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1.  The Coming of Age of Artificial Intelligence in Medicine* 
Summary
This paper is based on a panel discussion held at the Artificial Intelligence in Medicine Europe (AIME) conference in Amsterdam, The Netherlands, in July 2007. It had been more than 15 years since Edward Shortliffe gave a talk at AIME in which he characterized artificial intelligence (AI) in medicine as being in its “adolescence” (Shortliffe EH. The adolescence of AI in medicine: Will the field come of age in the ‘90s? Artificial Intelligence in Medicine 1993; 5:93–106). In this article, the discussants reflect on medical AI research during the subsequent years and attempt to characterize the maturity and influence that has been achieved to date. Participants focus on their personal areas of expertise, ranging from clinical decision making, reasoning under uncertainty, and knowledge representation to systems integration, translational bioinformatics, and cognitive issues in both the modeling of expertise and the creation of acceptable systems.
doi:10.1016/j.artmed.2008.07.017
PMCID: PMC2752210  PMID: 18790621
2.  Discerning Patterns of HIV Risk in Healthy Young Adults 
The American journal of medicine  2008;121(9):758-764.
Prior research has questioned the effectiveness of existing methods to identify individuals at high risk for contracting and transmitting the Human Immunodeficiency Virus (HIV) and other sexually transmitted diseases (STDs). Thus, new approaches are needed to provide these individuals with risk-reduction strategies. We review our research on young adults’ sexual decision making, using theories and methods from social and cognitive sciences. Four patterns of condom use and associated levels of risks and beliefs were identified. These patterns suggest value in targeting intervention strategies to individuals at different levels of risk. Findings also imply that the monogamous population may be at higher risk for infection than they realize. Primary-care physicians are the first line of contact for many individuals in the health care system, and may be in the best position to screen for at-risk individuals. Given time demands and other barriers, easy-to-use evidence-based guidelines for such screening are needed. We propose such guidelines for primary-care physicians to use in identifying an individual’s risk, from which custom-tailored intervention strategies can be developed.
doi:10.1016/j.amjmed.2008.04.022
PMCID: PMC2597652  PMID: 18724961
youth; HIV/AIDS; decision-making; patterns of reasoning; risky sexual behavior; screening; education
3.  Translational Cognition for Decision Support in Critical Care Environments: A Review 
Journal of biomedical informatics  2008;41(3):413-431.
The dynamic and distributed work environment in critical care requires a high level of collaboration among clinical team members and a sophisticated task coordination system to deliver safe, timely and effective care. A complex cognitive system underlies the decision-making process in such cooperative workplaces. This methodological review paper addresses the issues of translating cognitive research to clinical practice with a specific focus on decision-making in critical care, and the role of information and communication technology to aid in such decisions. Examples are drawn from studies of critical care in our own research laboratories. Critical care, in this paper, includes both intensive (inpatient) and emergency (outpatient) care. We define translational cognition as the research on basic and applied cognitive issues that contribute to our understanding of how information is stored, retrieved and used for problem-solving and decision-making. The methods and findings are discussed in the context of constraints on decision-making in real world complex environments and implications for supporting the design and evaluation of decision support tools for critical care health providers.
doi:10.1016/j.jbi.2008.01.013
PMCID: PMC2459228  PMID: 18343731
translational cognition; distributed cognition; critical care; intensive care; emergency triage; clinical workflow; technological design; medical errors; decision support; cognitive task analysis; ethnographic analysis; naturalistic decision-making
4.  The Nature and Occurrence of Registration Errors in the Emergency Department 
Research into the nature and occurrence of medical errors has shown that these often result from a combination of factors that lead to the breakdown of workflow. Nowhere is this more critical than in the emergency department (ED), where the focus of clinical decision is on the timely evaluation and stabilization of patients. This paper reports on the nature of errors and their implications for patient safety in an adult ED, using methods of ethnographic observation, interviews, and think-aloud protocols. Data were analyzed using modified “grounded theory,” which refers to a theory developed inductively from a body of data. Analysis revealed four classes of errors, relating to errors of misidentification, ranging from multiple medical record numbers, wrong patient identification or address, and in one case, switching of one patient’s identification information with those of another. Further analysis traced the root of the errors to ED registration.
These results indicate that the nature of errors in the emergency department are complex, multi-layered and result from an intertwined web of activity, in which stress of the work environment, high patient volume and the tendency to adopt shortcuts play a significant role. The need for information technology (IT) solutions to these problems as well as the impact of alternative policies is discussed.
doi:10.1016/j.ijmedinf.2007.04.011
PMCID: PMC2259219  PMID: 17560165
ED registration; medical errors; misidentification; workarounds; shortcuts; distributed cognition; emergency care
5.  Participant Perceptions of the Influences of the NLM-Sponsored Woods Hole Medical Informatics Course 
This report provides an evaluation of the National Library of Medicine–sponsored Woods Hole Medical Informatics (WHMI) course and the extent to which the objectives of the program are achieved. Two studies were conducted to examine the participants' perceptions of both the short-term (spring 2002) and the long-term influences (1993 through 2002) on knowledge, skills, and behavior. Data were collected through the use of questionnaires, semistructured telephone interviews, and participant observation methods to provide both quantitative and qualitative assessment. The participants of the spring 2002 course considered the course to be an excellent opportunity to increase their knowledge and understanding of the field of medical informatics as well as to meet and interact with other professionals in the field to establish future collaborations. Past participants remained highly satisfied with their experience at Woods Hole and its influence on their professional careers and their involvement in a broad range of activities related to medical informatics. This group considered their knowledge and understanding of medical informatics to be of greater quality, had increased their networking with other professionals, and were more confident and motivated to work in the field. Many of the participants feel and show evidence of becoming effective agents of change in their institutions in the area of medical informatics, which is one of the objectives of the program.
doi:10.1197/jamia.M1662
PMCID: PMC1090455  PMID: 15684135
6.  Medical Error: Is the Solution Medical or Cognitive? 
Is the solution for medical errors medical or cognitive? In this AMIA2001 panel on medical error, we argued that medical error is primarily an issue for cognitive science and engineering, not for medicine, although the knowledge of the practice of medicine is essential for the research and prevention of medical errors. The three panelists presented studies that demonstrate that cognitive research is the foundation for theories of medical errors and interventions of error reductions.
doi:10.1197/jamia.M1232
PMCID: PMC419424  PMID: 12386188
7.  A Primer on Aspects of Cognition for Medical Informatics 
As a multidisciplinary field, medical informatics draws on a range of disciplines, such as computer science, information science, and the social and cognitive sciences. The cognitive sciences can provide important insights into the nature of the processes involved in human– computer interaction and help improve the design of medical information systems by providing insight into the roles that knowledge, memory, and strategies play in a variety of cognitive activities. In this paper, the authors survey literature on aspects of medical cognition and provide a set of claims that they consider to be important in medical informatics.
PMCID: PMC130077  PMID: 11418539
8.  Variability in User Interaction with Physician Order Entry System 
Physician order entry systems offer numerous benefits to users and institutions, including the reduction of medical errors, and increase in the speed and quality of written communication. Standardization of care is also often cited as an important outcome facilitated by POE. However, order entry systems are frequently very complex and sophisticated tools that produce consistent results only if used in an efficient and consistent manner. The numerous benefits that order entry offers can only be realized when this technology is used to its full potential. This study characterizes the variations in user strategies in completing a task and the ensuing inconsistencies of output. Seven physicians were asked to enter orders based on a clinical scenario requiring inpatient admission. Inefficient task completion strategies, redundancy, omissions and errors in the entered orders are outlined and discussed.
PMCID: PMC2244383
11.  A Framework for Characterizing the Development of Expertise in the Domain of Orthodontics 
Studies of how expertise is acquired are reported in the literature and include the domains of chess, physics, sports, music, and medicine, representing different levels of cognitive skills. To what extent are general findings from these domains applicable to the acquisition of expertise in orthodontics? Using theories and methods from cognitive studies of expertise, we present a framework for characterizing the nature of expertise from residents to orthodontists. We present pilot data to support such a framework. Development of decision support and training systems will be informed by such characterization.
PMCID: PMC2244260
12.  Cognitive Models of HIV Decision-making in Young Adults 
Although studies show that many young adults have high HIV knowledge, the incidence rate of HIV among this population continues to increase. We investigated this discrepancy by using theories and methods from cognitive and decision sciences to develop models of young adults' decision making processes in real-life sexual encounters. We identified several factors influencing decision making, which were unrelated to participants' knowledge of HIV. This poster presents our theoretical framework and illustrates the power of the methods to model decision making. Initial data show that such models can be built and do provide critical information about sexual decision-making.
PMCID: PMC2244197
13.  Impact of a Computer-based Patient Record System on Data Collection, Knowledge Organization, and Reasoning 
Objective: To assess the effects of a computer-based patient record system on human cognition. Computer-based patient record systems can be considered "cognitive artifacts," which shape the way in which health care workers obtain, organize, and reason with knowledge.
Design: Study 1 compared physicians' organization of clinical information in paper-based and computer-based patient records in a diabetes clinic. Study 2 extended the first study to include analysis of doctor–patient–computer interactions, which were recorded on video in their entirety. In Study 3, physicians' interactions with computer-based records were followed through interviews and automatic logging of cases entered in the computer-based patient record.
Results: Results indicate that exposure to the computer-based patient record was associated with changes in physicians' information gathering and reasoning strategies. Differences were found in the content and organization of information, with paper records having a narrative structure, while the computer-based records were organized into discrete items of information. The differences in knowledge organization had an effect on data gathering strategies, where the nature of doctor-patient dialogue was influenced by the structure of the computer-based patient record system.
Conclusion: Technology has a profound influence in shaping cognitive behavior, and the potential effects of cognition on technology design needs to be explored.
PMCID: PMC129666  PMID: 11062231
14.  Design of Computer-aided Instruction for Radiology Interpretation: The Role of Cognitive Task Analysis 
Traditional task analysis for instructional design has emphasized the importance of precisely defining behavioral educational objectives and working back to select objective-appropriate instructional strategies. However, this approach may miss effective strategies. Cognitive task analysis, on the other hand, breaks a process down into its component knowledge representations. Selection of instructional strategies based on all such representations in a domain is likely to lead to optimal instructional design. In this demonstration, using the interpretation of cervical spine x-rays as an educational example, we show how a detailed cognitive task analysis can guide the development of computer-aided instruction.
PMCID: PMC2243627
19.  Cognitive Differences in Chart Reading: A Comparison of Nurses and Physicians 
This pilot study compares the mental models of a patient constructed by nurses and physicians while reading an electronic medical record. Preliminary results suggest that the participants' summaries were both quantitatively and qualitatively different. The physician made more inferences and focused on deeper relationships in the record, whereas the nurse focused on the descriptive surface structure of the record.
PMCID: PMC2243266
20.  Medical Informatics and the Science of Cognition 
Recent developments in medical informatics research have afforded possibilities for great advances in health care delivery. These exciting opportunities also present formidable challenges to the implementation and integration of technologies in the workplace. As in most domains, there is a gulf between technologic artifacts and end users. Since medical practice is a human endeavor, there is a need for bridging disciplines to enable clinicians to benefit from rapid technologic advances. This in turn necessitates a broadening of disciplinary boundaries to consider cognitive and social factors pertaining to the design and use of technology. The authors argue for a place of prominence for cognitive science. Cognitive science provides a framework for the analysis and modeling of complex human performance and has considerable applicability to a range of issues in informatics. Its methods have been employed to illuminate different facets of design and implementation. This approach has also yielded insights into the mechanisms and processes involved in collaborative design. Cognitive scientific methods and theories are illustrated in the context of two examples that examine human-computer interaction in medical contexts and computer-mediated collaborative processes. The framework outlined in this paper can be used to refine the process of iterative design, end-user training, and productive practice.
PMCID: PMC61330  PMID: 9824797
21.  Science and Practice 
Because scientific research is guided by concerns for uncovering “fundamental truths,” its time frame differs from that of design, development, and practice, which are driven by immediate needs for practical solutions. In medicine, however, as in other disciplines, basic scientists, developers, and practitioners are being called on increasingly to forge new alliances and work toward common goals. The authors propose that medical informatics be construed as a local science of design. A local science seeks to explain aspects of a domain rather than derive a set of unifying principles. Design is concerned with the creation, implementation, and adaptation of artifacts in a range of settings. The authors explore the implications of this point of view and endeavor to characterize the nature of informatics research, the relationship between theory and practice, and issues of scientific validity and generalizability. They argue for a more pluralistic approach to medical informatics in building a cumulative body of knowledge.
PMCID: PMC61329  PMID: 9824796
22.  Representing Clinical Guidelines in GLIF 
Abstract Objective: An evaluation of the cognitive processes used in the translation of a clinical guideline from text into an encoded form so that it can be shared among medical institutions.
Design: A comparative study at three sites regarding the generation of individual and collaborative representations of a guideline for the management of encephalopathy using the GuideLine Interchange Format (GLIF) developed by members of the InterMed Collaboratory.
Measurements: Using theories and methods of cognitive science, the study involves a detailed analysis of the cognitive processes used in generating representations in GLIF. The resulting process-outcome measures are used to compare subjects with various types of computer science or clinical expertise and from different institutions.
Results: Consistent with prior studies of text comprehension and expertise, the variability in strategies was found to be dependent on the degree of prior experience and knowledge of the domain. Differing both in content and structure, the representations developed by physicians were found to have additional information and organization not explicitly stated in the guidelines, reflecting the physicians' understanding of the underlying pathophysiology. The computer scientists developed more literal representations of the guideline; additions were mostly limited to specifications mandated by the logic of GLIF itself. Collaboration between physicians and computer scientists resulted in consistent representations that were more than the sum of the separate parts, in that both domain-specific knowledge of medicine and generic knowledge of guideline structure were seamlessly integrated.
Conclusion: Because of the variable construction of guideline representations, understanding the processes and limitations involved in their generation is important in developing strategies to construct shared representations that are both accurate and efficient. The encoded guidelines developed by teams that include both clinicians and experts in computer-based representations are preferable to those developed by individuals of either type working alone.
PMCID: PMC61328  PMID: 9760394

Results 1-25 (63)