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4/29/14	
  
1	
  
Alan H. Morris, M.D.
Psychological Foundation of
Clinical Decision-Support
Utah Health Services Research...
4/29/14	
  
2	
  
Arranging cafeteria
• able to ↑ or ↓ consumption of
many foods up to 25 %
• Influenced by small changes ...
4/29/14	
  
3	
  
%Measurements
Blood Glucose (mg/dl)
8
6
4
2
0
0 40 80 120 160 200 240 280 320
Simple Guideline
→
Target
...
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Psychological Foundation of Clinical Decision-Support

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Psychological Foundation of Clinical Decision-Support

  1. 1. 4/29/14   1   Alan H. Morris, M.D. Psychological Foundation of Clinical Decision-Support Utah Health Services Research Conference U of Utah, 30 April2014 Clinical Uncertainty- Complexity: >236 Variable Categories 1. Perception / Opinion 2. What does not work well 3. Nudging towards goals 4. Feasible solutions Survivor stories drive screening
 toward more Over diagnosis# More Intensive# Screening# More "Survivor"# Stories# More# Overdiagnosis# More Useful# Screening# Appears To Be# H. Gilbert Welch MD, MPH# Raffle AE, Gray JAM. Screening : evidence and practice. Oxford ; New York: Oxford University Press; 2007. xiv, 317 p Peter or# Andrew?# ECMO, Prayer# More # ECMO, Prayer# More Useful# ECMO,Prayer# Appear To Be# 1. Perception / Opinion 2. What does not work well 3. Nudging towards goals 4. Feasible solutions Central line associated blood stream infection: Hand hygiene at insertion: 62% (6-71% comply: infection control) 2014;42(2):94-9 1. Perception / Opinion 2. What does not work well 3. Nudging towards goals 4. Feasible solutions Many make bad decisions we would not have made if .. full attention.. had information and cognitive abilities.. self- control. p. 5. Yale University Press. Kindle Ed. 2008-04-08. Libertarian Paternalism Libertarian: people be free to opt out (liberty-preserving) Paternalistic: choice architects should influence behavior to make people healthier. Sunstein, Cass R.; Richard H. Thaler (2008-04-08). Nudge: Improving Decisions About Health, Wealth, and Happiness (p. 5). Yale University Press. Kindle Edition.
  2. 2. 4/29/14   2   Arranging cafeteria • able to ↑ or ↓ consumption of many foods up to 25 % • Influenced by small changes in context • Power: focus user attention Sunstein, Cass R.; Richard H. Thaler (2008-04-08). Nudge: Improving Decisions About Health, Wealth, and Happiness (p. 1-2). Yale University Press. Kindle Edition. Doctor is a choice architect • must describe alternative treatments to patients • organizing decision context • there is no neutral (uninfluenced) design. Sunstein, Cass R.; Richard H. Thaler (2008-04-08). Nudge: Improving Decisions About Health, Wealth, and Happiness (p. 1-2). Yale University Press. Kindle Edition. “Opt in” – Germany, 12% “Opt out” – Austria, 99% Drivers License Organ Donation http://www.nytimes.com/2009/09/27/business/economy/27view.html? _r=0&adxnnl=1&pagewanted=print&adxnnlx=1396455073-WPMVY2uodw+NxB1OxMBNrw Dual Process Theory (cognition) Slow Fast Conscious ~10-40 bits/s Burden: conserve X Unconscious ~11x106 bits/s No Burden X Aha! 2 1 System 2 Thinking (conscious) Dual Process Theory Beginning student SLOW- little data 10-60 bits/sec 15 Skilled performer Eyes closed No music “Autopilot”System 1 Thinking (unconscious) Dual Process Theory System 2 Thinking conscious System 1 Thinking unconscious Dual Process Theory - unburden conscious Traditional: Teach more Only small improvement (6-71% comply: infec control) 1. Perception / Opinion 2. What does not work well 3. Nudging towards goals 4. Feasible solutions Simple Guideline Bedside Paper Protocol Bedside Computer Protocol (eProtocol)
  3. 3. 4/29/14   3   %Measurements Blood Glucose (mg/dl) 8 6 4 2 0 0 40 80 120 160 200 240 280 320 Simple Guideline → Target Range %GlucoseMeasurements Bedside Paper Protocol Bedside Computer Protocol Expect 6-9 additional ICU Deaths/100 patients %GlucoseMeasurements Blood Glucose (mg/dl) 8 6 4 2 0 0 40 80 120 160 200 240 280 320 Western USA Southeast USA Northeast USA Singapore → Target Range Blood Glucose eProtocol-insulin %Measurements Blood Glucose (mg/dl) 8 6 4 2 0 0 40 80 120 160 200 240 280 320 ICU Type Pa- tients Measure- ments Research 493 21,321 Clinical Care 2,296 109,458 → Target Range %GlucoseMeasurements eProtocol-insulin: Research vs. Practice 1. Perception / Opinion 2. What does not work well 3. Nudging towards goals 4. Feasible solutions

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