Understanding Clinician Macrocognition to Inform the Design of a Congenital Heart Disease Clinical Decision Support System

Azadeh Assadi; Peter C Laussen; Gabrielle Freire; Patricia Trbovich

doi:10.3389/fcvm.2022.767378

Understanding Clinician Macrocognition to Inform the Design of a Congenital Heart Disease Clinical Decision Support System

Front Cardiovasc Med. 2022 Feb 3:9:767378. doi: 10.3389/fcvm.2022.767378. eCollection 2022.

Authors

Azadeh Assadi^{1

2}, Peter C Laussen^{3

4

5}, Gabrielle Freire⁶, Patricia Trbovich^{2

7

8}

Affiliations

¹ Department of Critical Care Medicine, Labatt Family Heart Centre, Toronto, ON, Canada.
² Department of Engineering and Applied Sciences, Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.
³ Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
⁴ Executive Vice President for Health Affairs, Boston Children's Hospital, Boston, MA, United States.
⁵ Harvard Medical School, Boston, MA, United States.
⁶ Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
⁷ Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
⁸ Research and Innovation, North York General Hospital, Toronto, ON, Canada.

Abstract

Background and objectives: Children with congenital heart disease (CHD) are at risk of deterioration in the face of common childhood illnesses, and their resuscitation and acute treatment requires guidance of CHD experts. Many children with CHD, however, present to their local emergency departments (ED) with gastrointestinal and respiratory symptoms that closely mimic symptoms of CHD related heart failure. This can lead to incorrect or delayed diagnosis and treatment where CHD expertise is limited. An understanding of the differences in cognitive decision-making processes between CHD experts and ED physicians can inform how best to support ED physicians when treating CHD patients.

Methods: Cardiac intensivists (CHD experts) and pediatric emergency department physicians (ED physicians) in a major academic cardiac center were interviewed using the critical decision method. Interview transcripts were coded deductively based on Schubert and Klein's macrocognitive frameworks and inductively to allow for new or modified characterization of dimensions.

Results: In total, 6 CHD experts and 7 ED physicians were interviewed for this study. Although both CHD experts and ED physicians spent a lot of time sensemaking, their approaches to sensemaking differed. CHD experts reported readily recognizing the physiology of complex congenital heart disease and focused primarily on ruling out cardiac causes for the presenting illness. ED physicians reported a delay in attributing the signs and symptoms of the presenting illness to congenital heart disease, because these clinical findings were often non-specific, and thus explored different diagnoses. CHD experts moved quickly to treatment and more time anticipating potential problems and making specific contingency plans, while ED physicians spent more time gathering a range of data prior to arriving at a diagnosis. These findings were then applied to develop a prototype web-based decision support application for patients with CHD.

Conclusion: There are differences in the cognitive processes used by CHD experts and ED physicians when managing CHD patients. An understanding of differences in the cognitive processes used by CHD experts and ED physicians can inform the development of potential interventions, such as clinical decision support systems and training pathways, to support decision making pertaining to the acute treatment of pediatric CHD patients.

Keywords: cognitive task analysis; congenital heart disease - cardiac; decision support; digital health (eHealth); emergency medicine (MeSH database); macrocognition.