One Size Does Not Fit All: EHR Clinical Summary Design Requirements for Nurses Sharon McLane, PhD, MBA, RN-BC1, 2, James P. Turley, PhD, RN2 Lakeland Regional Medical Center, Lakeland, FL1; The University of Texas School of Biomedical Informatics, Houston, TX2 Abstract Research has established the pivotal role of cognitive artifacts to human information visualization, the reduction of memory load, and critical thinking. A long-standing nursing practice is the development of a personal cognitive artifact that summarizes the clinical condition and plan of care for the patient(s) in the care of the nurse. Distributed cognition establishes the importance of the role of cognitive artifacts to the cognition of each individual. A feature/function of electronic health record applications is to supply a real-time clinical overview of a patient’s clinical condition and care needs, which is often referenced as a patient clinical summary. Research regarding the requirements of electronic clinical summaries to support clinician cognition has not been reported to date. This paper reports the results of initial research to establish foundational principles for the development of EHR patient clinical summaries that support the cognition and critical thinking of the registered nurse. Introduction Cognitive artifacts are external information and knowledge displays that reinforce or modify our extant knowledge. In the healthcare setting, cognitive artifacts are ubiquitous, with examples that include laboratory results, radiology images, hazardous waste icons, patient allergy alerts, clinical flowsheets, vital sign graphic records, and EHR data displays, including the patient clinical summary. Each of these instances of cognitive artifacts contains data that nurses interpret as information, and which guide critical thinking, development of the plan for delivery of care to an individual patient, and the actual process of patient care delivery. A nurse’s critical thinking1 is influenced by the data contained in a wide array of cognitive artifacts, and by how the nurse perceives and understands the data contained by cognitive artifacts. In the context of personal knowledge that is derived from education and experience, the nurse evaluates the data of a cognitive artifact and determines if the data warrants clinical intervention or modifications to the plan of care. Many nurses condense the clinical data displayed by multiple cognitive artifacts into a personal cognitive artifact to summarize the data the nurse perceives to be important and germane to the care of a patient during the next several hours or days. The nurse uses this personal cognitive artifact to prioritize care, provide reminders, serve as a temporary documentation resource, and reduce the need for memory storage and recall of clinical information important to the care of the patient. Many EHR information systems create a patient clinical summary that is intended to replace the personal cognitive artifact described above. This research was designed to study how these nurse-created personal cognitive artifacts influence critical thinking, cognition, and workflow prioritization of the nurse. The outcomes of this research establish a foundation of understanding that guide the design of EHR-generated patient clinical summaries that will not negatively influence or disrupt nurse critical thinking and cognition. Background The cognitive artifacts that nurses develop2 to meet their information and cognitive needs have evolved to meet several purposes. While the purpose and use of the nurse’s cognitive artifact may vary somewhat by individual, these cognitive artifacts provide the nurse with immediately available information and resources. Many nurses refer to this cognitive artifact as their “brain”; hereafter, we will reference this document as the PCCAT (personally created cognitive artifact). Table 1 contains examples of the purposes that a nurse’s PCCAT may serve, and was validated during artifact analysis and data collection. Distributed Cognition Theory3-6 provides insight regarding the data a nurse may choose to record on his/her PCCAT, and a model of the distributed cognition of a nurse is depicted in Figure 1. Distributed Cognition proposes that available clinical data (contained in external knowledge representations) and the experience and knowledge of the nurse (depicted as internal knowledge representations) iteratively influence the development of a nurse’s PCCAT. Information that the nurse perceives to be relevant to the care of the patient is influenced by the nurse’s perception and understanding of the data that is available, and the
nurse’s perception that the data is important. A nurse’s knowledge and experience influence the nurse’s perception that data contained in an external knowledge representation is relevant and important. The way in which the data is configured and organized in an external knowledge representation is another determinant of how the nurse perceives and understands of the data7. Table1. Baseline Summary PCCAT purpose as evidenced by the nurses Provide a summary of the clinical status of each assigned patient at the time of shift hand-off; may include recent or new symptoms and the outcome of clinical interventions Supply a snapshot of key physiologic data for each assigned patient, such as recent lab and radiology results, as well as results that are expected during the shift Provide a list of medications scheduled for the shift for each assigned patient; may include PRN and contingent medication orders (e.g. contingent electrolyte replacement orders) Remind the nurse to consult other care provider(s); remind the nurse to follow-up regarding incomplete or overdue consults Serve as a temporary data repository for updated clinical data (e.g. new lab results or medication orders) through the course of the shift and support recall for data transcription to the permanent medical record when available or when time permits Summarize the elements of the plan of care that need to be addressed or completed during the shift Figure 1 depicts a model of distributed cognition in the context of the daily development of the PCCAT. Within the context of his/her internal knowledge representations, the nurse may consult and evaluate several, all, or additional examples of external knowledge representations to create a personally meaningful external knowledge representation, or PCCAT.
Figure 1. Model of the Distributed Cognition of the Nurse An EHR-generated patient summary is another example of an external knowledge representation. The content of the patient summary, configuration of the data, spatial relationship between data elements, and organization of the data influence the nurse’s data perception and critical thinking. The patient summary generated by currently available EHR systems has limited functionality to enable personal customization by the nurse. The limited or absent ability to select the content, configuration, proximity/spatial relationships, and organization of patient summary data may
affect the critical thinking and cognition of the nurse. Regardless of whether a cognitive artifact is supplied by an external agent or created by the nurse, the PCCAT and EHR-generated patient summary are instantiations of external knowledge representations that have the potential to positively or negatively influence nurses’ critical thinking and cognition. The purpose of this research was to establish baseline functional requirements for an EHR-generated patient summary. This research was conducted in 2008-2009 at a major cancer care center located in the southern region of the United States. At the time, EHR documentation by nurses was limited to vital signs and allergies. This research investigated two informatics questions: 1. 2.
What data does the nurse record on the PCCAT, what are the characteristics of the data that is recorded, and how does the nurse use the PCCAT through the course of the shift? What criteria or requirements are necessary and foundational to guide the design of an effective EHRgenerated patient summary for nurses?
Methods Qualitative, multi-method data collection and triangulated, iterative data analysis were necessary to understand the complex cognitive dynamic of the PCCAT and how the nurse uses the PCCAT during patient care delivery. All registered nurses on three inpatient units were invited to participate in the study, and a convenience sample of 28 self-selected nurses was successfully recruited and consented. Six nurses were later withdrawn from the study due to changes in job status. The methods employed included analysis of 145 completed PCCATs gathered throughout data collection; shadowing 13 nurses as they developed and used the PCCAT; and 11 individual, digitally recorded, transcribed interviews. Three nurses completed digitally recorded and transcribed clinical scenario sessions. Clinical scenarios were constructed as presentation of a completed PCCAT based upon the clinical condition of two mock patients. The clinical scenarios included data identified as necessary by the nurses, included clinical data that were expected but not included on the PCCATs (i.e. patient education needs), and excluded selected data that the nurses had identified as necessary. Inclusions and exclusions were purposively intended to establish reliability. A content and taxonomic baseline analysis of the PCCAT artifact was created from 88 completed PCCATs collected from the subjects prior to subsequent data collection methods. The initial PCCAT analysis was supplemented by analysis of the PCCAT the nurse was using on the day of shadowing, interview, and the clinical scenario. The primary investigator (PI) employed a simple data collection tool during shadowing, handwriting the data generated. The role of the PI during shadowing was observational and largely silent, augmented by periodic questions to clarify an action or interaction. Shadowing sessions extended from 90-240 minutes. Interviews were 45-60 minute, one-on-one sessions using a set of prepared questions. The clinical scenario sessions were 30-45 minute, one-on-one, digitally recorded sessions that employed two prepared clinical scenarios. All digitally recorded sessions were professionally transcribed, and analyzed by the PI using NVivo8. Results Iterative, triangulated analysis of the qualitative data resulted in five major themes. Preparationp of the PCCAT disclosed that the process of seeking, selecting, and formatting the data on the PCCAT enabled the nurse to “develop a snapshot” and understanding of the patient’s clinical problems, current condition, and care needs. PCCAT preparation prompted consideration of data that may be missing, as well as data that should be expected – either anticipated or desirable – during the course of the shift. Annotations of whom the nurse needed to consult and the purpose of the consult, as well reminders, were frequently included. The second major theme was the value of personally handwritingh data on the PCCAT. The nurses expressed that handwriting promoted data recall. The act of recording data on the PCCAT reinforced awareness that data was available, as well as the benefit of knowing where the data was located on the PCCAT. A second advantage of the handwritten PCCAT was the utility of personal notations that enabled the nurse to record new results, create personal alerts and reminders, and make notations for later entry in the medical record. A third PCCAT theme was the PCCAT role in the nurse’s ability to recall/visual cuesr. Selecting and writing data on the PCCAT enabled the nurse to create visual cues or reminders that augmented the internal knowledge
representations of the nurse. The PCCAT also supported personal notes, and served as a temporary results repository until the nurse could document, or take the time to reflect prior to documentation. The PCCAT provided support on busy days filled with interruptions8, often serving as a tool to enable the nurse to refocus. One nurse succinctly summarized: “…[I am] constantly being interrupted – phone calls, called away…[I] stop what I’m doing and go do something else and then come back…[I can] look at my ‘brain’ and refocus and get back on track…”. Another reflection: “Without the brain, you just kind of – you’re floundering out there. It’s like, ‘Have it done this?’ ‘Have I not done it?’ ”. The nurse’s ability to visualize informationvi` in personally meaningful ways was clearly demonstrated during artifact analysis. Each nurse created PCCATs that demonstrated consistent and personally meaningful spatial, proximity, chronology, and other visual data display patterns. Many nurses used color and symbol codes to create visual cues with unique and personal meaning. Coding extended to the use of color highlighters, and often included various types of reminders and cues intended to call attention later in the shift. Cues included defined spaces to record information such as lab results expected during the shift, electrolyte replacement parameters, and ‘checkboxes’ that enabled the nurse to indicate that tasks had been completed or remained pending completion. Table2. Baseline Functional Requirements for Clinical Summaries in an EHR Requirement Preparation
p
Handwritingh
Information Visualizationvi
Recall/Visual Cuesr Organization & Prioritizationop
Requirement Examples
Rationale
Patient summary data elements can be selected by individual nurse Each nurse is able to create a personal task list or annotate the system generated summary for a single patient or group patients Each nurse may create personal reminders that are not part of the permanent EHR for nurse-specified events (e.g. call family, information to be discussed with physician, etc.) and forward to another nurse when appropriate Nurse may customize alerts & reminders as audio, visual, vibrate Each nurse defines spatial relationships between content elements Each nurse defines content of tables and graphs Each nurse defines use of chronology for individual or groups of patients Markups that are unique to the nurse, defined by the nurse, have meaning to the nurse, saved in the patient record for the length of the care episode but not part of the permanent record Nurse able to note questions that s/he wishes to address when consulting other team members Nurse able to create personal reminders
Supports individual internal knowledge representations Supports individual workflow, cognitive, and recall needs
Supports individual workflow, cognitive, and recall needs Supports individual workflow, cognitive, and recall needs Supports individual workflow, cognitive, and recall needs
The fifth important theme is the role of the PCCAT in organization and prioritizationop of the nurse’s work. The PCCAT served as a key instrument to identify and understand the needs of each patient in the nurse’s assignment, while also serving as a visual representation of the work that needed to be completed for all of the patients assigned to the care of the nurse. The assignment-centric view that most nurses created allowed the nurse to prioritize the care needs of the multiple patients included in his/her assignment. Several nurses comprehensively summarized the value and purpose of the PCCAT:
“[My brain] keeps [me] on track. It is a very complex to-do list…it’s kind of like (my) own private assistant that goes behind [me] and keeps [me] in line and keeps all [of my] appointments…”.
Whenever I get through and I’ve seen each patient, given all my meds, and gotten through that segment [of the day], I pull my brain out (see) what I need to do next…”.
“…[The brain] keeps (me) on track…gives (me) pertinent information about the patient. (I) can quickly reference the brain. I think it helps with time management, and good documentation too”.
“When it (the summary of the patient’s clinical condition and the plan of care) is all brought together in the same area, it’s like looking at a photo. It’s like, ‘Ta-da!’ There it is.”
Each of these five themes is critical to the design of EHR patient clinical summaries and task lists that are intended to support care delivery by nurses. These themes also point to the importance of assuring that new systems and functions, such as those embodied by an EHR implementation, do not create new risks to safe patient care through the disruption of the cognitive processes and critical thinking of the nurse. Discussion The five PCCAT themes translate into functional requirements to create an effective EHR-generated patient clinical summary targeted for use by nurses. These themes are summarized in Table 3. Absent an EHR-generated patient clinical summary that incorporates each of these five requirements, the EHR may disrupt key facets of distributed cognition by disturbing the perception and reasoning patterns of the nurse. These disruptions may create barriers to effective information visualization and processing, and promote workarounds that may compromise patient safety. The five functional requirements for an EHR-generated patient clinical summary are supported by Distributed Cognition theory and Information Visualization concepts: 1) the data a nurse needs to support effective cognition and critical thinking related to the plan of care is guided by the internal knowledge representations of the individual nurse; 2) internal knowledge representation is influenced by the experience, education, and knowledge of the individual nurse; and 3) internal knowledge representation is also influenced by personal information visualization needs. A ‘one-size-fits-all’ patient clinical summary is likely to result in suboptimal data content (i.e. extraneous data in the context of needed and missing data), and suboptimal data visualization (i.e., data proximity, spatiality, and chronology) to support data perception and critical thinking needs as determined by internal knowledge representations needs of the individual nurse. Absent the data content and configuration needed for optimal data perception to support critical thinking, the nurse may need to work harder to achieve perception and understand the data. Conversely, in the absence of optimal data content and configuration, the nurse may fail to effectively perceive information that is important to patient care decisions, and possibly increase risks to safe patient care. Conclusion The purpose of this research was to establish baseline functional requirements for an EHR-generated patient summary. Five requirements were established: 1) the importance of selecting and formatting the data, 2) the value of writing the data; 3) the importance of spatial, proximity and chronology data organization, 4) the role of visual cues that are personally meaningful to the individual nurse, and 5) the value of being able to see the care needs of an individual patient and an entire patient care assignment to the organization and prioritization of the nurse’s work. Generalization of this work is limited due to the sample size of 25 professional registered nurses, the inclusion of only one clinical profession, and the oncology setting. Replication in other clinical settings and with nurses and other clinical disciplines is needed. 1. 2. 3. 4. 5. 6. 7.
8.
References Scheffler BK, RUbenfeld MG. A consensus statement on critical thinking in nursing. Journal of Nursing Education. November 2000;39(8):352-359. McLane S, Esquivel A, Engebretson J, et al. Concept Analysis of Cognitive Artifacts. Advances in Nursing Science. December 2010;32(4):352-361. Hazelhurst B, Gorman PN, McMullen CK. Distributed cognition: An alternative model of cognition for medical informatics. International Journal of Medical Informatics. 2008;77:226-234. Hutchins E. Distributed Cognition. International Encyclopedia of the Social & Behavioral Sciences. 2004:2068-2072. Zhang J, Wang H. An Exploration of the Relations between External Representations and Working Memory. PLoS ONE. 2009;4(8):e6513. Zhang J, Patel VL. Distributed cognition, representation, and affordance. Cognition & Pragmatics. 2006;14(2):333-341. Card SK, Mackinlay JD, Shneiderman B, eds. Readings in Information Visualization: Using Vision to Think. San Francisco, CA: Morgan Kaufmann Publishers; 1999. Card S, Grudin J, Linton M, Nielsen J, Skelly T, eds. The Morgan Kaufmann Series in Interactive Technologies. Brixey JJ, Robinson DJ, Turley JP, Zhang J. The roles of MDs and RNs as initiators and recipients of interruptions in workflow. International Journal of Medical Informatics. 2010;79(6):e109-e115.
nurse’s perception that the data is important. A nurse’s knowledge and experience influence the nurse’s perception that data contained in an external knowledge representation is relevant and important. The way in which the data is configured and organized in an external knowledge representation is another determinant of how the nurse perceives and understands of the data7. Table1. Baseline Summary PCCAT purpose as evidenced by the nurses Provide a summary of the clinical status of each assigned patient at the time of shift hand-off; may include recent or new symptoms and the outcome of clinical interventions Supply a snapshot of key physiologic data for each assigned patient, such as recent lab and radiology results, as well as results that are expected during the shift Provide a list of medications scheduled for the shift for each assigned patient; may include PRN and contingent medication orders (e.g. contingent electrolyte replacement orders) Remind the nurse to consult other care provider(s); remind the nurse to follow-up regarding incomplete or overdue consults Serve as a temporary data repository for updated clinical data (e.g. new lab results or medication orders) through the course of the shift and support recall for data transcription to the permanent medical record when available or when time permits Summarize the elements of the plan of care that need to be addressed or completed during the shift Figure 1 depicts a model of distributed cognition in the context of the daily development of the PCCAT. Within the context of his/her internal knowledge representations, the nurse may consult and evaluate several, all, or additional examples of external knowledge representations to create a personally meaningful external knowledge representation, or PCCAT.
Figure 1. Model of the Distributed Cognition of the Nurse An EHR-generated patient summary is another example of an external knowledge representation. The content of the patient summary, configuration of the data, spatial relationship between data elements, and organization of the data influence the nurse’s data perception and critical thinking. The patient summary generated by currently available EHR systems has limited functionality to enable personal customization by the nurse. The limited or absent ability to select the content, configuration, proximity/spatial relationships, and organization of patient summary data may
affect the critical thinking and cognition of the nurse. Regardless of whether a cognitive artifact is supplied by an external agent or created by the nurse, the PCCAT and EHR-generated patient summary are instantiations of external knowledge representations that have the potential to positively or negatively influence nurses’ critical thinking and cognition. The purpose of this research was to establish baseline functional requirements for an EHR-generated patient summary. This research was conducted in 2008-2009 at a major cancer care center located in the southern region of the United States. At the time, EHR documentation by nurses was limited to vital signs and allergies. This research investigated two informatics questions: 1. 2.
What data does the nurse record on the PCCAT, what are the characteristics of the data that is recorded, and how does the nurse use the PCCAT through the course of the shift? What criteria or requirements are necessary and foundational to guide the design of an effective EHRgenerated patient summary for nurses?
Methods Qualitative, multi-method data collection and triangulated, iterative data analysis were necessary to understand the complex cognitive dynamic of the PCCAT and how the nurse uses the PCCAT during patient care delivery. All registered nurses on three inpatient units were invited to participate in the study, and a convenience sample of 28 self-selected nurses was successfully recruited and consented. Six nurses were later withdrawn from the study due to changes in job status. The methods employed included analysis of 145 completed PCCATs gathered throughout data collection; shadowing 13 nurses as they developed and used the PCCAT; and 11 individual, digitally recorded, transcribed interviews. Three nurses completed digitally recorded and transcribed clinical scenario sessions. Clinical scenarios were constructed as presentation of a completed PCCAT based upon the clinical condition of two mock patients. The clinical scenarios included data identified as necessary by the nurses, included clinical data that were expected but not included on the PCCATs (i.e. patient education needs), and excluded selected data that the nurses had identified as necessary. Inclusions and exclusions were purposively intended to establish reliability. A content and taxonomic baseline analysis of the PCCAT artifact was created from 88 completed PCCATs collected from the subjects prior to subsequent data collection methods. The initial PCCAT analysis was supplemented by analysis of the PCCAT the nurse was using on the day of shadowing, interview, and the clinical scenario. The primary investigator (PI) employed a simple data collection tool during shadowing, handwriting the data generated. The role of the PI during shadowing was observational and largely silent, augmented by periodic questions to clarify an action or interaction. Shadowing sessions extended from 90-240 minutes. Interviews were 45-60 minute, one-on-one sessions using a set of prepared questions. The clinical scenario sessions were 30-45 minute, one-on-one, digitally recorded sessions that employed two prepared clinical scenarios. All digitally recorded sessions were professionally transcribed, and analyzed by the PI using NVivo8. Results Iterative, triangulated analysis of the qualitative data resulted in five major themes. Preparationp of the PCCAT disclosed that the process of seeking, selecting, and formatting the data on the PCCAT enabled the nurse to “develop a snapshot” and understanding of the patient’s clinical problems, current condition, and care needs. PCCAT preparation prompted consideration of data that may be missing, as well as data that should be expected – either anticipated or desirable – during the course of the shift. Annotations of whom the nurse needed to consult and the purpose of the consult, as well reminders, were frequently included. The second major theme was the value of personally handwritingh data on the PCCAT. The nurses expressed that handwriting promoted data recall. The act of recording data on the PCCAT reinforced awareness that data was available, as well as the benefit of knowing where the data was located on the PCCAT. A second advantage of the handwritten PCCAT was the utility of personal notations that enabled the nurse to record new results, create personal alerts and reminders, and make notations for later entry in the medical record. A third PCCAT theme was the PCCAT role in the nurse’s ability to recall/visual cuesr. Selecting and writing data on the PCCAT enabled the nurse to create visual cues or reminders that augmented the internal knowledge
representations of the nurse. The PCCAT also supported personal notes, and served as a temporary results repository until the nurse could document, or take the time to reflect prior to documentation. The PCCAT provided support on busy days filled with interruptions8, often serving as a tool to enable the nurse to refocus. One nurse succinctly summarized: “…[I am] constantly being interrupted – phone calls, called away…[I] stop what I’m doing and go do something else and then come back…[I can] look at my ‘brain’ and refocus and get back on track…”. Another reflection: “Without the brain, you just kind of – you’re floundering out there. It’s like, ‘Have it done this?’ ‘Have I not done it?’ ”. The nurse’s ability to visualize informationvi` in personally meaningful ways was clearly demonstrated during artifact analysis. Each nurse created PCCATs that demonstrated consistent and personally meaningful spatial, proximity, chronology, and other visual data display patterns. Many nurses used color and symbol codes to create visual cues with unique and personal meaning. Coding extended to the use of color highlighters, and often included various types of reminders and cues intended to call attention later in the shift. Cues included defined spaces to record information such as lab results expected during the shift, electrolyte replacement parameters, and ‘checkboxes’ that enabled the nurse to indicate that tasks had been completed or remained pending completion. Table2. Baseline Functional Requirements for Clinical Summaries in an EHR Requirement Preparation
p
Handwritingh
Information Visualizationvi
Recall/Visual Cuesr Organization & Prioritizationop
Requirement Examples
Rationale
Patient summary data elements can be selected by individual nurse Each nurse is able to create a personal task list or annotate the system generated summary for a single patient or group patients Each nurse may create personal reminders that are not part of the permanent EHR for nurse-specified events (e.g. call family, information to be discussed with physician, etc.) and forward to another nurse when appropriate Nurse may customize alerts & reminders as audio, visual, vibrate Each nurse defines spatial relationships between content elements Each nurse defines content of tables and graphs Each nurse defines use of chronology for individual or groups of patients Markups that are unique to the nurse, defined by the nurse, have meaning to the nurse, saved in the patient record for the length of the care episode but not part of the permanent record Nurse able to note questions that s/he wishes to address when consulting other team members Nurse able to create personal reminders
Supports individual internal knowledge representations Supports individual workflow, cognitive, and recall needs
Supports individual workflow, cognitive, and recall needs Supports individual workflow, cognitive, and recall needs Supports individual workflow, cognitive, and recall needs
The fifth important theme is the role of the PCCAT in organization and prioritizationop of the nurse’s work. The PCCAT served as a key instrument to identify and understand the needs of each patient in the nurse’s assignment, while also serving as a visual representation of the work that needed to be completed for all of the patients assigned to the care of the nurse. The assignment-centric view that most nurses created allowed the nurse to prioritize the care needs of the multiple patients included in his/her assignment. Several nurses comprehensively summarized the value and purpose of the PCCAT:
“[My brain] keeps [me] on track. It is a very complex to-do list…it’s kind of like (my) own private assistant that goes behind [me] and keeps [me] in line and keeps all [of my] appointments…”.
Whenever I get through and I’ve seen each patient, given all my meds, and gotten through that segment [of the day], I pull my brain out (see) what I need to do next…”.
“…[The brain] keeps (me) on track…gives (me) pertinent information about the patient. (I) can quickly reference the brain. I think it helps with time management, and good documentation too”.
“When it (the summary of the patient’s clinical condition and the plan of care) is all brought together in the same area, it’s like looking at a photo. It’s like, ‘Ta-da!’ There it is.”
Each of these five themes is critical to the design of EHR patient clinical summaries and task lists that are intended to support care delivery by nurses. These themes also point to the importance of assuring that new systems and functions, such as those embodied by an EHR implementation, do not create new risks to safe patient care through the disruption of the cognitive processes and critical thinking of the nurse. Discussion The five PCCAT themes translate into functional requirements to create an effective EHR-generated patient clinical summary targeted for use by nurses. These themes are summarized in Table 3. Absent an EHR-generated patient clinical summary that incorporates each of these five requirements, the EHR may disrupt key facets of distributed cognition by disturbing the perception and reasoning patterns of the nurse. These disruptions may create barriers to effective information visualization and processing, and promote workarounds that may compromise patient safety. The five functional requirements for an EHR-generated patient clinical summary are supported by Distributed Cognition theory and Information Visualization concepts: 1) the data a nurse needs to support effective cognition and critical thinking related to the plan of care is guided by the internal knowledge representations of the individual nurse; 2) internal knowledge representation is influenced by the experience, education, and knowledge of the individual nurse; and 3) internal knowledge representation is also influenced by personal information visualization needs. A ‘one-size-fits-all’ patient clinical summary is likely to result in suboptimal data content (i.e. extraneous data in the context of needed and missing data), and suboptimal data visualization (i.e., data proximity, spatiality, and chronology) to support data perception and critical thinking needs as determined by internal knowledge representations needs of the individual nurse. Absent the data content and configuration needed for optimal data perception to support critical thinking, the nurse may need to work harder to achieve perception and understand the data. Conversely, in the absence of optimal data content and configuration, the nurse may fail to effectively perceive information that is important to patient care decisions, and possibly increase risks to safe patient care. Conclusion The purpose of this research was to establish baseline functional requirements for an EHR-generated patient summary. Five requirements were established: 1) the importance of selecting and formatting the data, 2) the value of writing the data; 3) the importance of spatial, proximity and chronology data organization, 4) the role of visual cues that are personally meaningful to the individual nurse, and 5) the value of being able to see the care needs of an individual patient and an entire patient care assignment to the organization and prioritization of the nurse’s work. Generalization of this work is limited due to the sample size of 25 professional registered nurses, the inclusion of only one clinical profession, and the oncology setting. Replication in other clinical settings and with nurses and other clinical disciplines is needed. 1. 2. 3. 4. 5. 6. 7.
8.
References Scheffler BK, RUbenfeld MG. A consensus statement on critical thinking in nursing. Journal of Nursing Education. November 2000;39(8):352-359. McLane S, Esquivel A, Engebretson J, et al. Concept Analysis of Cognitive Artifacts. Advances in Nursing Science. December 2010;32(4):352-361. Hazelhurst B, Gorman PN, McMullen CK. Distributed cognition: An alternative model of cognition for medical informatics. International Journal of Medical Informatics. 2008;77:226-234. Hutchins E. Distributed Cognition. International Encyclopedia of the Social & Behavioral Sciences. 2004:2068-2072. Zhang J, Wang H. An Exploration of the Relations between External Representations and Working Memory. PLoS ONE. 2009;4(8):e6513. Zhang J, Patel VL. Distributed cognition, representation, and affordance. Cognition & Pragmatics. 2006;14(2):333-341. Card SK, Mackinlay JD, Shneiderman B, eds. Readings in Information Visualization: Using Vision to Think. San Francisco, CA: Morgan Kaufmann Publishers; 1999. Card S, Grudin J, Linton M, Nielsen J, Skelly T, eds. The Morgan Kaufmann Series in Interactive Technologies. Brixey JJ, Robinson DJ, Turley JP, Zhang J. The roles of MDs and RNs as initiators and recipients of interruptions in workflow. International Journal of Medical Informatics. 2010;79(6):e109-e115.
