Choices…
“Chunking”- breaking up task
Examples?
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Germaine Load- Learning
Intr
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c (T
ask)
Lear
nin
g
Extr
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c (P
rese
nta
tio
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Working Memory < Cognitive Load
Best place for learning? Perhaps not the middle of an office visit
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•Cognitive Load is the aggregate mental effort required in problem solving and learning.
Working MemoryWorking 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
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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]
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Michael [email protected]
Jonathan Rodriguez, Sr.(774) [email protected]
I just want to thank everyone who made this day necessary.
-Yogi Berra (1925-2015)