Feasibility of Real-Time Cognitive Load Assessment Using Electronic Health Record Data and Wearable Sensors in Emergency Medicine: A Pilot Study

Background Emergency Department (ED) physicians experience high cognitive workload that can impair patient safety and physician well-being. Despite this critical challenge, robust methods for real-time cognitive load measurement remain elusive. Cognitive Load Theory (CLT) provides a framework distinguishing intrinsic load (IL: inherent task complexity) from extraneous load (EL: factors that interfere with task completion). Building on this framework, the ALERT (Adaptive Load Estimation in Real-Time) project aims to develop dynamic cognitive load models using passively collected Electronic Health Record (EHR) data, validated through biometric and subjective measures.

This pilot study aimed to (1) demonstrate the feasibility of collecting, synchronizing, and processing multimodal data (EHR interactions, patient encounter data, wearable biometrics, subjective cognitive load reports) from ED physicians during clinical shifts, and (2) explore preliminary relationships between these data modalities to identify promising signals of cognitive load, including the utility of biometrics in predicting high subjective load.

Two ED physicians (Physician A: 11 shifts; Physician B: 7 shifts) from an academic medical center were monitored. Data included: (a) EHR interaction logs (15-minute aggregations) linked with (b) patient encounter data (ESI scores mapped to an inverted numeric acuity scale) to derive IL and EL proxies; (c) continuous wearable biometric data (EDA, HRV features processed in 5-minute windows, aggregated to 15 minutes); and (d) subjective cognitive load ratings (Paas Scale), entered when physicians experienced notable high or low load. Data were merged onto a synchronized 15-minute timeline. Pearson correlations explored relationships. Logistic regression using selected biometric features (LF/HF, heart rate, RMSSD, skin conductance level) plus a physician dummy variable was used to predict high subjective load (Paas ≥ 7).

Multimodal data collection and synchronization were successfully achieved across 864 15-minute intervals. For Physician A, EHR activity diversity (EL proxy) showed a moderate positive correlation with Paas scores (r = 0.38), while maximum patient acuity (IL proxy) showed a smaller positive association (r = 0.10). For Physician B, several EL proxies demonstrated moderate positive correlations with Paas scores (r = 0.30–0.32), while the number of critical patients (IL proxy) showed a small positive association (r = 0.05). Physician A exhibited a moderate positive correlation between LF/HF ratio and Paas (r = 0.50). A logistic regression model using four selected biometric features and a physician identifier achieved an Area Under the ROC Curve (AUC) of 0.781 in discriminating high vs. low Paas scores (N = 60 observations with Paas data).

This pilot study demonstrates the feasibility of a multimodal approach for cognitive load assessment in the ED. Preliminary findings suggest EHR-derived load proxies correlate with subjective effort, and importantly, a small set of objective biometric features can discriminate high subjective cognitive load with good accuracy. These results strongly support the potential for the larger ALERT project. Competing Interest Statement The authors have declared no competing interest. Funding Statement Research reported in this preprint was supported by the National Library of Medicine of the National Institutes of Health under Award L70LM014637 (Christian Rose) and by the National Heart, Lung, and Blood Institute under Award R01HL172794 (David Kim). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: IRB of Stanford University gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All data produced in the present study are available upon reasonable request to the authors.