Enhancing informatics competency under uncertainty at the point of decision: a knowing about knowing vision

Most informatics activity is aimed at reducing unnecessary errors, mistakes and misjudgements at the point of decision, insofar as these arise from inappropriate accessing and processing of data and information. Healthcare professionals use the results of scientific research, when available, and 'big data', when rigorously analysed, as inputs into the probability judgements that need to be made in decision making under uncertainty. But these judgements are needed irrespective of the state of 'the evidence' and personalised evidence on person/patient-important criteria is very often poor or lacking. This final stage in 'translation to the bedside' has received relatively little attention in the medical, nursing, or health informatics literature, until the recent appearance of 'cognitive informatics'. Positive experience and feed-back from several thousand students who have experienced exercises in assigning probabilities informs our future vision in which better decisions result from healthcare professionals--indeed all of us--having accepted that probability assignment is a skill, with the internal coherence and external correspondence of the probabilities assigned as twin evaluative criteria. As a route to improved correspondence--in the absence of the systematic recording and monitoring of real world judgments that would be the normal pathway to quality improvement--a 'Prober' is a set of statements to which the respondent supplies their personal probabilities that a statement is true. They receive the proper Brier score and its decomposition as analytical feedback, along with graphic representations of their discrimination and calibration, the two key components of good correspondence. Provided with estimates of their sensitivity (mean probability true for true statements) and specificity (1 minus mean probability true for false statements) they can visualise themselves as a 'test' when making diagnostic and prognostic judgements , thereby being given the cognitive foundation for such reflection in their clinical practice, including 'reflection in action'. They acknowledge that an appropriate balance of intuition and analysis is required, as in Hammond's Cognitive Continuum, and are made aware of the cognitive and motivated biases that can prevent us knowing 'how much we know about how much we know', with its deleterious effect on decision quality. Probability exercises, such as 'Probers', are proposed as an enhancement of professional courses and virtual learning environments, such as the TIGER initiative in nursing, through which the competency portfolio of all those seeking to deliver high quality person/patient-centred care can be expanded.