By Yuval Bitan, Ph.D.
The Cognitive Technology Laboratory (CtL) was a unique research lab. Richard Cook assembled a multidisciplinary team of clinicians and human factors researchers that worked together on challenges clinicians face when working in healthcare systems. Richard, Michael O’Connor, Mark Nunnally, Chris Nemeth, and Allan Klock were the permanent members of the lab, which was housed in the Research Pavilion building at the University of Chicago. Visiting researchers such as Yoel Donchin, Sara Albolino, John Wreathall, Geva Greenfield (nee Vashitz) and myself joined for varied periods of times. For me, as a young researcher that had just finished his PhD, this was an opportunity not only to work with very experienced researchers but also to have direct access to the “field” – the operating rooms and the intensive care units of the University of Chicago hospitals.
One of the many challenges we studied was medication reconciliation. Medication reconciliation plays an important role in patient safety as it is a window into healthcare that highlights conflicting priorities and inconsistencies in patient care. One of the first things we learned was that medications were reconciled with respect to a patient’s ongoing needs, not their prior or current medication list. When we started to study medication reconciliation, we used a cognitive artefact to represent the thinking process clinicians apply when performing this task. The idea was to use cards that represent medications and patient conditions from a real patient record, and to capture how clinicians arrange these cards on a table. In the first study conducted by Geva Greenfield we used a camera that was mounted above the table and captured the cards’ movements. In the following study we further developed our card sorting task (CaST) method and used software running on an Android tablet computer as a mobile platform to collect data from clinicians in the intensive care units. This allowed us to recruit 153 on-duty clinicians and improved our ability to analyze the cards’ positions. The findings from these studies were presented in three papers that Richard led. We concluded that clinicians apply various cognitive strategies while reconciling medications and medical conditions, and that clinical information systems should support multiple cognitive strategies, allowing flexibility in organizing information. Richard elaborated on this concept in his 2017 chapter “Medication reconciliation is a window into “ordinary” work” in the book “Cognitive Systems Engineering: The Future for a Changing World” that was edited by Smith and Hoffman. He referred to medication reconciliation as a seemingly simple task that must be carefully weaved into the processes and tools of the healthcare system. A system that did this well would generate good outcomes for its patients and resilience with respect to other vulnerabilities; a system that did this poorly could cause failures and degrade its resilience.
References
Cook, R. I. (2017). Medication reconciliation is a window into “ordinary” work. In Cognitive Systems Engineering (pp. 53-76). CRC Press.
Vashitz G., Nunnally ME., Bitan Y., Parmet Y., O’Connor MF., Cook RI. (2011). Making sense of disease in medication reconciliation. Cognition, Technology & Work, 13(2), 151-158.
Vashitz G., Nunnally ME., Bitan Y., Parmet Y., O’Connor MF, Cook RI. (2013). How do clinicians reconcile conditions and medications? The cognitive context of medication reconciliation. Cognition, Technology & Work, 15(1), 109-116.
Bitan Y., Parmet Y., Greenfield G., Teng S., Cook R.I. and Nunnally M.E. (2019). Making sense of the cognitive task of medication reconciliation using a card sorting task. Human Factors, 61 (8).