THE EFFECT OF RISK ATTITUDE AND UNCERTAINTY COMFORT ON PRIMARY CARE PHYSICIANS’ USE OF ELECTRONIC INFORMATION RESOURCES by Kathleen Ann McKibbon BSc, Honours Chemistry, University of Guelph, 1971 MLS, University of Western Ontario, 1972 Submitted to the Graduate Faculty of Center for Biomedical Informatics, School of Medicine in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2005 UNIVERSITY OF PITTSBURGH CENTER FOR BIOMEDICAL INFORMATICS FACULTY OF MEDICINE This dissertation was presented by Kathleen Ann McKibbbon It was defended on June 27, 2005 and approved by Rebecca S. Crowley, MD, MSIS, Assistant Professor Ellen G. Detlefsen, PhD, Associate Professor Douglas B. Fridsma, MD, PhD, Assistant Professor Charles P. Friedman, PhD, Professor and Director R. Brian Haynes, MD, PhD, Professor and Departmental Chair, McMaster University Dissertation Director: Douglas B. Fridsma, MD, PhD, Assistant Professor ii Copyright © by K. Ann McKibbon 2005 iii THE EFFECT OF RISK ATTITUDE AND UNCERTAINTY COMFORT ON PRIMARY CARE PHYSICIANS’ USE OF ELECTRONIC INFORMATION RESOURCES Kathleen Ann McKibbon, PhD University of Pittsburgh, 2005 Background: Clinicians use information regularly in clinical care. New electronic information resources provided in push, pull, and prompting formats have potential to improve information support but have not been designed for individualization. Physicians with differing risk status use healthcare resources differently often without an improvement in outcomes. Questions: Do physicians who are risk seeking or risk avoiding and comfortable or uncomfortable with uncertainty use or prefer electronic information resources differently when answering simulated clinical questions and can the processes be modeled with existing theoretical models? Design: Cohort study. Methods: Primary care physicians in Canada and the United States were screened for risk status. Those with high and low scores on 2 validated scales answered 23 multiple-choice questions and searched for information using their own electronic resources for 2 of these questions. They also answered 2 other questions using information from 2 electronic information sources: PIER©1 and Clinical Evidence©2. Results: The physicians did not differ for number of correct answers according to risk status although the number of correct answers was low and not substantially higher than chance. Their searching process was consistent with 2 information-seeking models from information science (modified Wilson Problem Solving and Card/Pirolli Information Foraging/Information Scent models). Few differences were seen for any electronic searching or 1 PIER is copyrighted © 2005 by the American College of Physicians, 190 North Independence Mall West, Philadelphia, PA 19106-1572, USA. (http://pier.acponline.org/index.html?chapinc). Accessed July 12, 2005. 2 Clinical Evidence is copyrighted © by the BMJ Publishing Group Limited, London, England, UK. 2005. (http://www.clinicalevidence.com/ceweb/conditions/index.jsp). Accessed July 12, 2005. iv information use outcome based on risk status although those physicians who were comfortable with uncertainty used more searching heuristics and spent less effort on direct searching. More than 20% of answers were changed after searching—almost the same number going from incorrect to correct and from correct to incorrect. These changes from a correct to incorrect answer indicate that some electronic information resources may not be ideal for direct clinical care or integration into electronic medical record systems. Conclusions: Risk status may not be a major factor in the design of electronic information resources for primary care physicians. More research needs to be done to determine which computerized information resources and which features of these resources are associated with obtaining and maintaining correct answers to clinical questions. v EXECUTIVE SUMMARY Clinicians use external information regularly to support their clinical decisions and have traditionally consulted books and people. New computerized information resources such as electronic textbooks are available that provide push, pull, and prompting information support. We do not know if these electronic resources, and in which format, are effective; which ones are best implemented into electronic medical record systems; or if they need to be personalized to provide effective support for clinicians based on individual characteristics or specifications. One major way physicians differ is how they view risk and uncertainty. Risk-avoiding physicians and those uncomfortable with uncertainty use more healthcare resources and incur more care costs than their peers, often without improvement in outcomes. Risk and uncertainty affect all health care decisions and therefore are important issues in understanding health care and building effective computer-based systems. Risk and uncertainty also guide information seeking and use of external information. Design is important in computer systems because huge differences in productivity occur across users, often in the range of 20:1. Good design, understanding user needs, and training can mitigate this difference in computer productivity. This dissertation was designed to determine if primary care physicians use electronic information resources differently according to their attitude towards risk (risk seeking or avoiding) and comfort with uncertainty (low or high levels). Canadian and US physicians with different risk status answered 23 multiple-choice questions and searched for information using their own and provided electronic information resources in an hour-long interview. Quantitative methods and think-aloud protocol analyses showed small differences in searching outcomes and processes when using their own computer resources. Design may not need to factor in risk status for production of effective electronic information resources. However the use of some electronic information resources was associated with answers changing from an initially correct answer to being wrong. Further research must determine what features of a resource, and which electronic resources are associated with obtaining and maintaining initially correct answers to their clinical questions. vi TABLE OF CONTENTS PREFACE .................................................................................................................................................................xvi 1 HOW PRIMARY CARE PHYSICIANS USE INFORMATION RESOURCES AND CHALLENGES TO FIND AND IMPLEMENT THE BEST...............................................................................................................2 1.1 THE NEED FOR GOOD INFORMATION RESOURCES............................................................................2 1.2 CLINICAL STORY—RESIDENT WOES.....................................................................................................3 1.3 INFORMATION IS CRITICAL TO EFFECTIVE PATIENT CARE............................................................5 1.4 USER CHARACTERISTCS AFFECT HOW INFORMATION IS SOUGHT AND USED .........................6 1.5 PHYSICIAN RESPONSE TO RISK AND UNCERTAINTY AFFECTS PROCESS OF CARE AND RESOURCE USE ...........................................................................................................................................6 1.6 NEW RESOURCES PROLIFERATE IN OUR ELECTRONIC ERA ...........................................................7 1.7 INFORMATION RESROUCES ARE BEING INTEGRATED INTO ELECTRONIC MEDICAL RECORD SYSTEMS......................................................................................................................................9 1.8 QUESTIONS TO ANSWER...........................................................................................................................9 1.9 WORK PROCESS ........................................................................................................................................11 1.10 MAIN FINDINGS.........................................................................................................................................12 1.11 GUIDE TO THE READER ..........................................................................................................................13 2 REVIEW OF THE THEORETICAL BASIS OF INFORMATON RESOURCES AND HOW PHSICIANS USE THEM IN CLINICAL CARE...................................................................................................15 2.1 QUESTIONS AND SUMMARY OF DISSERTATION..............................................................................15 2.2 INFORMATION IS CRITICAL TO EFFECTIVE PATIENT CARE..........................................................17 vii 2.3 USER CHARACTERISTICS AND INFORMATION SOURCES AND SEARCHING.............................20 2.4 PHYSICIAN RESPONSE TO RISK AND UNCERTAINTY AFFECTS PROCESS AND RESOURCE USE ...............................................................................................................................................................24 2.4.1 Standard gambles to assess attitude toward uncertainty and their association with process and outcomes ............................................................................................................................................................28 2.4.2 Geller Tolerance for Ambiguity Scale.................................................................................................28 2.4.3 Pearson’s Risk Taking Scale—description,