Understanding the nature of information seeking behavior in critical care: Implications for the design of health information technology

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Abstract

Objective

Information in critical care environments is distributed across multiple sources, such as paper charts, electronic records, and support personnel. For decision-making tasks, physicians have to seek, gather, filter and organize information from various sources in a timely manner. The objective of this research is to characterize the nature of physicians’ information seeking process, and the content and structure of clinical information retrieved during this process.

Method

Eight medical intensive care unit physicians provided a verbal think-aloud as they performed a clinical diagnosis task. Verbal descriptions of physicians’ activities, sources of information they used, time spent on each information source, and interactions with other clinicians were captured for analysis. The data were analyzed using qualitative and quantitative approaches.

Results

We found that the information seeking process was exploratory and iterative and driven by the contextual organization of information. While there was no significant differences between the overall time spent paper or electronic records, there was marginally greater relative information gain (i.e., more unique information retrieved per unit time) from electronic records (t(6) = 1.89, p = 0.1). Additionally, information retrieved from electronic records was at a higher level (i.e., observations and findings) in the knowledge structure than paper records, reflecting differences in the nature of knowledge utilization across resources.

Conclusion

A process of local optimization drove the information seeking process: physicians utilized information that maximized their information gain even though it required significantly more cognitive effort. Implications for the design of health information technology solutions that seamlessly integrate information seeking activities within the workflow, such as enriching the clinical information space and supporting efficient clinical reasoning and decision-making, are discussed.

Introduction

Human are often characterized as informavores [1]. We actively seek, gather, consume and share information for satisfying diverse needs [2]. The purpose of information seeking depends on, among other things, specific user needs and tasks at hand. In complex organizational contexts, the ability of humans to access and utilize the necessary task-related information leads to better productivity and performance. But, the unaided mind, no matter how competent, simply cannot focus on all available information for making optimal decisions. Cognitive barriers such as memory capacity limitations, lack of knowledge, information overload affect the optimality of decision-making strategies.

Critical care environments represent a prototypical information-intensive, distributed and collaborative setting [3], [4], where significant information is generated by health care professionals (physicians, residents, nurses, and other support staff), and from patient care related events (e.g., bed-side monitors laboratory tests, medication orders). Most often, this information is redundantly distributed across multiple sources, such as paper and electronic records, and physicians face the onerous task of finding, retrieving, and filtering the necessary information for decision-making tasks. The distributed nature of information organization in critical care settings poses significant challenges for physicians in their information seeking activities including: (a) increased patient care time resulting from longer time for finding, filtering and organizing information due to the redundancy in available information and (b) increased possibility of missing information due to the distributed nature of information. All of these significantly affect the quality of care, increase the possibility of adverse events and can potentially impact patient safety. With the increasing role of health IT and digital repositories in clinical settings, it is relevant to evaluate the role of technology in supporting (or impeding) clinical reasoning and decision-making [5].

We utilize a cognitively driven approach to characterize the efficacy of physicians’ information seeking process, and the structure and nature of clinical information that is retrieved and used for decision-making tasks. While the importance of cognitive science research on understanding the nuances of reasoning and decision-making has been well established, primarily through laboratory evaluations (e.g., [6], [7], [8]), we investigate information seeking and decision-making “in the wild,” [9] by preserving the constraints of information sources and their availability that physicians encounter in their regular clinical practice.

Insights on the information seeking behavior of physicians can help in identifying the inefficiencies (e.g., process loses) in the physician information seeking process, for developing cognitive models of physicians’ information choice behavior and for designing and developing integrated intelligent health IT solutions that can assist in clinical decision making. Additionally, understanding the structure and nature of information used by clinicians during this process can trigger the development of clinical systems that streamline information retrieval and visualization mechanisms.

Section snippets

Background and significance

The complexity of patient care is exacerbated in distributed, information-rich critical care environments where physicians have to find the “right information at the right time” for making timely decisions. There is significant empirical evidence that a large percentage of physicians’ information needs during the patient care process is often unmet. In a highly cited study, Covell et al. [10] found that only about 30% of a physician's information needs during patient encounters were met. Gorman

Setting

The study was conducted at a large academic hospital in the Gulf Coast area that had over 33,000 admissions in 2010. Our study focuses on a 16-bed “closed” [32] MICU (medical intensive care unit) managed by intensivists. In the unit, both paper and electronic charts were simultaneously maintained and used for patient care documentation. The distribution of information across these artifacts is detailed in Table 1. At the time of this study, the MICU did not have a CPOE (Computerized Physician

Qualitative evaluation: information seeking process

First, we provide a brief overview of the information seeking process in the MICU. Similar to what was reported in prior studies (e.g., [3], [47], [48]), we found that information was distributed among various sources: paper and electronic records, monitors, and people (nurses, pharmacists, respiratory therapists, and residents). During their information seeking process, physicians gathered information from paper charts, electronic records, through patient evaluation, and indirectly, from other

Discussion

We investigated information seeking behavior of physicians during clinical decision-making, focusing on the time spent on various sources from which the information was retrieved, the relative information gained and the structure of medical knowledge retrieved from the various sources. We found that physicians spent relatively equal amount of time on electronic and paper records for retrieving information during their decision making process. Overall, more information was retrieved from paper

Conclusion

Critical care environments present significant challenges for information seeking as information is distributed across multiple sources, such as paper charts, electronic records, bedside monitors and support personnel. Physicians have to expend cognitive resources to seek, filter and organize information from various sources for making diagnostic and therapeutic decisions. Based on a study of the information seeking behavior of physicians in a MICU, we found the information seeking process

Acknowledgments

This research project was partially supported by Grant No. 220020152 by James S McDonnell Foundation (JSMF) for Cognitive Complexity and Error in Critical Care to Vimla L. Patel and by Grant No. 10510592 for Patient-Centered Cognitive Support under the Strategic Health IT Advanced Research Projects Program (SHARP) from the Office of the National Coordinator for Health Information to Jiajie Zhang. We would like to thank Archana Laxmisan and Suchita Batwara for their help in data analysis, and

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