Understanding Clinician Macrocognition to Inform the Design of a Congenital Heart Disease Clinical Decision Support System

Abstract

Background and ObjectivesChildren with congenital heart disease (CHD) are at risk of deterioration in the face of common childhood illnesses, and their resuscitation and acute treatment requires guidance of CHD experts. Many children with CHD, however, present to their local emergency departments (ED) with gastrointestinal and respiratory symptoms that closely mimic symptoms of CHD related heart failure. This can lead to incorrect or delayed diagnosis and treatment where CHD expertise is limited. An understanding of the differences in cognitive decision-making processes between CHD experts and ED physicians can inform how best to support ED physicians when treating CHD patients.MethodsCardiac intensivists (CHD experts) and pediatric emergency department physicians (ED physicians) in a major academic cardiac center were interviewed using the critical decision method. Interview transcripts were coded deductively based on Schubert and Klein's macrocognitive frameworks and inductively to allow for new or modified characterization of dimensions.ResultsIn total, 6 CHD experts and 7 ED physicians were interviewed for this study. Although both CHD experts and ED physicians spent a lot of time sensemaking, their approaches to sensemaking differed. CHD experts reported readily recognizing the physiology of complex congenital heart disease and focused primarily on ruling out cardiac causes for the presenting illness. ED physicians reported a delay in attributing the signs and symptoms of the presenting illness to congenital heart disease, because these clinical findings were often non-specific, and thus explored different diagnoses. CHD experts moved quickly to treatment and more time anticipating potential problems and making specific contingency plans, while ED physicians spent more time gathering a range of data prior to arriving at a diagnosis. These findings were then applied to develop a prototype web-based decision support application for patients with CHD.ConclusionThere are differences in the cognitive processes used by CHD experts and ED physicians when managing CHD patients. An understanding of differences in the cognitive processes used by CHD experts and ED physicians can inform the development of potential interventions, such as clinical decision support systems and training pathways, to support decision making pertaining to the acute treatment of pediatric CHD patients.

Decision-centered design of a clinical decision support system for acute management of pediatric congenital heart disease

“…In a previous study, we identified key components of decision making for ED physicians that were not being met (2). Specifically, we used Critical Decision Method (CDM) to…”

“…In a previous study, we identified key components of decision making for ED physicians that were not being met ( 2 ). Specifically, we used Critical Decision Method (CDM) to identify differences between ED physicians and subject matter experts (CHD experts) in how they acquire data and construct mental models to interpret patient data and determine course of therapy ( 2 ).…”

“…In a previous study, we identified key components of decision making for ED physicians that were not being met ( 2 ). Specifically, we used Critical Decision Method (CDM) to identify differences between ED physicians and subject matter experts (CHD experts) in how they acquire data and construct mental models to interpret patient data and determine course of therapy ( 2 ). CDM is a CTA technique used to study challenging incidents by eliciting concreate assessment indicators (e.g., cues and patterns) to treat incidents, particularly those that might have been missed by less experienced personnel ( 9 ).…”

“…To understand the decision-making differences between CHD experts and ED physicians, clinicians from each specialty participated in a virtual, audio recorded, semi-structured, two-hour interview where they recalled details of a prior clinical encounter managing an acutely ill pediatric patient with CHD. Details of the study can be found in ( 2 ) and sample questions for the semi-structured interview can be found in ( Supplementary Material S1 ). Transcripts of these interviews were used to compare the macrocognitive processes of CHD experts and ED physicians during their encounter.…”

“…The expertise required to correctly identify these physiologies and decide on a treatment strategy is often limited in the ED ( 1 ). As such, further CHD expertise is often sought to facilitate an understanding of the patient's physiology, expected baseline, and treatment strategies before transferring the patient to the cardiology service ( 2 ). In-person CHD expertise, however, is often lacking in community EDs which are often the initial site of care for acutely ill patients with CHD.…”