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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.

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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)

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% M

easu

rem

ents

Blood Glucose (mg/dl)

8

6

4

2

0 0 40 80 120 160 200 240 280 320

Simple Guideline

→ Target Range

% G

luco

se M

easu

rem

ents

Bedside Paper Protocol Bedside Computer Protocol

Expect 6-9 additional ICU Deaths/100 patients

% G

luco

se M

easu

rem

ents

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

% M

easu

rem

ents

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

% G

luco

se M

easu

rem

ents

eProtocol-insulin: Research vs. Practice

1. Perception / Opinion 2. What does not work well 3. Nudging towards goals 4. Feasible solutions