Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department.

OBJECTIVE: The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework. MATERIALS AND METHODS: In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system. RESULTS: Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record. DISCUSSION: Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses. CONCLUSION: Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

Exploring website gist through rapid serial visual presentation.

BACKGROUND: Users can make judgments about web pages in a glance. Little research has explored what semantic information can be extracted from a web page within a single fixation or what mental representations users have of web pages, but the scene perception literature provides a framework for understanding how viewers can extract and represent diverse semantic information from scenes in a glance. The purpose of this research was (1) to explore whether semantic information about a web page could be extracted within a single fixation and (2) to explore the effects of size and resolution on extracting this information. Using a rapid serial visual presentation (RSVP) paradigm, Experiment 1 explored whether certain semantic categories of websites (i.e., news, search, shopping, and social networks/blogs) could be detected within a RSVP stream of web page stimuli. Natural scenes, which have been shown to be detectable within a single fixation in the literature, served as a baseline for comparison. Experiment 2 examined the effects of stimulus size and resolution on observers' ability to detect the presence of website categories using similar methods. RESULTS: Findings from this research demonstrate that users have conceptual models of websites that allow detection of web pages from a fixation's worth of stimulus exposure, when provided additional time for processing. For website categories other than search, detection performance decreased significantly when web elements were no longer discernible due to decreases in size and/or resolution. The implications of this research are that website conceptual models rely more on page elements and less on the spatial relationship between these elements. CONCLUSIONS: Participants can detect websites accurately when they were displayed for less than a fixation and when the participants were allowed additional processing time. Subjective comments and stimulus onset asynchrony data suggested that participants likely relied on local features for the detection of website targets for several website categories. This notion was supported when the size and/or resolution of stimuli were decreased to the extent that web elements were indistinguishable. This demonstrates that schemas or conceptualizations of websites provided information sufficient to detect websites from approximately 140 ms of stimulus exposure.

Measuring the time course of selection during visual search.

In visual search tasks, observers can guide their attention towards items in the visual field that share features with the target item. In this series of studies, we examined the time course of guidance toward a subset of items that have the same color as the target item. Landolt Cs were placed on 16 colored disks. Fifteen distractor Cs had gaps facing up or down while one target C had a gap facing left or right. Observers searched for the target C and reported which side contained the gap as quickly as possible. In the absence of other information, observers must search at random through the Cs. However, during the trial, the disks changed colors. Twelve disks were now of one color and four disks were of another color. Observers knew that the target C would always be in the smaller color set. The experimental question was how quickly observers could guide their attention to the smaller color set. Results indicate that observers could not make instantaneous use of color information to guide the search, even when they knew which two colors would be appearing on every trial. In each study, it took participants 200-300 ms to fully utilize the color information once presented. Control studies replicated the finding with more saturated colors and with colored C stimuli (rather than Cs on colored disks). We conclude that segregation of a display by color for the purposes of guidance takes 200-300 ms to fully develop.

Directly Comparing Handoff Protocols for Pediatric Hospitalists.

BACKGROUND AND OBJECTIVES: Handoff protocols are often developed by brainstorming and consensus, and few are directly compared. We hypothesized that a handoff protocol (Flex 11) developed using a rigorous methodology would be more favorable in terms of clinicians' attitudes, behaviors, cognitions, or time-on-task when performing handoffs compared with a prevalent protocol (Situation Background Assessment Recommendation [SBAR]). METHODS: Using a between-groups, randomized control trial design (Flex 11 versus SBAR) during a pilot study in a simulated environment, 20 clinicians (13 attending physicians and 7 residents) received 3 patient handoffs from a standardized physician, managed the patients, and handed off the patients to the same standardized physician. Participants completed surveys assessing their attitudes and cognitions, and behaviors and handoff duration were assessed through observations. RESULTS: All data were analyzed using independent samples t tests. For attitudes, "ease of use" ratings were lower for SBAR participants than Flex 11 participants (P < .01), and "being helpful" ratings were lower for SBAR participants than Flex 11 participants (P = .02). For behaviors, results indicate no significant difference in the information acquired between the SBAR and Flex 11 protocols. However, SBAR participants gave significantly less information than Flex 11 participants (P < .01). For cognitions, SBAR and Flex 11 participants reported similar workload except for frustration. For handoff duration, there were no significant differences between the protocols (P = .36). CONCLUSIONS: The results suggest that Flex 11 is an efficient, beneficial tool in a simulated environment with pediatric clinicians. Future studies should evaluate this protocol in the inpatient setting.

Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes.

OBJECTIVE: The overall purpose was to understand the effects of handoff protocols using meta-analytic approaches. BACKGROUND: Standardized protocols have been required by the Joint Commission, but meta-analytic integration of handoff protocol research has not been conducted. METHOD: The primary outcomes investigated were handoff information passed during transitions of care, patient outcomes, provider outcomes, and organizational outcomes. Sources included Medline, SAGE, Embase, PsycINFO, and PubMed, searched from the earliest date available through March 30th, 2015. Initially 4,556 articles were identified, with 4,520 removed. This process left a final set of 36 articles, all which included pre-/postintervention designs implemented in live clinical/hospital settings. We also conducted a moderation analysis based on the number of items contained in each protocol to understand if the length of a protocol led to systematic changes in effect sizes of the outcome variables. RESULTS: Meta-analyses were conducted on 34,527 pre- and 30,072 postintervention data points. Results indicate positive effects on all four outcomes: handoff information (g = .71, 95% confidence interval [CI] [.63, .79]), patient outcomes (g = .53, 95% CI [.41, .65]), provider outcomes (g = .51, 95% CI [.41, .60]), and organizational outcomes (g = .29, 95% CI [.23, .35]). We found protocols to be effective, but there is significant publication bias and heterogeneity in the literature. Due to publication bias, we further searched the gray literature through greylit.org and found another 347 articles, although none were relevant to this research. Our moderation analysis demonstrates that for handoff information, protocols using 12 or more items led to a significantly higher proportion of information passed compared with protocols using 11 or fewer items. Further, there were numerous negative outcomes found throughout this meta-analysis, with trends demonstrating that protocols can increase the time for handover and the rate of errors of omission. CONCLUSIONS: These results demonstrate that handoff protocols tend to improve results on multiple levels, including handoff information passed and patient, provider, and organizational outcomes. These findings come with the caveat that publication bias exists in the literature on handoffs. Instances where protocols can lead to negative outcomes are also discussed. APPLICATION: Significant effects were found for protocols across provider types, regardless of expertise or area of clinical focus. It also appears that more thorough protocols lead to more information being passed, especially when those protocols consist of 12 or more items. Given these findings, publication bias is an apparent feature of this literature base. Recommendations to reduce the apparent publication bias in the field include changing the way articles are screened and published.

Differentiating global and local contour completion using a dot localization paradigm.

Competing theories of partially occluded object perception (amodal completion) emphasize either relatively local contour relationships or global factors such as symmetry. These disparate theories may reflect 2 separate processes: a low-level contour interpolation process and a higher-order global recognition process. The 2 could be distinguished experimentally if only the former produces precise representations of occluded object boundaries. Using a dot localization paradigm, we measured the precision and accuracy of perceived object boundaries for participants instructed to complete occluded objects with divergent local and global interpretations. On each trial, a small red dot was flashed on top of an occluder. Participants reported whether the dot fell inside or outside the occluded object's boundaries. Interleaved, 2-up, 1-down staircases estimated points on the psychometric function where the probability was .707 that the dot would be seen as either outside or inside the occluded object's boundaries. The results reveal that local contour interpolation produces precise and accurate representations of occluded contours, and consistency across observers, but completion according to global symmetry does not. These results support a distinction between local, automatic contour interpolation processes and global processes based on recognition from partial information. (PsycINFO Database Record

The Aperture Capture Illusion: misperceived forms in dynamic occlusion displays.

Visual illusions can reveal unconscious representations and processes at work in perception. Here we report a robust illusion that involves the misperception of moving, partially occluded objects. When a dynamically occluded object is seen through 2 misaligned apertures, the object appears misaligned in the direction of the apertures, creating the Aperture Capture Illusion. Specifically, when part of a dynamically occluded object disappears behind an occluding surface and then another part of the object comes into view immediately afterward, the 2 parts appear misaligned in the direction of the offset of the apertures through which they were seen. This illusion can be nulled: Separating the 2 object parts to increase the time interval between their appearance produced the percept of alignment. The ability to null the illusion in this manner demonstrates that dynamically occluded regions of moving objects continue to persist in perceptual awareness but, we argue, are perceived to move at a slower velocity than visible regions. We report 7 experiments establishing the existence of the illusion and ruling out several classes of explanation for it. We interpret the illusion and the ability to nullify it within the context of Palmer, Kellman, and Shipley's (2006) theory of spatiotemporal object formation.

Intrinsic motivation and attentional capture from gamelike features in a visual search task.

In psychology research studies, the goals of the experimenter and the goals of the participants often do not align. Researchers are interested in having participants who take the experimental task seriously, whereas participants are interested in earning their incentive (e.g., money or course credit) as quickly as possible. Creating experimental methods that are pleasant for participants and that reward them for effortful and accurate data generation, while not compromising the scientific integrity of the experiment, would benefit both experimenters and participants alike. Here, we explored a gamelike system of points and sound effects that rewarded participants for fast and accurate responses. We measured participant engagement at both cognitive and perceptual levels and found that the point system (which invoked subtle, anonymous social competition between participants) led to positive intrinsic motivation, while the sound effects (which were pleasant and arousing) led to attentional capture for rewarded colors. In a visual search task, points were awarded after each trial for fast and accurate responses, accompanied by short, pleasant sound effects. We adapted a paradigm from Anderson, Laurent, and Yantis (Proceedings of the National Academy of Sciences 108(25):10367-10371, 2011b), in which participants completed a training phase during which red and green targets were probabilistically associated with reward (a point bonus multiplier). During a test phase, no points or sounds were delivered, color was irrelevant to the task, and previously rewarded targets were sometimes presented as distractors. Significantly longer response times on trials in which previously rewarded colors were present demonstrated attentional capture, and positive responses to a five-question intrinsic-motivation scale demonstrated participant engagement.

Signal detection evidence for limited capacity in visual search.

The nature of capacity limits (if any) in visual search has been a topic of controversy for decades. In 30 years of work, researchers have attempted to distinguish between two broad classes of visual search models. Attention-limited models have proposed two stages of perceptual processing: an unlimited-capacity preattentive stage, and a limited-capacity selective attention stage. Conversely, noise-limited models have proposed a single, unlimited-capacity perceptual processing stage, with decision processes influenced only by stochastic noise. Here, we use signal detection methods to test a strong prediction of attention-limited models. In standard attention-limited models, performance of some searches (feature searches) should only be limited by a preattentive stage. Other search tasks (e.g., spatial configuration search for a "2" among "5"s) should be additionally limited by an attentional bottleneck. We equated average accuracies for a feature and a spatial configuration search over set sizes of 1-8 for briefly presented stimuli. The strong prediction of attention-limited models is that, given overall equivalence in performance, accuracy should be better on the spatial configuration search than on the feature search for set size 1, and worse for set size 8. We confirm this crossover interaction and show that it is problematic for at least one class of one-stage decision models.

What are the shapes of response time distributions in visual search?

Many visual search experiments measure response time (RT) as their primary dependent variable. Analyses typically focus on mean (or median) RT. However, given enough data, the RT distribution can be a rich source of information. For this paper, we collected about 500 trials per cell per observer for both target-present and target-absent displays in each of three classic search tasks: feature search, with the target defined by color; conjunction search, with the target defined by both color and orientation; and spatial configuration search for a 2 among distractor 5s. This large data set allows us to characterize the RT distributions in detail. We present the raw RT distributions and fit several psychologically motivated functions (ex-Gaussian, ex-Wald, Gamma, and Weibull) to the data. We analyze and interpret parameter trends from these four functions within the context of theories of visual search.

Reaction time distributions constrain models of visual search.

Many experiments have investigated visual search for simple stimuli like colored bars or alphanumeric characters. When eye movements are not a limiting factor, these tasks tend to produce roughly linear functions relating reaction time (RT) to the number of items in the display (set size). The slopes of the RTxset size functions for different searches fall on a continuum from highly efficient (slopes near zero) to inefficient (slopes>25-30ms/item). Many theories of search can produce the correct pattern of mean RTs. Producing the correct RT distributions is more difficult. In order to guide future modeling, we have collected a very large data set (about 112,000 trials) on three tasks: an efficient color feature search, an inefficient search for a 2 among 5s, and an intermediate colorxorientation conjunction search. The RT distributions have interesting properties. For example, target absent distributions overlap target present more than would be expected if the decision to end search were based on a simple elapsed time threshold. Other qualitative properties of the RT distributions falsify some classes of model. For example, normalized RT distributions do not change shape as set size changes as a standard self-terminating model predicts that they should.

A theory of dynamic occluded and illusory object perception.

Humans see whole objects from input fragmented in space and time, yet spatiotemporal object perception is poorly understood. The authors propose the theory of spatiotemporal relatability (STR), which describes the visual information and processes that allow visible fragments revealed at different times and places, due to motion and occlusion, to be assembled into unitary perceived objects. They present a formalization of STR that specifies spatial and temporal relations for object formation. Predictions from the theory regarding conditions that lead to unit formation were tested and confirmed in experiments with dynamic and static, occluded and illusory objects. Moreover, the results support the identity hypothesis of a common process for amodal and modal contour interpolation and provide new evidence regarding the relative efficiency of static and dynamic object formation. STR postulates a mental representation, the dynamic visual icon, that briefly maintains shapes and updates positions of occluded fragments to connect them with visible regions. The theory offers a unified account of interpolation processes for static, dynamic, occluded, and illusory objects.