Cognitive Load Theory:
Why using your EHR is so painful and how to fix it
Michael Zimmerman, MD CHUG 2016 Oct 15th, 2016
Risk Factors
Family Medications History Diabetes
Problem Social Patient CHF History List
Asthma
Surgical Data History
Care Team
Risk Factors
Family Medications History Diabetes
Problem Social Patient CHF History List
Asthma
Surgical Data History
Care Team Family History
Social History
Surgical History
Risk Factors
Medication
Data
Care Team
Problem List Got Cognitive Load?
Do you feel… Tired Overwhelmed Burned Out Disengaged Rushed Short Temper Lack of enthusiasm
Ask you doctor… •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. Working Memory
Problem Solving->Learning Working Memory 24 divided by 3 1. Novel Information is Collected and Processed 1. Auditory 2. Visual
The Problem or Task
24 divided by 3 Here’s what I already know… Working Memory Concepts of division and multiplication; 24/6 = 4
Working Memory Problem Solving->Learning ÷ X24 divided by 3 1. Novel Information is Collected 24/6 and Processed 1. Auditory 2. Visual
2. Interpretation and consideration of The information in context of existing Problem or knowledge schemas. (Long Term Memory) Task
24 divided by 3 24/3=8
Working Memory Problem Solving->Learning ÷ 24 2424 divided divided by 3by 3 X /3 1. Novel Information is Collected 24/6 and Processed 1. Auditory 2. Visual
The 2. Interpretation and consideration of Problem or information in context of existing Task knowledge schemas. (Long Term Memory) 3. Build and retention of new knowledge based on the problem solving experience.
24 divided by 3 Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load
Intrinsic
Germaine
Extraneous
Problem Solution Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load
Intrinsic The inherent complexity of the task. Cognitive Load Interactivity of elements.
2+2 18 + 37 879834+79275 Medical Problem Solving?
Complexity 0- Interactivity 0- Intrinsic Minimal Moderate Heavy Cognitive Load Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load
manner in which information is presented to solver/learner Extraneous Cognitive Load 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 and complete complex tasks.
a round plane figure whose boundary consists of points equidistant from a fixed point. What’s Missing? Cognitive Load is the aggregate mental effort required in problem solving and learning. = Intrinsic Load + Extraneous Load + Germaine Load
“Germaine” Load imposed by constructing new schemas Cognitive Load- and automating them…Learning and Problem Learning Solving! This is germane cognitive load. Aggregate CognitiveLoad
Intrinsic (Task)
Extrinsic (presentation)
Learning WorkingMemory Working Memory Learned some newthings Learned Task Completed >= CognitiveLoad Intrinsic (Task)
Extrinsic (Presentation)
Learning WorkingMemory What now? Intrinsic (Task)
Extrinsic (presentation)
Learning Working Memory Working Memory 4. 3. 2. 1. Choices… Learned some new things newsome Learned Task Completed Forgolearningknowledge new Task“Shrink” the Decrease Accepterrors/ incomplete solutions Extraneous CognitiveLoad < >= CognitiveLoad CognitiveLoad
Accept cognitive shortcuts and ultimately errors
Working Memory Capacity Beyond Capacity
Intellectual Performance Increase errors Suboptimal task completion
Cognitive Load Maladaptive Response to Cognitive Overload Mental shortcuts (Heuristics and Biases)
Aggregate bias Hindsight bias Search satisfying Anchoring Multiple alternatives bias Sutton’s slip Ascertainment bias Omission bias Sunk costs Availability Order effects Triage cueing Base-rate Outcome bias Unpacking principle Commission bias Overconfidence bias Vertical line failure Confirmation bias Playing the odds Visceral bias Feedback sanction Posterior probability error Yin-Yang out Framing effect Premature closure Fundamental attribution error Psych-out error Gambler’s fallacy Representativeness restraint Gender bias Lets assume we prefer not to accept errors or leave problems unsolved.
Intrinsic Germaine Choices… Extraneous 1.Decrease INTRINSIC LOAD 2.Decrease EXTRANEOUS LOAD 3.Limit Germaine Load during visit – learning
Problem Solution Risk Factors Family Meds History Diabetes
Social Problem Patient CHF History List
Asthma
Surgical Data History Care Team 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 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 Reducing Cognitive Load – layout basics Reducing Cognitive Load – layout basics Reducing Cognitive Load – layout basics Oh yeah, also 800x600 Resolution is so 1999
Reducing Intrinsic Cognitive Load
Working Memory < Cognitive Load
Choices… Extrinsic Extrinsic
Learning “Chunking”- breaking up task
(Presentation) Intrinsic (Task) Intrinsic
Examples?
Reducing Intrinsic Load - example
• Define and Support Medical Assistant Work • Create “Hand off to Provider” within the Providers Context Reducing Extraneous Cognitive Load
Working Memory < Cognitive Load
Choices… Extrinsic Extrinsic
Learning Presentation (Presentation) Intrinsic (Task) Intrinsic Offloading Facilitate Next Steps
Examples? Reducing Extraneous Cognitive Load
• Presentation of information in format and structure consistent with how providers see the world (schema).
Remember our card game? clk Reducing Extrinsic Cognitive Load - Example
• Subjective • What does the patient want to accomplish? • What do I want to accomplish? • Where did we leave off from Previous Visit? • Where were we relative to other problems NOT on previous visit? • Assessment and Plan • In context of previous • Last assessment date • Surrounding data • Instructions • Communications Reducing Extraneous Cognitive Load - example
• 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 • Example- jumpstart 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 eg get colonoscopy • Right tool for the job- quick visit • examples Germaine Load- Learning
Working Memory < Cognitive Load Extrinsic Extrinsic
Learning Best place for learning? Perhaps (Presentation) Intrinsic (Task) Intrinsic not the middle of an office visit •Cognitive Load is the aggregate mental effort required in problem solving and learning.
Working memory is finite and Working Memory is the rate limiting step
Help the doctor help the patient Shrink Intrinsic Load by breaking down tasks Shrink Extraneous Load by addressing presentation of information Limit Learning (Germaine) Load by avoiding “education” during visits 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] I just want to thank everyone who made this day necessary. -Yogi Berra (1925-2015)
Jonathan Rodriguez, Sr. Michael Zimmerman (774) 226-9684 [email protected] [email protected]