Background
Jean Piaget was a Swiss psychologist and philosopher known for his epistemological studies with children. His theories of cognitive development helped pioneer the field of developmental psychology that influenced generations of elementary school curriculum.
The usability of healthcare software, or lack thereof, has been a topic of discussion in recent years. The problem has become so widespread that the American Medical Association (AMA) has issued a framework for improving the ease of use of Electronic Health Record (EHR) systems that, in part, includes the reduction of cognitive load.
Piaget’s theories can be applied to understanding some of the reasons why many EHRs are just too hard to use. The theories can provide guidance for finding ways to reduce the cognitive workload that so often hinders the user experience of EHR systems.
According to Piaget, people are born with a very basic mental structure or schema (genetically inherited and evolved) on which all subsequent learning and knowledge is based. What Piaget called a schema is the basic building block of intelligent behavior, a way of organizing knowledge. Piaget (1952) defined a schema as “a cohesive, repeatable action sequence possessing component actions that are tightly interconnected and governed by a core meaning.” Piaget’s theories emphasized the importance of schemas in cognitive development and described how they were developed or acquired.
Schemas in Everyday Life
All people have schemas for interacting with the world in everyday life. Schemas provide us with the mental facility and knowledge needed to perform daily tasks. When eating out at a restaurant, for example, we all know how things will progress: The restaurant staff will greet us and then seat us, offer a drink, provide the menu, let us look at it, and then order, etc. As long as the scenario goes according to our existing schema everything goes smoothly.
Medical professionals have many schemas they use in their practice. Workflows are a real-world application of schema. Much like the restaurant example, seeing and treating a patient most often follows this set pattern or workflow: The patient arrives, vitals are taken then entered into the patient record, the doctor consults with the patient, then the doctor orders any tests or prescriptions, etc.
Learning through Assimilation and Accommodation
What happens when the scenario doesn’t match an existing schema? As we gain more experience with the world, our schema must evolve via the processes of learning. According to Piaget, the learning takes place via the processes of assimilation and accommodation.
Assimilation and Accommodation
Piaget used the terms “assimilation” and “accommodation” to describe how children are able to process and adapt their schema to new situations that have created a state of what he called disequilibrium in their cognitive structure.
Assimilation occurs when you can take an existing mental structure and incorporate it into a new event. Assimilation does not cause much cognitive load on the person because they are using an already existing mental structure to understand a new event. For example, when renting a car while on a business trip, once you get into the car, you are able to get going and drive out of the parking lot fairly quickly. This is because the rental car matches your mental model of how to drive a car: You put on the seat belt, adjust the seat and mirrors, and go.
Accommodation occurs when you must change your mental structure in order to understand and incorporate a new event. Accommodation requires considerably more cognitive load than assimilation because it requires you to rewire your brain and update, or create, a new mental structure to understand the event. This is the thinking that Steve Krug refers to when he claims, “Don’t make me think.”
Perhaps you use a Windows® based computer. Did it make sense that in order to shut down the computer you needed to first select the Start button? It probably is something that today you don’t even think about, but what about the very first time that you used a Windows-based computer? Did it make sense then? Probably not. Your mental understanding of how to use computers had to accommodate the Windows feature that in hindsight seems logically counter-intuitive.
Reducing Cognitive Load in EHR Systems
When EHR systems are created with little or no input from healthcare professionals, or without fully understanding their workflows, or schemas, it can increase the cognitive load placed upon the users of that system. EHR systems that require medical professionals to constantly accommodate schema or assimilate workflow increase the cognitive load placed upon the users. Because these engineering-centric designed systems force their users to accommodate to a new way of doing things, they are not perceived by healthcare professionals as usable.
Figure 1 shows an example of a vital signs entry form from an EHR we tested in 2022. The task was to enter a patient blood pressure reading.
Most people have a schema for understanding blood pressure. We know that blood pressure follows a set pattern of systolic/diastolic, or 120/70. In the EHR system we tested, each of the vitals is presented in an unknown order in a custom list control. To enter the blood pressure, the user had to find Systolic, scroll down, select Systolic, and then enter the value. Once that value had been entered, they had to find Diastolic, scroll up, and select Diastolic, and then enter the value.
In order to use this control and this method for entering blood pressure, the medical professionals had to make several accommodations to their understanding of data entry and of blood pressure readings. They also had to remember which value is systolic and which is diastolic.
Figure 2 shows an example of the blood pressure entry from another system we tested.
Figure 2: EHR user interface with fields based on workflow.
In this system, systolic is presented over the diastolic, and the entry is as simple as selecting the fields and entering the value. This system matches the mental model of how to enter blood pressure readings and doesn’t require the user to accommodate to a new way of doing things.
As evident from the sample systems presented above, there can be huge differences in the user interactions across EHRs. One of the systems above can be easily assimilated into a healthcare professional’s understanding of blood pressure entry, whereas the other forces them to make several schema accommodations. Which one would be perceived as more usable?
Conclusion
The field of psychology, especially cognitive psychology has, among other things, focused on understanding the processes by which we store information, make decisions, and communicate with others. Understanding and integrating Piaget’s theories and those of other cognitive psychologists can help inform a strategic user experience plan that focuses on the cognitive skills of users. Doing so will provide better EHR user experiences and can positively impact business ROI. Usability in healthcare saves money, but it also saves lives.
