Cognitive Load Theory:Why using your EHR is so painful and

how to fix it

Michael Zimmerman, MD

Temescal Creek Medicine

A moment of clarityS30.201A- Contusion of unspecified external genital

organ, male, related to an altercation with a superhero,

initial encounter

Patient

Risk Factors

Medications

Problem List

Data

Care Team

Surgical History

Social History

Family History

Diabetes

CHF

Asthma

Family History

Social History

Surgical History

Problem List

Data

Risk Factors

Medication

Care Team

Got Cognitive Load?

Do you feel…TiredOverwhelmedBurned OutDisengagedRushedShort TemperLack of enthusiasm

Ask you doctor…

•Cognitive Load is the aggregate mental effort required in problem solving and learning.

Working Memory Working Memory is the space you have to do that work.It is finite and fixed.

Working Memory

Working MemoryProblem Solving->Learning

The Problem or

Task

1. Novel Information is Collected and Processed1. Auditory2. Visual

24 divided by 3

24 divided by 3

Working Memory

Working Memory Problem Solving->Learning

The Problem or

Task

1. Novel Information is Collected and Processed

1. Auditory2. Visual

24 divided by 3

2. Interpretation and consideration of information in context of existing knowledge schemas. (Long Term Memory)

Concepts of division and multiplication; 24/6 = 4

Here’s what I already know…

÷X

24/6

24 divided by 3

Working Memory Problem Solving->Learning

The Problem or

Task

1. Novel Information is Collected and Processed

1. Auditory2. Visual

24 divided by 3

2. Interpretation and consideration of information in context of existing knowledge schemas. (Long Term Memory)

3. Build and retention of new knowledge based on the problem solving experience.

÷X

24/6

24/3

24 divided by 3

24/3=8

24 divided by 3

Cognitive Load is the aggregate mental effort required in problem solving and learning.

Intrinsic Cognitive Load

The inherent complexity of the task.

Interactivity of elements.

2+2 18 + 37 879834+79275

Complexity 0-

Interactivity 0-

IntrinsicCognitive Load

Minimal Moderate Heavy

Medical Problem Solving?

= Intrinsic Load + Extraneous Load + Germaine Load

Extraneous Cognitive Load

manner in which information is presented to solver/learner

it is imposed by mental activities that can have a negative effect on learning if not designed appropriately. Extraneous load can interfere with the construction or automation of schemas.

a round plane figure whose

boundary consists of points

equidistant from a fixed point.

Cognitive Load is the aggregate mental effort required in problem solving and learning.

= Intrinsic Load + Extraneous Load + Germaine Load

What’s Missing?

“Germaine” Cognitive Load-

Learning

Load imposed by constructing new schemas and automating them…Learning! This is germane cognitive load.

Cognitive Load is the aggregate mental effort required in problem solving and learning.

= Intrinsic Load + Extraneous Load + Germaine Load

Intr

insi

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Lear

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Extr

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Task Completed Learned some new things

Working Memory >= Cognitive Load

Working MemoryAggregate Cognitive Load

Intr

insi

c (T

ask)

Lear

nin

g

Extr

insi

c (P

rese

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tio

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Intr

insi

c (T

ask)

Lear

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g

Extr

insi

c (p

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Task Completed Learned some new things

Working Memory >= Cognitive Load

Working Memory < Cognitive Load

Choices…1. Accept errors/ incomplete solutions2. Decrease Extrinsic Cognitive Load3. “Shrink” the Task4. Forgo new knowledge learning

Working Memory

What now?

Intr

insi

c (T

ask)

Lear

nin

g

Extr

insi

c (P

rese

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Working Memory < Cognitive Load

Choices…1. Accept errors/ incomplete solutions2. Decrease Extrinsic Cognitive Load3. “Shrink” the Task4. Forgo new knowledge learning

Working Memory

Accept cognitive shortcuts and ultimately errors

Intellectual Performance

Cognitive Load

Working Memory Capacity Beyond Capacity

Increase errorsSuboptimal task completion

Maladaptive Response to Cognitive Overload Mental shortcuts (Heuristics and Biases)

Aggregate biasAnchoringAscertainment biasAvailabilityBase-rateCommission biasConfirmation biasFeedback sanctionFraming effectFundamental attribution errorGambler’s fallacyGender bias

Hindsight biasMultiple alternatives biasOmission biasOrder effectsOutcome biasOverconfidence biasPlaying the oddsPosterior probability errorPremature closurePsych-out errorRepresentativeness restraint

Search satisfying Sutton’s slipSunk costsTriage cueingUnpacking principle Vertical line failureVisceral biasYin-Yang out

Reducing Extrinsic Load

Lear

nin

g

Extr

insi

c (P

rese

nta

tio

n)

Working Memory < Cognitive Load

Decrease Extrinsic Cognitive Load!

Intr

insi

c (T

ask)

Patient

Risk Factors

Meds

Problem List

Data

Care Team

Surgical History

Social History

Family History

Diabetes

CHF

Asthma

Getting started

Reduce Incidental Processing

Basic layout – Simple

• Structure• Predictable, Consistent, Minimize scanning

• Colors/Symbols• Meaningful, Consistent

• Content • Increase Signal to Noise Ratio, Eliminate non essential information

Reduce Incidental Processing

Basic layout – Simple

• Presentation• Consistent with the providers Mental Model/schema

• Flow• Consistent with clinical thinking, Return me where I left off, Predict

and make available 3 next most common actions

• *Make documentation a byproduct of the clinical work

example

Oh yeah, also 800x600 Resolution is so 1999

Reducing Extrinsic Cognitive Load

• Presentation of information in format and structure consistent with how providers see the world (schema).

Remember our card game?

Examples

• Problems• Last Assessment

• Comments

• Last Assessment Date

• Previous HPI/Plan

• Flowsheets-Clinical Clusters

Reducing Extrinsic Cognitive Load

• Structured documentation/data collection- Good templates, bad templates• My office phone number

• (1)5 (2)1 (3)0 (4)2 (5)3 (6)0 (7)2 (8)3 (9)7 (10)2

• (510) 230-2372

• If you want discrete data captured, you must make it easy

• example

Reducing Extrinsic Cognitive Load

• Make it easy to offload working memory when appropriate• Update in family hx, surgical hx.

• Refill medication

• Future reminder

• Flag task to MA

• Right tool for the job- quick visit

• Facilitate next steps

• examples

Reducing Intrinsic Load?

Intr

insi

c (T

ask)

Lear

nin

g

Extr

insi

c (P

rese

nta

tio

n)

Working Memory < Cognitive Load

Choices…

“Chunking”- breaking up task

Examples?

Germaine Load- Learning

Intr

insi

c (T

ask)

Lear

nin

g

Extr

insi

c (P

rese

nta

tio

n)

Working Memory < Cognitive Load

Best place for learning? Perhaps not the middle of an office visit

•Cognitive Load is the aggregate mental effort required in problem solving and learning.

Working MemoryWorking memory is finite and is the rate limiting step

Help the doctor help the patient Shrink Intrinsic Load by breaking down tasks Shrink Extrinsic Load by addressing presentation of information Limit Learning (Germaine) Load by avoiding “education” during visits

References

• Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003; 78: 775-780.

• Groopman J. How doctors think. Boston: Houghton Mifflin Company; 2007.

• Mayer R. Nine Ways to Reduce Cognitive Load in Multimedia Learning EDUCATIONAL PSYCHOLOGIST 2003, 38(1), 43–52

• Daniel Kahneman. Thinking, fast and slow; New York : Farrar, Straus and Giroux, [2011]

Michael Zimmermanmzimmerman@tcreekmed.com

Jonathan Rodriguez, Sr.(774) 226-9684jrodriguez@ehs-corp.com

I just want to thank everyone who made this day necessary.

-Yogi Berra (1925-2015)