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Alan H. Morris, M.D.
Psychological Foundation of
Clinical Decision-Support
Utah Health Services Research
Conference
U of Utah, 30 April2014
Clinical Uncertainty- Complexity: >236
Variable Categories
1. Perception / Opinion
2. What does not work well
3. Nudging towards goals
4. Feasible solutions
Survivor stories drive screening
toward more Over diagnosis#
More Intensive#
Screening#
More "Survivor"#
Stories#
More#
Overdiagnosis#
More Useful#
Screening#
Appears To Be#
H. Gilbert Welch
MD, MPH#
Raffle AE, Gray JAM. Screening : evidence and practice. Oxford ; New York: Oxford University Press; 2007. xiv, 317 p
Peter or#
Andrew?# ECMO, Prayer#
More #
ECMO, Prayer#
More Useful#
ECMO,Prayer#
Appear To Be#
1. Perception / Opinion
2. What does not work well
3. Nudging towards goals
4. Feasible solutions
Central line associated blood
stream infection: Hand hygiene
at insertion: 62%
(6-71% comply: infection control)
2014;42(2):94-9
1. Perception / Opinion
2. What does not work well
3. Nudging towards goals
4. Feasible solutions
Many make bad
decisions we
would not have
made if .. full
attention.. had
information and
cognitive
abilities.. self-
control.
p. 5. Yale University Press. Kindle Ed. 2008-04-08.
Libertarian Paternalism
Libertarian: people be free to
opt out (liberty-preserving)
Paternalistic: choice architects
should influence behavior to
make people healthier.
Sunstein, Cass R.; Richard H. Thaler (2008-04-08). Nudge: Improving Decisions About
Health, Wealth, and Happiness (p. 5). Yale University Press. Kindle Edition.

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Arranging cafeteria
• able to ↑ or ↓ consumption of
many foods up to 25 %
• Influenced by small changes in
context
• Power: focus user attention
Sunstein, Cass R.; Richard H. Thaler (2008-04-08). Nudge: Improving Decisions About
Health, Wealth, and Happiness (p. 1-2). Yale University Press. Kindle Edition.
Doctor is a choice architect
• must describe alternative
treatments to patients
• organizing decision context
• there is no neutral
(uninfluenced) design.
Sunstein, Cass R.; Richard H. Thaler (2008-04-08). Nudge: Improving Decisions About
Health, Wealth, and Happiness (p. 1-2). Yale University Press. Kindle Edition.
“Opt in” – Germany, 12%
“Opt out” – Austria, 99%
Drivers License Organ Donation
http://www.nytimes.com/2009/09/27/business/economy/27view.html?
_r=0&adxnnl=1&pagewanted=print&adxnnlx=1396455073-WPMVY2uodw+NxB1OxMBNrw
Dual Process Theory (cognition)
Slow Fast
Conscious
~10-40 bits/s
Burden: conserve
X
Unconscious
~11x106 bits/s
No Burden
X
Aha!
2
1
System 2
Thinking
(conscious)
Dual Process Theory
Beginning student
SLOW- little data
10-60 bits/sec
15
Skilled performer
Eyes closed
No music
“Autopilot”System 1
Thinking
(unconscious)
Dual Process Theory
System 2
Thinking
conscious
System 1
Thinking
unconscious
Dual Process Theory - unburden conscious
Traditional:
Teach more
Only small
improvement
(6-71% comply: infec control)
1. Perception / Opinion
2. What does not work well
3. Nudging towards goals
4. Feasible solutions
Simple Guideline
Bedside Paper Protocol
Bedside Computer
Protocol (eProtocol)

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%Measurements
Blood Glucose (mg/dl)
8
6
4
2
0
0 40 80 120 160 200 240 280 320
Simple Guideline
→
Target
Range
%GlucoseMeasurements
Bedside Paper Protocol
Bedside Computer Protocol
Expect 6-9 additional
ICU Deaths/100 patients
%GlucoseMeasurements
Blood Glucose (mg/dl)
8
6
4
2
0
0 40 80 120 160 200 240 280 320
Western USA
Southeast USA
Northeast USA
Singapore
→
Target
Range
Blood Glucose eProtocol-insulin
%Measurements
Blood Glucose (mg/dl)
8
6
4
2
0
0 40 80 120 160 200 240 280 320
ICU Type Pa-
tients
Measure-
ments
Research 493 21,321
Clinical
Care 2,296 109,458
→
Target
Range
%GlucoseMeasurements
eProtocol-insulin: Research vs. Practice
1. Perception / Opinion
2. What does not work well
3. Nudging towards goals
4. Feasible solutions