The Medical Home model is now being implemented widely across the VA. The need for a computerized medical record that effectively supports coordination and shared awareness among clinicians will become even more urgent and important. A substantial body of evidence now exists regarding the benefits of supporting shared mental models between clinicians. Although the current electronic health record has created many positive changes in care, it has also created substantial unintended negative consequences, including information overload, decreases in communication effectiveness and even increases in medical errors. A recent white paper by the NSF has documented the general failure of computerized records to provide adequate cognitive support for individuals and for shared awareness among clinicians. The advent of a new clinical model, the Medical Home, requires an even greater demand for effective computerized support for shared mental models. The purpose of this pilot is to test a theoretical supposition from the cognitive literature regarding how mental models for contextual information are created and shared within the Medical Home Health care system. The objectives of this study are to: 1) Conduct a cognitive task analysis (CTA) of case managers working in a Medical Home care environment; 2) Develop a use case and vignettes as simulation materials; 3) Assess the impact of a 'story-form' model versus an 'information' model on shared situational awareness in an experimental design study.
Aim 1 : CTA will be conducted through semi-structured interviews, observations with 'think- aloud' and simulated reports. All will be tape-recorded and transcribed. Analysis will use content coding, proposition analysis and descriptive counts.
Aim 2 : An expert panel (n=5) will construct a use case of a patient with dementia with a moderate amount of com-morbidities and social complexities. Two vignettes, either a story-form or a disease-based construction in a written 'report' will be constructed with independent face validation.
Aim 3 : Design. Forty nurses will be randomized to a 2 between (story-form vs disease-based) by 2 within (complete/incomplete). Procedures. Participants will receive a written report plus additional patient data. After reading, they will write a plan, and give a taped verbal report. Data Collected. Measures are based on situation awareness and include: 1) Perception/Recall of problems, contextual information, errors 2) Comprehension - high level understanding (gist); 3) Projection/Planning as measured by COCOMM control modes. Mean differences on measures will be analyzed using an ANOVA.
The Patient Centered Medical Home model of health-care delivery in primary care is becoming a national model of care and a high priority of the VA. A key component to the success of the model is effective information technology. Current Electronic Health Recors (EHR ) systems are often difficult to navigate, use precious cognitive resources and fail to provide a big picture view of the patient. In addition, the EHR is organized around disease entitites and neglect the patient's contextual information. Our long-term aim is to enhance the abiltiy of an EHR to support a shared awareness of the team regarding the patient's personal situation, pattern of care, social support and personal preferences. Cognitive literature suggests that mental models regarding social and episodic information is stored differently in memory than semantic knowledge structures. The purpose of this pilot is to test two modes of delivering contextual information to determine future design directions of the EHR.
