Detecting adverse events for patient safety research: a review of current methodologies <s> Comprehension of natural language text information <s> Preface Acknowledgements 1. Introduction Part I. The Theory: 2. Cognition and representation 3. Propositional representations 4. Modeling comprehension processes: the construction-integration model Part II. Models of Comprehension: 5. Word identification in discourse 6. Textbases and situation models 7. The role of working memory in comprehension 8. Memory for text 9. Learning from text 10. Word problems 11. Beyond text References name index Subject index. <s> BIB001 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Comprehension of natural language text information <s> Objective: Using electronic rather than paper-based record systems improves clinicians' information retrieval from patient narratives. However, few studies address how data should be organized for this purpose. Information retrieval from clinical narratives containing free text involves two steps: searching for a labeled segment and reading its content. The authors hypothesized that physicians can retrieve information better when clinical narratives are divided into many small, labeled segments (''high granularity''). Design: The study tested the ability of 24 internists and 12 residents at a teaching hospital to retrieve information from an electronic medical record — in terms of speed and completeness — when using different granularities of clinical narratives. Participants solved, without time pressure, predefined problems concerning three voluminous, inpatient case records. To mitigate confounding factors, participants were randomly allocated to a sequence that was balanced by patient case and learning effect. Results: Compared with retrieval from undivided notes, information retrieval from problem- partitioned notes was 22 percent faster (statistically significant), whereas retrieval from notes divided into organ systems was only 11 percent faster (not statistically significant). Subdividing segments beyond organ systems was 13 percent slower (statistically significant) than not subdividing. Granularity of medical narratives affected the speed but not the completeness of information retrieval. Conclusion: Dividing voluminous free-text clinical narratives into labeled segments makes patient-related information retrieval easier. However, too much subdivision slows retrieval. Study results suggest that a coarser granularity is required for optimal information retrieval than for structured data entry. Validation of these conclusions in real-life clinical practice is recommended. n J Am Med Inform Assoc. 1998;5:571 - 582. The primary function of the medical record is to sup- ply information for direct clinical practice. The med- ical record originally served as a memory-aid for the individual practitioner but has evolved to become a communication tool used by different professionals <s> BIB002 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Comprehension of natural language text information <s> A process for the preparation of R alpha -cyclopentenoids and then R alpha , R omega -cyclopentanoids is described. The process involves the reaction of a compound of the formula where X is halo, particularly Br or I and P is a protecting group with an alkylborane to produce the R alpha -cyclopentenone. The R alpha -cyclopentenone is reacted with a R omega cuprate to produce the R alpha , R omega -cyclopentenoid. The process is used for the preparation of prostaglandins which are known pharmaceutically active compounds. <s> BIB003 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Comprehension of natural language text information <s> This article provides a theoretical and methodological framework for the use of cognitive analysis to support the representation of biomedical knowledge and the design of clinical systems, using clinical-practice guidelines (CPGs) as an example. We propose that propositional and semantic analyses, when used as part of the system-development process, can improve the validity, usability, and comprehension of the resulting biomedical applications. The framework we propose is based on a large body of research on the study of how people mentally represent information and subsequently use it for problem solving. This research encompasses many areas of psychology, but the more important ones are the study of memory and the study of comprehension. Of particular relevance is research devoted to investigating the comprehension and memory of language, expressed verbally or in text. In addition, research on how contextual variables affect performance is informative because these psychological processes are influenced by situational variables (e.g., setting, culture). One important factor limiting the acceptance and use of clinical-practice guidelines (CPGs) may be the mismatch between a guideline's recommended actions and the physician-user's mental models of what seems appropriate in a given case. Furthermore, CPGs can be semantically complex, often composed of elaborate collections of prescribed procedures with logical gaps or contradictions that can promote ambiguity and hence frustration on the part of those who attempt to use them. An improved understanding of the semantics and structure of CPGs may help to improve such matching, and ultimately the comprehensibility and usability of CPGs. Cognitive methods of analysis can help guideline designers and system builders throughout the development process, from the conceptual design of a computer-based system to its implementation phases. By studying how guideline creators and developers represent guidelines, both mentally and in text, and how end-users understand and make decisions with such guidelines, we can inform the development of technologies that seek to improve the match between the representations of experts and practitioners. We urge informaticians to recognize the potential relevance of cognitive analysis methods and to begin more extensive experimentation with the their use in biomedical informatics research. <s> BIB004 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Comprehension of natural language text information <s> The purpose of this study is to investigate and characterize the errors in cognitive processes deployed in the comprehension of procedural texts found on pharmaceutical labels by subjects of different cultural and educational backgrounds. In this study, participants were asked to read and interpret three pharmaceutical labels related to children's medications of varying complexity: oral rehydration therapy (ORT); over-the-counter cough medicine; and over-the-counter fever medicine. Results indicate that: (1) all groups of participants had considerable difficulty in interpreting the instructions; (2), cultural and educational background appeared to be only weakly related to the accuracy of dosage and administration; and (3) errors of comprehension were related to three features of the texts: situation-representational complexity, inherent quantification complexity, and conformity with intuitive models of therapy based on prior knowledge. The results are discussed in terms of the role of multiple representations (boundary objects) and theories of text comprehension to facilitate the reduction of errors. <s> BIB005 </s> Detecting adverse events for patient safety research: a review of current methodologies <s> Comprehension of natural language text information <s> As the healthcare industry transitions from paper to electronic medical records (EMRs), medical informatics researchers face the task of ensuring that the electronic presentation of the information remains usable and effective while capitalizing on the ability of EMRs to tailor information to different users. In our research, we focus on utilizing formal cognitive science methodology to guide the conversion of paper-based narrative discharge summaries to a more dynamic, structured electronic version. In this paper, we present the results of a cognitive analytic study (1) that determines a ‘core’ component in medical narratives and (2) that compares the use of structured and narrative texts by physicians with varying expertise. Specifically, we studied six psychiatrists at three levels of expertise— experts, intermediates, and novices. The subjects were given two clinical case scenarios with discharge summaries and asked to verbalize their thoughts as they read through the summaries. The interview transcripts were analyzed for recalls and inferences generated in the verbalization. Based on experts’ verbalizations, the discharge summaries were organized into a more structured form and used in the interview of other subjects. Novice-level subjects had more recall with the structured than with the narrative format. More errors were also made in recall with the narrative than with the structured text. We discuss how these results are valuable in designing an EMR interface to reduce errors and to support users of different expertise. <s> BIB006
Another major cognitive framework necessary for the study of medical errors is comprehension and natural language processing of text information. A narrative text reflects natural prose, which is typically the way to express ones observations and thoughts. It does not guarantee, however, that the reader would understand this information exactly as the author meant it BIB001  . Natural language text understanding has two central and complementary component processes -production and interpretation. Both of these can be analyzed in terms of natural linguistic structures (e.g., syntax), propositions, concepts and discourse dynamics  . Information retrieval from such text has two steps. First, the user has to search through the text, which is guided by its internal structure, to select the section that might contain the relevant information. Second, the user has to read the content of this section to retrieve the information needed BIB002 . Structured text, in contrast, is a format that has an inherent order to it and is highly organized. Patel and colleagues  BIB004 point out that processing natural language text requires a distinction between the Ôtext baseÕ and Ôsituation modelÕ. A Ôtext baseÕ is a propositional representation of the meaning of the text itself. The reader generates meaning from the text by transforming the written information into some semantic form or conceptual message. In similar context, understanding may be regarded as a process whereby readers attempt to infer the knowledge structure of a writer through the text, based on what they already know. Thus the mental model developed by an individual who is reading a text is not limited to the information contained in the text itself but is extended to incorporate the readerÕs prior knowledge. In this sense, the reader constructs a Ôsituation modelÕ of the scenario described in the text. It is, then, from the interaction between the text-base and the situation model that the conceptual representation emerges BIB004 . This representation varies greatly from reader to reader as prior knowledge and experiences (i.e., expertise) differ. One example of such application is the paper by Sharda and colleagues BIB006 , who applied the theoretical concepts of variation in format and expertise to a study of discharge summaries. The doctor-patient interaction generated patient chart was viewed mostly as the Ôtext baseÕ since the chart represents the clinical information gathered from and provided by the patient. The discharge summary created from the data interpretation of the physician, reflects the representation of biomedical and clinical information originating from the physicians experience, and was equated to the Ôsituation modelÕ. In the field of comprehension, propositional analysis is one of the formal cognitive methods for investigating representation of meaning in memory. Details of the use of such methods are given in Patel et al. BIB004 , where the focus is on understanding and the use clinical practice guidelines. Propositional analysis provides the means to identify concepts and relation among these concepts, generating network structures at various levels of granularity. Text-based and situation-based structures to evaluate the level of understanding can be identified through these networks. The recall and the generation of inferences in reading a text can be coded and is linked to the understandability and the coherence of a text  . The amount of prior knowledge (expertise) in reading a text is also related to the process of inference generation and comprehensibility. The detail of the analysis detects and captures the nature of conceptual and procedural errors and problems in understanding this text, such as discharge summaries or data gathering in EMRs BIB004 . This method of detecting adverse effect through investigating cognitive process in comprehension equally applies to the reasoning by lay people, such as patients. For example, a study reported by Patel and colleagues on errors in interpreting quantities as procedures in the case of pharmaceutical labels addresses the case in point. Specifically, the correct interpretation of these labels demands that the reader translate minimal, quantitative formulas into qualitative, and often complex, procedures BIB005 . Given that medication errors involving the use of therapeutic drugs are amongst the most frequent BIB003 , an understanding of the way in which the users of such drugs interpret these labels when administering therapy, is a key step in reducing errors In this investigation of comprehension of instructions on pharmaceutical labels by people of diverse cultural and education backgrounds, participants were asked to read and interpret (using think aloud methods) pharmaceutical labels related to childrenÕs medications of varying complexity: (1) oral rehydration therapy (ORT); (2) over-the-counter cough medicine; and (3) over-thecounter fever medicine. Results show that all groups of participants had considerable difficulty in interpreting the instructions, generating errors of overdose or underdose. The errors of comprehension were attributed to three features of the therapeutic situation the labels presupposed: the uniformity of the application procedure, the complexity of the quantified variables, and the congruency with intuitive models of therapy. Uniformity of application was violated when there are irregular intervals or varying amounts of medication between doses. Complexity of quantified variables took the form of inherently difficult conversions, such as converting milligrams to milliliters, or too many calculations. Congruency with intuition was violated when procedures or their instruments must be applied in non-standard ways, such as when the recommended frequency of administration exceeded the readerÕs intuitive representation of the application situation. Instructions to the public could be monitored knowing the basic nature of the problems lay people have in understanding health instructions.