Transcript No Slide Title

The Science of Cognition and
Human-Computer Interaction in
Health Care
Vimla L. Patel, PhD, DSc
Cognitive Studies in Medicine:
Centre for Medical Education
McGill University
Montreal, Canada
Evolution of Medical Informatics:
Importance of Interface Design
High
Unfilled
Technology
Need
Sophistication
of Typical User
Low
Technology
Delivers Basic
Need
Low
Technology
Matched to
Technology is “good
Increasing User
enough”
Sophistication
User Experience
Dominates
System
Risk
of Excess
Complexity
Functionality
Masked
from Lay
User
High
Sophistication of Technology
Current
Trend ?
What is the User Interface?
Those aspects of the system with
which the human user comes in
contact
Examples: ATM,
Output
Language
Input
Language
point-and-click
navigation in web
browsers...
Communication
Protocol
Ways to Deal with User
Interface Design
• Focus on the way the user has
traditionally functioned
• Focus on optimizing the interface
and requiring user adaptation
• Study Interaction to see:
• what aspects of the user can
change
• what aspects of the system can
change
Dimensions of Human
Computer Interaction (HCI)
Technological
• Hardware and Software Advances
Cognitive
• Representation
• Knowledge Organization
• Reasoning and Strategies
Cognitive Aspects of Interface Design
Human Processes:
• Comprehension
• Navigation
• Communication
These Affect:
• Learning
• Performance
Comprehension and
Levels of Meaning
• Text-based Model - Surface
• Syntax / Semantics
• Generation of Local Inferences
• Propositions
• Situation Model - Deep
• Representation of Events, Actions and Persons
in Context
• Conceptual
• Generation of High-Level Inferences
• Pragmatics: Context-Bound Inferences
Comprehension Processes
CLINICAL DATA
Data-driven Process
Representation of
Clinical Information
Generalization
NEW KNOWLEDGE
PRIOR
KNOWLEDGE
Comprehension
Interpretation
(in Context)
Instantiation
Conceptually
Driven Process
Semantic Representation of
Natural Language Analysis
Semantic Network
(relationships between
propositions)
PROPOSITIONAL
REPRESENTATION
text-based model
CONCEPTUAL
REPRESENTATION
situational model
Propositional Analysis
(a form of representation of a
semantic network in memory)
NATURAL
LANGUAGE
THOUGHTS
AND IDEAS
expressed through
SYSTEMS
LEVEL
C1
DIAGNOSTIC
LEVEL
D1
INTERMEDIATE
CONSTRUCT
FINDING
LEVEL
FA1
D2
FA2
D3
FA3
FA4
FA5
F1 F2 F3 F4 F5 F6 F7 F8 F9
O
1
O
7
+
+
+
OBSERVATION
LEVEL
Structure of
Medical
Knowledge in
Problem
Solving
C2
O
2
O
8
O
3
O
9
O
4
O
10
O
5
O1
1
O
6
O
12
Cognition and HCI
• Learning to use technology
• “Effects with” technology
• Learning beyond technology
• “Effects of” technology
Human-Machine Cognition
• Human experts skip steps during
the reasoning process
• Decision-support systems go
through every step methodically in
the logical process
• This distinction can lead to
cognitive dissonance between
users and machines
Usability
• Usability Testing
• Testing of ease of use must be
theory-driven
• Usability Inspection
• Cognitive walkthrough as a
method for gaining insight into
user perceptions and
misconceptions
Usability Inspection
Use of Medline
• Cognitive Walkthrough:
• Assess usability for specific
tasks
• Usability analyst steps through
system interface methodically
• Question:
• Can we anticipate user goals,
actions and potential problems in
using an information retrieval
system like Medline?
Cognitive Walkthrough - Medline Search
TASK: To find articles from Medline related to
pregnancy and diabetes
Goal 1: Find articles related to diabetes
Sub-Goal: Do a keyword search on diabetes
Action: enter key combination <control R>
System Response: “Enter a word or phrase”
Action: type in diabetes and press enter
System Response: Returns 22998 entries
Potential Problem: List too extensive
Goal 2: Find articles on pregnancy
As above (Goal 1)
Goal 3: Merge list of entries on diabetes and
pregnancy
Potential Problem: Subject must map term
“combine” to action “merge”
Sub-Goal: Combine data sets (diabetes and
pregnancy)
Action: Key combination <control n>
System Response: Screen with 2 sets and
instructions “Use spacebar to select at least
two sets to combine and then press <Enter>”
Action: Scroll to diabetes, press space-bar
Action: Scroll to pregnancy, press space-bar
Action: Press <enter>
System Response: Combine sets screen:
Choose Boolean connective “and” or “or”
Potential Problem: Choice of connectives
Action: Select “and” and press <enter>
….
Results
• Numerous potential problems
• To perform the task required:
• 12 sub-goals
• 22 actions
• 9 transitions between screens
• The goal-action analysis shows
the cognitive load put on the user
in doing simple tasks
Impact of a CPR System on
Human Cognition
• Studies of transition from paper
records to CPR and back to paper
record
• Impact on knowledge organization,
reasoning, and learning
Changes in Reasoning Patterns
• Paper Records
• Data driven reasoning
• Computer-Based Record
• Problem directed reasoning
• Return to Paper Record after CPR
• Problem Directed Reasoning
• Residual effect of CPR on learning (after
CPR removed)
Changes in Information
Management and CPR Use
100
80
% of Record 60
Contents 40
Relevant
Irrelevant
20
0
Pre-CPR
CPR
Diagnostic Reasoning Using
Paper Record
Patient Data
Multiple Hypotheses
Diagnostic Reasoning Using CPR
Patient Data
Hypotheses
Information in CPR and Hand-Written Records
Category of Information
Hand-Written
Patient Record
1. Chief Complaint
2. Past Medical History
3. Life Style
4. Psychological Profile
5. Family History
6. History of Present Illness
7. Review of Systems
8. Physical Examination
9. Diagnosis
10. Investigation
11. Treatment
Total Entries
Computer-Based
Patient Record
10
13
33
10
7
55
52
60
14
29
21
28
13
19
11
14
27
8
55
9
17
24
304
225
Collaboration and
Distributed Cognition
• Investigate communication
between humans, between
machines, and between humans
and machines
• Understand
• How people think
• analog processing, imprecise
• How machines think
• digital processing, precise
• Capitalize on individual and group
expertise
Sociometric Analysis of Email
Communication Patterns
Stanford
A
B
Columbia
E
F
C
D
G
InterMed
Central
H
K
J
DSG
I
L
M
MGH
Email Communication Patterns
Episode 1: Vocabulary Server and Guidelines
(Jan-Feb 95)
Stanford
A
Columbia
B
E
F
C
D
INTERMED
CENTRAL
K
MGH
L
M
Email Communication Patterns
Episode 2: Guidelines Representation
(Feb-Mar 96)
Stanford
Columbia
A
B
E
F
C
D
G
INTERMED
CENTRAL
H
K
J
DSG
I
MGH
Evaluation of PatCIS
1. Video Based
Usability Testing
4. Log File - System
Usage Database
(“think aloud”)
(e.g. infobutton)
Patient
2. Telephone
Interviews
(audiotape)
Interact via
Internet
3. E-mail
(to evaluators
& designers)
PatCIS
5. On-line
Questionnaire
Data
(from pilot study)
Patient-System Interaction
Lay people’s conceptual model of:
• Normal health and illness
• How people reason about
health
• How technology works
• Study activities of people as
they interact with systems
Reasoning Patterns, Data Entry
• Organization of knowledge differs
among lay and professionals
• Reasoning patterns of
professionals and patients are
also different
0
Cytryn & Patel (1998)
Categories of Information
Affect
Social Support
Health Care
Team
Fear
Regimen
Daily Activities
Biomedical
Knowledge
Lay Knowledge
of Symptom
Causality
Percent Frequency
Patients’ Use of Concepts in Explanations of
their Decisions about Diabetes
30
Data Entered into the System Accurately
by Patients and Physicians
Patients
Physicians
Mean Percent Frequency
100
75
50
25
0
Blood Glucose
Level
Cytryn & Patel (1998)
Diet, Activity,
Stress
Insulin
Type of Information
Hypoglycemic
Reaction
Reasoning Pattern: Patient
Instruction:
Explain decision
Response:
“Well let’s say if I’ll eat a pound of candies my sugar will go sky
high and it might even cause a stroke!”
Increased
Carbohydrate Intake
Cytryn & Patel (1998)
COND
Increased Blood
Glucose Level
COND
(lead to)
Complications
Reasoning Pattern: Physician
Instruction:
Interpret Scenario
Response:
“A fasting blood sugar of 160 pretty much says she’s diabetic.
The postprandial is 200 also tells us she’s diabetic. She’s
overweight, that’s already got me thinking that if she’s insulin
resistant, then I might be able to improve that by having her lose
weight.”
Fasting Blood Glucose
COND
Diabetes
Postprandial Blood Glucose
Cytryn & Patel (1998)
COND
COND
Insulin Resistant
Overweight
COND
Reprise: Reasoning Patterns
Patient
Increased
Carbohydrate Intake
COND
Increased Blood
Glucose Level
COND
(lead to)
Complications
Physician
Fasting Blood Glucose
COND
Diabetes
Postprandial Blood Glucose
Cytryn & Patel (1998)
COND
COND
Insulin Resistant
Overweight
COND
Summing Up: What’s Next?
• Cognitive and social sciences are mandatory for
design and implementation of UI’s
• Must have deep understanding of what people
do and how they reason about it before
developing systems that support those
activities
• Must have better understanding of how people
think about the systems they use
(acknowledging different expert and lay models)
• Recognize the movement towards distributed
systems, with human beings as heuristicallydriven, analogue thinkers partnering with
precise digital systems.
More Future Challenges
• We will move to greater
complexity in systems, but need
to consider smaller, manageable
tasks and thus less complex
systems as experienced by users
• Recognize relation between
education and training
• Training is not enough
• Must educate to support
training
Education to Support Training
Easily & Quickly
Accessible
User Interface
Typical
(Certain)
Training
(Action)
Decision
Making
Ambiguous
(incomplete,
inconsistent)
Education
(Knowledge)
Guidelines
Linked to
other
Information
Systems
Action
Update
Discussion/Dialogue
Seminars,
Community-based
groups
The Key Role of Theory in Generating
Design Recommendations
Interpretation
Theory
Guides
Generalize
Data
Analysis
and
Results
X
Recommendations
Customization to Case