Clinical decision-making in acute paediatrics : evaluation of the impact of an internet-delivered paediatric decision support system

Imperial Users onl

Automation bias and prescribing decision support – rates, mediators and mitigators

Purpose: Computerised clinical decision support systems (CDSS) are implemented within healthcare settings as a method to improve clinical decision quality, safety and effectiveness, and ultimately patient outcomes. Though CDSSs tend to improve practitioner performance and clinical outcomes, relatively little is known about specific impact of inaccurate CDSS output on clinicians. Although there is high heterogeneity between CDSS types and studies, reviews of the ability of CDSS to prevent medication errors through incorrect decisions have generally been consistently positive, working by improving clinical judgement and decision making. However, it is known that the occasional incorrect advice given may tempt users to reverse a correct decision, and thus introduce new errors. These systematic errors can stem from Automation Bias (AB), an effect which has had little investigation within the healthcare field, where users have a tendency to use automated advice heuristically. Research is required to assess the rate of AB, identify factors and situations involved in overreliance and propose says to mitigate risk and refine the appropriate usage of CDSS; this can provide information to promote awareness of the effect, and ensure the maximisation of the impact of benefits gained from the implementation of CDSS. Background: A broader literature review was carried out coupled with a systematic review of studies investigating the impact of automated decision support on user decisions over various clinical and non-clinical domains. This aimed to identify gaps in the literature and build an evidence-based model of reliance on Decision Support Systems (DSS), particularly a bias towards over-using automation. The literature review and systematic review revealed a number of postulates - that CDSS are socio-technical systems, and that factors involved in CDSS misuse can vary from overarching social or cultural factors, individual cognitive variables to more specific technology design issues. However, the systematic review revealed there is a paucity of deliberate empirical evidence for this effect. The reviews identified the variables involved in automation bias to develop a conceptual model of overreliance, the initial development of an ontology for AB, and ultimately inform an empirical study to investigate persuasive potential factors involved: task difficulty, time pressure, CDSS trust, decision confidence, CDSS experience and clinical experience. The domain of primary care prescribing was chosen within which to carry out an empirical study, due to the evidence supporting CDSS usefulness in prescribing, and the high rate of prescribing error. Empirical Study Methodology: Twenty simulated prescribing scenarios with associated correct and incorrect answers were developed and validated by prescribing experts. An online Clinical Decision Support Simulator was used to display scenarios to users. NHS General Practitioners (GPs) were contacted via emails through associates of the Centre for Health Informatics, and through a healthcare mailing list company. Twenty-six GPs participated in the empirical study. The study was designed so each participant viewed and gave prescriptions for 20 prescribing scenarios, 10 coded as “hard” and 10 coded as “medium” prescribing scenarios (N = 520 prescribing cases were answered overall). Scenarios were accompanied by correct advice 70% of the time, and incorrect advice 30% of the time (in equal proportions in either task difficulty condition). Both the order of scenario presentation and the correct/incorrect nature of advice were randomised to prevent order effects. The planned time pressure condition was dropped due to low response rate. Results: To compare with previous literature which took overall decisions into account, taking individual cases into account (N=520), the pre advice accuracy rate of the clinicians was 50.4%, which improved to 58.3% post advice. The CDSS improved the decision accuracy in 13.1% of prescribing cases. The rate of AB, as measured by decision switches from correct pre advice, to incorrect post advice was 5.2% of all cases at a CDSS accuracy rate of 70% - leading to a net improvement of 8%. However, the above by-case type of analysis may not enable generalisation of results (but illustrates rates in this specific situation); individual participant differences must be taken into account. By participant (N = 26) when advice was correct, decisions were more likely to be switched to a correct prescription, when advice was incorrect decisions were more likely to be switched to an incorrect prescription. There was a significant correlation between decision switching and AB error. By participant, more immediate factors such as trust in the specific CDSS, decision confidence, and task difficulty influenced rate of decision switching. Lower clinical experience was associated with more decision switching (but not higher AB rate). The rate of AB was somewhat problematic to analyse due to low number of instances – the effect could potentially have been greater. The between subjects effect of time pressure could not be investigated due to low response rate. Age, DSS experience and trust in CDSS generally were not significantly associated with decision switching. Conclusion: There is a gap in the current literature investigating inappropriate CDSS use, but the general literature supports an interactive multi-factorial aetiology for automation misuse. Automation bias is a consistent effect with various potential direct and indirect causal factors. It may be mitigated by altering advice characteristics to aid clinicians’ awareness of advice correctness and support their own informed judgement – this needs further empirical investigation. Users’ own clinical judgement must always be maintained, and systems should not be followed unquestioningly

The evaluation and enhancement of case driven diagnostic advice systems: a study in three domains

Relevant literature has been reviewed regarding the performance, implementation and evaluation of computer based medical decision support systems. The diagnostic performance of five simple case driven acute chest pain advice systems, have been compared using a standardized set of clinical records. A Bayesian inference model demonstrated superiority over two derived by logistic regression. Small data set flow charts performed well but both relied upon the use of expert opinion. A Bayesian acute abdominal pain diagnostic advice system has been evaluated in a clinical trial. Standardized data collection improved the diagnostic performance of doctors. In practice, the computer system offered little additional user benefit. From further tests in primary care, it was concluded that, whereas general practitioners might enhance their performance by using data collection sheets, paramedics might benefit through direct use of the computer. DERMIS is a new dermatology primary care diagnostic advice system. Components include a database derived from 5203 prospectively collected clinical records, a user interface, and an enhanced Bayesian inference model incorporating combined frequency estimates, expert beliefs and rationalized end-point groups. On laboratory testing, the diagnostic accuracy of DERMIS was 83%. The correct diagnosis appeared in the top three, of a possible 42 disease list on 97% of occasions. In a semi-field trial of DERMIS involving 49 general practitioners, doctors did not always collect the same information as a dermatologist but were able to significantly increase their chance of making a correct diagnosis through use of the computer system. It has been concluded that although implementation of DERMIS might well increase general practitioner diagnostic accuracy and lead to improvements in the management of skin disease in primary care, rates of referral for specialist opinion might not be affected unless standard management plans are adopted

An expert system in school psychology for PMHP

Primary Mental Health Project (PMHP) is a program for early detection and prevention of problems with school adjustment. PMHP identifies young children that have the potential for school problems early in their school careers, and uses trained paraprof essionals as child associates to work preventively with these children. To implement this program, several evaluation forms must be filled out for each student, to determine which children should, or should not, be referred to the program. Unfortunately, a limited number of PMHP professionals are available to evaluate students. Due to this limitation, it was the desire of the author to create an expert system that would take as input the PMHP evaluation forms and produce two forms of output: a profile on each student, giving ratings on various categories and making suggested referrals to the PMHP program when appropriate, and for students referred to PMHP, objectives or goals to be reached within some given timeframe

When AIs Outperform Doctors: Confronting the Challenges of a Tort-Induced Over-Reliance on Machine Learning

Someday, perhaps soon, diagnostics generated by machine learning (ML) will have demonstrably better success rates than those generated by human doctors. What will the dominance of ML diagnostics mean for medical malpractice law, for the future of medical service provision, for the demand for certain kinds of doctors, and in the long run for the quality of medical diagnostics itself? This Article argues that once ML diagnosticians, such as those based on neural networks, are shown to be superior, existing medical malpractice law will require superior ML-generated medical diagnostics as the standard of care in clinical settings. Further, unless implemented carefully, a physician\u27s duty to use ML systems in medical diagnostics could, paradoxically, undermine the very safety standard that malpractice law set out to achieve. Although at first doctor + machine may be more effective than either alone because humans and ML systems might make very different kinds of mistakes, in time, as ML systems improve, effective ML could create overwhelming legal and ethical pressure to delegate the diagnostic process to the machine. Ultimately, a similar dynamic might extend to treatment also. If we reach the point where the bulk of clinical outcomes collected in databases are ML-generated diagnoses, this may result in future decisions that are not easily audited or understood by human doctors. Given the well-documented fact that treatment strategies are often not as effective when deployed in clinical practice compared to preliminary evaluation, the lack of transparency introduced by the ML algorithms could lead to a decrease in quality of care. This Article describes salient technical aspects of this scenario particularly as it relates to diagnosis and canvasses various possible technical and legal solutions that would allow us to avoid these unintended consequences of medical malpractice law. Ultimately, we suggest there is a strong case for altering existing medical liability rules to avoid a machine-only diagnostic regime. We argue that the appropriate revision to the standard of care requires maintaining meaningful participation in the loop by physicians the loop

Health informatics in developing countries: An analysis and two African case studies.

This thesis relates informatics to the problems of health and medicine experienced in less developed countries. It evaluates the potential of health informatics and investigates the issues that constrain successful implementations. This serves as a basis for establishing a generic description of viable computer applications in the developing world. The thesis contains two case studies from sub-Saharan Africa. The first, undertaken in The Gambia, is based on a computer-assisted data collection system used in a longitudinal child health survey. The second, undertaken in Kenya, relates to a medical decision-aid system used in an out-patient clinic of a district hospital. In each case, an outline is given of the background to the application domain, and an analysis is made of some comparable prior systems that have been developed and evaluated. The two case studies provide interesting investigatory comparisons since both systems are used by health personnel with little computer experience, and exploit some state-of-the-art technologies despite the identified constraints that exist in developing countries. The context, system design, methods, and results of each case are described. A generalised evaluation approach is proposed and is used to summarise the case study findings. The evaluation framework employed includes components related to functional and human perspectives as well as the anticipated benefits to the health care system. The thesis concludes by suggesting some guidelines for the design and evaluation of future health information systems

Building expert systems: cognitive emulation.

Chapter 1 briefly introduces the concept of cognitive emulation, and outlines its current status. Chapter 2 reviews psychological research on human expert thinking. First, the study of expert thinking is placed in the context of modern cognitive psychology. Next, the principal methods and techniques employed by psychologists examining expert cognition are examined. The remainder of the chapter is given over to a review of the published literature on the nature and development of human expertise. Chapter 3 reviews the main arguments for and against cognitive emulation in expert system design. The tentative conclusion reached is that a significant degree of emulation is inevitable, but that a pure, unselective strategy of emulation is neither realistic nor desirable. Chapter 4 examines the prospects for cognitive emulation from a more pragmatic angle. Several factors are identified that represent constraints on the usefulness of a cognitive approach. However, a second set of factors is identified which should facilitate an emulation strategy - especially in the longer term. Some guidance is given on when to seriously consider adopting an emulation strategy. Chapter 5 presents a critical survey of expert system research that has already addressed the emulation issue. Six basic approaches to cognitive emulation are distinguished and evaluated. This helps draw out in more detail the implications of an emulation strategy for knowledge acquisition, knowledge representation and system architecture. The chapter concludes by discussing the issues that arise when different approaches to emulation are combined. Some guidance is offered on how this might be achieved. Chapter 6 summarizes the main themes and issues to have emerged, the design advice contained in the thesis, and the original contributions made by the thesis