Medication omissions and dosing failures are frequent during transitions in patient care. Medication reconciliation (MR) requires bridging discrepancies in a patient’s medical history as a setting for care changes. MR has been identified as vulnerable to failure, and a clinician’s cognition during MR remains poorly described in the literature. We sought to explore cognition in MR tasks. Specifically, we sought to explore how clinicians make sense of conditions and medications. We observed 24 anesthesia providers performing a card-sorting task to sort conditions and medications for a fictional patient. We analyzed the spatial properties of the data using statistical methods. Most of the participants (58%) arranged the medications along a straight line (p < 0.001). They sorted medications by organ systems (Friedman’s χ 2(54) = 325.7, p < 0.001). These arrangements described the clinical correspondence between each two medications (Wilcoxon W = 192.0, p < 0.001). A cluster analysis showed that the subjects matched conditions and medications related to the same organ system together (Wilcoxon W = 1917.0, p < 0.001). We conclude that the clinicians commonly arranged the information into two groups (conditions and medications) and assigned an internal order within these groups, according to organ systems. They also matched between conditions and medications according to similar criteria. These findings were also supported by verbal protocol analysis. The findings strengthen the argument that organ-based information is pivotal to a clinician’s cognition during MR. Understanding the strategies and heuristics, clinicians employ through the MR process may help to develop practices to promote patient safety.

Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians.

BACKGROUND:A wide therapeutic gap exists between evidence-based guidelines and their practice in the primary care, which is primarily attributed to physician and patient adherence.OBJECTIVE:This study aims to differentiate physician and patient adherence to dyslipidemia secondary prevention guidelines and various factors affecting it.METHODS:A post hoc analysis of data collected by a prospective cluster randomized trial with 7041 patients diagnosed with clinical atherosclerosis requiring secondary prevention of dyslipidemia and 127 primary care physicians over an 18-month period. Adherence was measured by physicians' and patients' actions taken according to the guidelines and correlated using multivariate logistic regressions.RESULTS:Physician adherence was 36.9% for lipid profile screening, 27.6% for pharmacotherapy up-titration and 21.0% for pharmacotherapy initiation. Physician adherence was positively correlated with frequent patient visits [odds ratios (OR = 1.304)], having more dyslipidemic patients (OR = 1.304) and treating immigrants (OR = 1.268). Patient adherence was 83.8%, 71.9% and 62.6% for medication up-titration, lipid profile screening and pharmacotherapy initiation, respectively. Patient adherence was affected by attending clinics with many dyslipidemic patients (OR = 1.542), being older (OR = 1.271) and being treated by a male physician (OR = 0.870).CONCLUSIONS:We learn from this study that (i) physician non-adherence was a major cause for the failure to follow guidelines, (ii) pharmacotherapy initiation was the most challenging issue to tackle and (iii) greater adherence occurred mainly in high volume conditions (patients and visits). Practical implications are designated focus on metabolic condition prevention in primary care by cardiologists or primary care clinics specializing in metabolic conditions and the need to facilitate more frequent follow-up visits.

Patients are most at risk during transitions in care across settings and providers. The communication and reconciliation of an accurate medication list throughout the care continuum are essential in the reduction in transition-related adverse drug events. Most current research focuses on the outcomes of reconciliation interventions, yet not on the clinician’s perspective. We aimed to explore clinicians’ cognitive processes and heuristics of making sense of patients’ disease histories. We used the affinity diagram method to simulate real-life medication reconciliation with 24 clinicians. The participants were given paper cards with diseases and medications representing a real case from an anesthesiology department. The task was to sort the cards in a set that made sense to the clinician. The experiment was video-recorded, and the data were analyzed using a quantitative spatial analysis technique. Levene’s test for equality of variance showed that 79% of the 24 participants arranged the diseases along a straight line (p < 0.001). With only few exceptions, the diseases were arranged along the line in a fixed order, from cardiac conditions to depression (Friedman’s χ2(44) = 291.9, p < 0.001). We learn from this study that although clinicians employ a variety of coping strategies while reconciling patients’ medical histories, there are common reconciliation strategies. Understanding heuristics and the mental models clinicians have for the reconciliation process may help to develop and implement methods and tools to promote safety research and practice.

BACKGROUND:There is a wide treatment gap between evidence-based guidelines and their implementation in primary care.OBJECTIVE:To evaluate the extent to which physicians "literally" follow guidelines for secondary prevention of dyslipidemia and the extent to which they practice "substitute" therapeutic measures.METHODS:We performed a post hoc analysis of data collected in a prospective cluster randomized trial. The participants were 130 primary care physicians treating 7745 patients requiring secondary prevention of dyslipidemia. The outcome measure was physician literal adherence or substitute adherence. We used logistic regressions to evaluate the effect of various clinical situations on literal and substitute adherence.RESULTS:Literal adherence was modest for ordering a lipoprotein profile (35.1%) and for pharmacotherapy initiations (26.0%), but rather poor for drug up-titrations (16.1%) and for referrals for specialist consultation (3.8%). In contrast, many physicians opted for substitute adherence for up-titrations (75.9%) and referrals for consultation (78.7%). Physicians tended to follow the guidelines literally in simple clinical situations (such as the need for lipid screening) but to use substitute measures in more complex cases (when dose up-titration or metabolic consultation was required). Most substitute actions were less intense than the actions recommended by the guidelines.CONCLUSIONS:Physicians often do not blindly follow guidelines, but rather evaluate their adequacy for a particular patient and adjust the treatment according to their assessment. We suggest that clinical management be evaluated in a broader sense than strict guideline adherence, which may underestimate physicians' efforts.

Second opinion is a decision-support tool for ratification or modification of a suggested treatment, by another physician. Second opinion may have a critical influence on the diagnosis, treatment and prognosis. The patient can benefit from treatment optimization and avoid unnecessary risks. The physician can benefit from less exposure to legal claims, and healthcare organizations can benefit from increased treatment, quality assurance and costs saving from unnecessary surgery and treatments. Nevertheless, injudicious use of this tool can provoke unnecessary medical costs. In recent years, many patients prefer to seek a second opinion on their disease and available treatments. Private and public insurance companies are trying to control surgery costs by urging and even demanding a second opinion before surgery. Although second opinions are common in medical practice, relatively little is known on this subject. Most of the studies reviewed in this article evaluated the clinical benefit of second opinions, the reasons patients seek a second opinion and the characteristics of these patients, as well as technological interventions to promote second opinions, and ethical or legal issues related to second opinions. Yet, there are opportunities for further studies about physicians attitudes and barriers towards second opinions, their effect on patient-physician communication and cost-effectiveness analyses of second opinions. Due to the relevance of second opinions for public heath, this review aims to summarize the current research on second opinions.

Clinical reminders can promote adherence with evidence-based clinical guidelines, but they may also have unintended consequences such as alert fatigue, false alarms and increased workload, which cause clinicians to ignore them. The described clinical reminder system identifies patients eligible for primary prevention of cardiovascular diseases and lets the physician to choose which patients will be included in the reminders intervention. We analyzed data of 87,165 visits of 35,699 patients and evaluated factors which may affect clinicians' decision to enroll patients to the intervention. The physicians included most of the patients suggested for inclusion (85.7%). Yet, they skipped the enrollment suggestion in 62.6% of the visits. Patients with a cardiovascular disease, dyslipidemia, diabetes, or hypertension were more likely to be included in the intervention, while older patients were less likely to be included. Insights regarding the usability of clinical reminders are discussed.

While clinical reminders can promote adherence with evidence-based clinical guidelines, they may have unintended consequences such as alert fatigue, false alarms and increased workload, which cause clinicians to ignore them. We evaluated clinicians' response rates to suggestions to enroll patients in a nationwide clinical reminders intervention, aiming to promote prevention of clinical arthrosclerosis. Analysis of 203,164 suggestions for 108,636 patients showed that the clinicians mostly ignored suggestions from the system and followed only 21.4% of the inclusion suggestions. The data show that when physicians could choose for which patients the reminders will be generated, they mostly chose not to include patients in the clinical reminders intervention. It seems that they tried to abort the process as soon as possible, rather than complete the workflow orderly. Insights regarding the usability of clinical reminders are discussed.

While clinical reminders can promote adherence with evidence-based clinical guidelines, they may have unintended consequences such as alert fatigue, false alarms and increased workload, which cause clinicians to ignore them. We evaluated clinicians' response rates to suggestions to enroll patients in a nationwide clinical reminders intervention, aiming to promote prevention of clinical arthrosclerosis. Analysis of 203, 164 suggestions for 108, 636 patients showed that the clinicians mostly ignored suggestions from the system and followed only 21.4% of the inclusion suggestions. The data show that when physicians could choose for which patients the reminders will be generated, they mostly chose not to include patients in the clinical reminders intervention. It seems that they tried to abort the process as soon as possible, rather than complete the workflow orderly. Insights regarding the usability of clinical reminders are discussed.

Decision-support systems, and specifically rule-based clinical reminders, are becoming common in medical practice. Despite their potential to improve clinical outcomes, physicians do not always use information from these systems. Concepts from the cognitive engineering literature on users' responses to warning systems may help to define physicians' responses to reminders. Based on this literature, we suggest an exhaustive set of possible responses to clinical reminders, consisting of four responses named "Compliance", "Reliance", "Spillover" and "Reactance". We suggest statistical measures to estimate these responses and empirically demonstrate them on data from a large-scale clinical reminder system for secondary prevention of cardiovascular diseases. There was evidence for Compliance, probably since the physicians found the reminders informative, but not for Reliance, in line with the notion that Compliance and Reliance are two distinct types of trust in information from decision-support systems. Our research supports the notion that CDSS can promote closing the treatment gap and improve physicians' adherence to guidelines.

Introduction: In-vehicle information systems can improve safety, improve driver's situational awareness and reduce anxiety, but they may also increase mental workload and distraction. This issue is particularly important in road tunnels because they create extremely dangerous driving conditions.Goals: To evaluate the effect of in-vehicle displays on driving safety in road tunnels, this paper address two questions: (1) can we still add information to in-vehicle displays without compromising safety? and (2) if information can still be added, how much information should added?Method: We simulated tunnel driving and evaluated the effects of driving performance with innovative in-vehicle displays in terms of safety and satisfaction. We compared a highly informative display and a minimal information display with driving without a display as a control.Results: Using the displays, drivers improved their speed control but had some difficulty in maintaining lane stability, apparently due to some distraction imposed by the displays. Yet, neither of them increased the mental workload relative to driving without a display. The drivers found the in-vehicle displays useful and responded well to the presented information. The drivers preferred the more informative display to the minimalist display, although it slightly increased distraction from road.Conclusions: In light of the potential benefits of in-vehicle displays, the level of distraction was relatively minor and should not compromise driving safety. Apparently, the highly informative display provided drivers with more information that reduced anxiety and boredom, which are common psychological experiences during tunnel driving. Thus, safety-related information displays can be added to improve safety even when some of their benefits are offset by increased distraction. (c) 2007 Elsevier Ltd. All rights reserved.

A variety of computer-based applications, including computerized clinical reminders, are intended to increase adherence to evidence-based clinical guidelines. The value of these systems in clinical practice is still unclear. One reason for the limited success of clinical reminders may be physicians' low tendency to adhere to their advice. We studied the determinants of physicians' adherence to clinical advice regarding the management of dyslipidemia. Overall, the clinical reminders increased physicians' adherence to the clinical guidelines. Physicians were more compliant with the reminders when they experienced a greater patients' load, when they were less acquainted with the patient, and when more time has passed since the last major cardiac event. These findings can help to predict physicians' adherence and to improve the usage of clinical reminders for the benefit of patients, physicians and HMOs.

This paper addresses theoretical aspects of human responses to warning systems and applies them to the responses to a clinical reminder system. The literature on warnings describes a number of responses, such as compliance and reliance, automation bias, and the “cry-wolf” effect. This paper suggests two complementary responses to compliance and reliance, named spillover and reactance, which can be placed within the framework of operators' responses to warning systems, and which altogether describe a complete set of possible responses to cues from warning systems. This set of responses is demonstrated on the example of a clinical reminder system, which mails reminders to primary care physicians regarding patients who require secondary prevention of clinical arteriosclerosis. The results mainly show evidence for compliance. Some theoretical conclusions are drawn.

Human Factors research on warning systems may have relevance beyond the specific domain of operators receiving warnings about potential problems in technological systems. We present an analysis of physicians' responses to letters generated by an automated decision support system in terms of findings in the human factors literature on warnings. The automated system mails reminders to primary medical teams about patients requiring screening or lipid-lowering drugs. The effectiveness of the system depends, among other factors, on physicians' responses to the reminders. Some properties of the reminder letter have parallels in warning systems. They should affect physicians' responses as they affect the responses of operators of technological systems. We report the results of preliminary analyses of data after a 16 months follow-up of 6,571 patients. The compliance rate to recommendations in the letters in the intervention group, in which physicians receive reminder letters, was significantly higher than in the control group. Physicians in the control group were found to be less compliant as the number of their patients requiring the medical care grows. In contrast, physicians in the intervention group, who received the reminder letters, maintained similar levels of compliance irrespective of the number of patients who required their care. Thus the letters appear to provide valuable information for physicians who have to cope with more difficult patient populations.