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NeoReviews Vol.10 No.11 2009 e527
© 2009 American Academy of Pediatrics

Neonatal Informatics—Dream of a Paperless NICU

Part Two: Understanding Clinical Expertise

^* Professor of Pediatrics, Physiology & Large Animal Clinical Sciences, Division of Neonatology, Departments of Pediatrics & Physiology, University of Florida Colleges of Medicine and Veterinary Medicine, Gainesville, Fla

Expert versus novice clinical data gathering, cognitive modeling strategies, and physical skills for evaluating medical problems differ markedly in complexity, clinical accuracy, and speed. Experts’ mental models develop during a decade of education and practical training. Clinical experts use data-based clinical information flow in near real-time to assess complex intensive care unit (ICU) situations and to act definitively and correctly within 2 to 30 seconds of acute problem recognition. Critical care bedside medical management of unstable neonates, when parents are present, challenges all existing clinical processes and computerized information systems. Success is currently-site dependent. Details are very important.

The critical care expert's working mental model is a temporally sequenced, multidimensional, physiologically based matrix, in which 20 to 60 simultaneous clinical variables can be assimilated nearly instantaneously. The mental data-seeking exercise follows an expert's cognitive pattern of simultaneously developing answers, while still seeking more data. Any computerized, paperless incarnation of clinical data management in NICUs should have instant data access at the bedside for full support of focused, expert-level, cognitive work and decision making. High-speed information reporting is essential in all ICU environments.

Critical care clinicians often are interrupted by a more urgent situation. Standard computer access/use/log-off is very difficult to incorporate seamlessly into a NICU workflow. Critical care physicians report feeling cognitively blinded by computer-related fragmentation of the temporally flowing clinical data streams. Nurses are distracted by time-consuming, adult-designed charting systems requiring typed data entry. Reports are slow and fragmented.

Neonatologists and criticalists find that existing computerized charting methods in NICUs waste time. Without bedside data tracking, quick understanding of the overall situation of a particular patient, at the bedside, at a particular moment is virtually impossible. New computerization introduces change that often disrupts generations-old clinical workflow functions and may have many unintended consequences. Planning, developing, or purchasing and implementing effective systems for totally computerizing an NICU is an interdisciplinary work in progress.

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