Distributed creative activity: expanding Tikhomirov’s original notion of creative activity

Faiola, A. Indiana University—School of Informatics and Computing, Indianapolis, USA

Introduction

Oleg K. Tikhomirov remains one of themost significant contemporary Russian psychologists, whose name is among theother pioneers from the post-Vygotskian School, following the work of AlekseyLeontiev and Alexander Luria (Aleksandrova-Howell, Abramson, & Craig, 2011;Babaeva et al., 2009). Tikhomirov’s work relies on the cultural and historicalaspects of activity in his study of creative activity theory, which expands thetraditional subject matter in the study on the “psychology of creativity.”Tikhomirov was the first to ask questions about the place of creative processesin everyday life, such as those in professional activity (Tikhomirov, 1971;Tikhomirov 1984). Tikhomirov’s theory of creative activity argues that interactionis realized through the activity of social intercourse or collective activity(Rozin, 2002). He significantly altered the concept of “intuition” to includethe observation of the mechanisms of unconscious processes in creative work,thus identifying the most essential moments of the creative act in addition todefining intellectual activity as the central activity using knowledge. Thus,the study of creativity in the works of Tikhomirov and his students disclosedthe interaction mechanisms between creative activities and the routinecomponents in complex forms of intellectual activities for both the individualand society.

Tikhomirov (1999) notes that creativeactivity is not only characterized by motives, goals, and operations, but moresignificantly by “acts generating new motives, goals, and operations... thegeneration of new psychic formations, the real function of which is givinghumans the opportunity to generate a new world of objects” (p. 350). Moreover,he says that goal formation (the generation of new goals in the subject’sactivity) is “one of the central acts in the structure of creative activity”(Tikhomirov, 1999, p. 351).

Application of creativeactivity to information technology

Secondary to his research oncreativity, was Tikhomirov’s work in the application of activity theory toinformation technology (IT). His groundbreaking contribution in the area ofactivity theory and computing identified IT as a new form of mediation. AsKozhanova (2003) notes, the traditional interpretation of activity did notaccount for diversity in the application of psychological aspects of human-computerinteraction (HCI), for either IT users or programmers. As such, much of Tikhomirov’smost relevant work on creative activity is in the area of goal formation in thecontext of computing. Tikhomirov repeatedly posed two questions that areimportant for our discussion: “How does the computer affect the developmentof... intellectual activity?” and “What is the specific nature of humanactivity in human-computer systems as opposed to other forms of activity?”(Tikhomirov, 1972, 1988, 1999).

More importantly, in the chapter ofhis book entitled, “The theory of activity changed by informationtechnology,” Tikhomirov outlines his theory of creativity activity, but inthe context of the new pervasiveness of computerization (Tikhomirov, 1999). Heholds that creative activity is an “independent activity type,” one that isoften not discussed (Tikhomirov, 1999, p. 348). He argues that with theincreasing appearance of new problems caused by IT, it is imperative that weconsider these problems in the context of creativity; otherwise the “sphere ofapplicability of activity theory in psychology” will hinder our means tofinding solutions (Tikhomirov, 1999, p. 349). The computer, he argues, is “notonly a universal data-processing device, it is also a universal means ofinfluencing human activity and, consequently, the human psyche” (Tikhomirov, 1999,p. 353).

In Tikhomirov’s earlier research, hedid not support the view that computerization could supplement or become asubstitute for psychological processes (Tikhomirov, 1972). He argued that thecomputer should be viewed simply as a new sign system that mediates humanactivity with some forms of qualitative thinking, and that its primary functionis to support efficient decision-making from the viewpoint of productivity. Hisoriginal premise on the boundaries of computerized mediation did not take intoaccount the evolutionary and ubiquitous nature of today’s computing, and itsinfluence on creative activity. Later, making reference to current empiricalresearch, we see a slight shift in his view, where he addressed “goal formationas a manifestation of creativity in the dialogue with computers,”showing its potential for “broadening human creative activity”(Tikhomirov, 1988; Tikhomirov, 1999, p. 353).

Particular to these studies issignificant evidence of goal formation in the context of joint activity,including the complexity of social roles in an array of everyday events andenvironments. In such places and times, both routine and creative components ofactivity are manifested. Tikhomirov addresses the problem by making adistinction between creative and routine activities. In sum, creative activityis able to provide solutions to existing problems and those that are possible,those that move outside the routine, because creative activity is in a sensecontrary to an algorithm, an “anti-algorithm” (Tikhomirov, 1999, p. 357).However, the “transfer of routine components to the computer means itsinclusion in the performance of a social role” — this, Tikhomirov argues,results in the “fundamental transformation of the content of the social roles”(1999, p. 354).

We should also understand his latterexpanded view as an enhancement of intelligence during joint activity, that is,subject-to-subject interpersonal cognition.[1]  Tikhomirov argues that in creative activity, the object appears in twoforms: “as a new product of activity (a product that didn’t exist before) andas an image of a yet to be created object” (Tikhomirov, 1999, p. 350). Heclearly differentiates between creative and routine activities, with the formerproviding solutions to existing and possible problems (those outside routine).In sum, he states that goal-formation in the subject’s activity is “one of thecentral acts in the structure of creative activity” (Tikhomirov, 1999, p. 351).

Clinical activity:communication and collaboration

Cognitive activity in healthcare isnow a focal point of much research in the field of HCI. At the center of thediscussion is the design and use of health information technology (HIT) as thekey form of mediation in patient care during the diagnostic processes. Theactivity goal is the sustainability of patient health and the mitigation ofhuman error.[2] Complex clinical spacessuch as the intensive care unit (ICU) are especially susceptible to diagnosticerror, not only because of the severity of the ailment and the fragility andinstability of the patient, but also because clinical knowledge and patientdata is distributed among clinical specialists and artifacts.[3] Specific studiesdemonstrate that 80% of medical error is attributed to human factors, e.g.,clinician cognitive overload, task and workflow management, inadequate teamcollaboration, and communication breakdown (Winters et al., 2012).

As Tikhomirov (1988) points out,communication is a highly complex activity. Understanding the cognition of othersrelating to their goals and motives entails problems to solve and conflicts toresolve, especially in a joint activity. In particular, he includes: “1)interpretation of another person’s reactions and movements; 2) understanding(interpreting, explaining, forecasting) the results of object-related actions(directly observed or previously registered) of another person and of activityas a whole, of an individual act (he gives me things, consequently he likesme); and 3) understanding verbal output (oral and written) (p. 179). In fact,health inter- personal cognition could include the “forming of concepts aboutanother person’s way of thinking” (p. 179), including their style of thinking,and what others may think about my thinking. Often in team communication,interpersonal cognition involves an opposition of persons, and their goals andmotives, resulting in communication breakdown and group conflict.

From the perspective of jointactivity, neither the patient nor the clinical team can be observed in isolation,nor can their activities be observed as individual and secluded actions withoutinfluence from the environment, available HIT, or other stakeholders (Leont’ev,1981). For this reason, the “concept of activity in psychology is a systemicconcept, for activity is considered as a system. ...Through activity, humansinteract with the surrounding world. Communication is an integral aspect ofjoint activity” (Tikhomirov, 1999, p. 348). As such, researchers will need toincreasingly observe the connection between communication, effectivecollaborative work, reduction of error, and overall patient safety (Reader,Flin, Cuthbertson, 2007).

Team Communication: One of the most extensive human factors that investigations of errordue to poor communication in the ICU discovered was that although nurse anddoctor communication only occurred in 2% of all activities, these wereassociated with over a third of detected errors (Donchin et al., 1995).Research suggests that team communication failure between physicians and nurseintensivists[4]contributes to 91% ofmedical mishaps (Khairat & Gong, 2011). Clinical communication among ICUteam members is reported as the main cause of 75% of medical errors and 65% ofsentinel events (Khairat & Gong, 2011). Another study found 2,075 incidentsof error that were related to communication breakdown in 23 ICUs over a periodof two years, with 42% of incidents related to medication administration and20% related to incorrect or incomplete delivery of care (Pronovost, et al., 2006).Researchers argue that communication is frequently interrupted and of poorquality, leading to inefficiencies and potential errors in the ICU (O’Connor etal., 2009). Increased length of stay, increased patient harm, and increasedresource utilization have been associated with ineffective communication(Sexton, Thomas, & Helmreich, 2000).[5]

Team Collaboration: Collaboration is defined as the process of decision-making involvingjoint activity and ownership of decisions, and collective responsibility for outcomes(McCaffrey et al., 2010). Measures of the quality of patient ICU care can alsobe assigned to high degrees of collaboration between nurses and doctors, whichhas a direct impact on improving patient mortality rates and reducing theaverage length of stay of patients. For this reason, investigations ofcommunication and error in the ICU offer valuable information for understandingthe connection between collaborative teamwork, reduction of error, and overallpatient safety (Reader, Flin, & Cuthbertson, 2007). Maxson et al., (2011)state that as the “complexity of patient care increases and more standardizationof postoperative pathways occurs, good communication and collaboration betweenmultidisciplinary teams of caregivers will be essential (p. 34).” Critical carerequires substantial cognitive work, with a synchronization of people,technology and facilities. Critical care also requires that individualcognitive tasks be distributed (Nemeth, 2008). Good communication andcollaboration between multidisciplinary teams is essential, since nurses andphysicians have significantly different perceptions of clinical decision-making(Maxson et al., 2011).

Moreover, communication and thedistribution of intelligence across clinical team members must be contextuallyrelevant when using HIT. To strengthen the collaborative experience, it is nowimperative to recognize that the social experience is transferred not only toothers, but also to information technology (Tikhomirov, 1999). Tikhomirovacknowledged that the manifestation of new problems contributed to the humandelegation of tasks to computers. As such, he asked: what is the nature of theactivity performed by humans in the context of advanced computerization, andhow does human activity change when humans use computers? He notes that to“shift responsibility to the computer could promote the formation ofsuperficial and even meaningless goals” (Tikhomirov, 1988, p.189).

Distributed cognition andhit

The increasing use of HIT has helpedto improve real-time collaboration among clinical teams, while reducing oreliminating decision latency through clinician-centered tools that support moreeffective communication. The goal is to maximize cognitive capabilities,mitigate constraints associated with collaboration and coordination betweenteam members in the form of communication activities such as dialogue, and toexchange patient diagnostic information. While human intelligence in support ofcritical care has focused primarily on individual cognition or cognitive load,the work of intensivists is intrinsically collective, with no one person beingchiefly able to execute all or most of the clinical activities. As such,complex cognitive processes that underlie critical care medicine need communicationsystems that can support the mitigation of diagnostic error by not focusing onthe thought process of any one individual.

Rather, clinical activity resides notin the mind of any particular individual, but is distributed across the mindsof multiple clinicians, technologies, and data sources (Cohen et al., 2006;Nemeth, 2008). Intensivists experience what we refer to as “distributedcognition,” being part of a broader clinical team who engage in patient supporteither face-to-face or through an assortment of HIT (Cohen et al., 2006;Rajkomar, & Blandford, 2011; Hollan, Hutchins, and Kirsch, 2000, & Hutchins,1995).[6] It is not unusual to findteam communication failure cited as a “root cause” of healthcare accidents.Single-factor solutions, such as standards on how to conduct patient recordhand-offs, are recommended in reaction to such conclusions. From a socialconstruction perspective, efforts to improve information transmission areinherently limited, because they fail to address how enduring patterns ofcommunication both create and sustain a team’s definition of itself and itssituation. However, healthcare team communication is both about transmissionand a social construction or framework in which team members develop a set ofclinical goals, roles, and behavior that help to establish order in a workenvironment (Pearce, 2006).

What is imperative is the need toexamine healthcare team communication along with the evolving complexity of theactivity’s context, the innovation of new HIT systems, and their impact on theaccurate transmission of information that supports collaboration. In lookingfor ways to reduce the fragmentation of communication systems that avoid thetraditional and ineffective hierarchical model of the division of labor,healthcare teams should explore alternative models of team activity thatpromote “shared situational awareness and support distributed action.” (p. 15).

Figure 1 illustrates the complexity ofthe ICU environment, with clinical workers placed in three zones of activity:in the ICU, in the hospital, and outside the hospital. Through the use of amedical information visualization system, referred to as MIVA (medicalinformation visualization assistant), its mobile technology supports complexdata visualization. Specifically, MIVA has been designed to enhance andmaximize the clinician’s ability to control what data is visualized during aspecific context-related patient episode or general periodic diagnosis. Systemslike MIVA can offer further support to extend clinical joint activity, givingnew meaning to “using vision to think” and the potential to do more thansupplement human intelligence (Card, Mackinlay, & Shneiderman, 1999). MIVAcan aid in identifying latent systemic conditions that lead to medical errorand facilitate the formation of joint clinical creative intelligence (Cohen etal., 2006). By using the mediating power of visualization, we are bridging visualform, creative extrapolation, and comprehension to produce new clinicalknowledge (Kazmierczak, 2003). By exploiting the brain’s visual engine,clinicians are empowered to think creatively about complex patient data, whileeasing cognitive load — hence, amplifying cognition and discovering newdiagnostic knowledge.

Figure 1. Shows how bio data flows from the patient through the bedside device to the EMR (electronic medical record) to MIVA. Clinicians experience an increase in distributed intelligence during joint activity across all three zones for both communication and patient data, thus facilitating distributed creative activity regardless of geographic location.

Figure 1 demonstrates the generalpractice of daily activity and how coordination mechanisms and communicationflow facilitate a distribution of information that can support critical carepatients within the confines of complex ICU settings (Doherty, Karamanis, &Luz, 2012). It also shows that managing the increased levels of geographic andtemporal distribution of activity, and the near-ubiquitous accessibility ofpatient data via HIT, provides the potential for “workflow-based tools.” Theuse of technologies supporting information exchange has had an immense impacton the way work is carried out and distributed between individuals. This trendtowards increased distribution of information and tasks across administrative,spatial and temporal boundaries is referred to by Gerson (2008) as “increasedreach.” Increased reach raises a number of profound challenges within anactivity system, where members need to coordinate their goals and taskswith others, communicate, and generally maintain awareness of workflow throughan increase of distributed knowledge of the patient’s condition and patientdata. While HIT has enabled an exponential distribution of knowledge, it hasalso generated a condition where the devices used for communication andcoordination differ from those employed in normal face-to-face situations(Doherty, Karamanis, & Luz, 2012).

By no longer being bound to thedesktop, communication and the distribution of information is pervasivelyavailable in every kind of environment. The most distributed collaborativeapproach is achieved through mobility and its corresponding benefits, such asflexibility, agility, and support for creative activities. The utilization ofmobile computing applications (e.g. smartphones and tablets) in the ICU has thepotential to support a vast array of functionality and shared creativeactivity, e.g., data display and analysis, communication, coordination, andconsultation (synchronously and asynchronously) with other clinicians, and thefinal diagnosis. A more significant benefit in using mobile computing, however,is the potential for “real-time activity sharing” among the ICU intensiviststeam (Bardram, 2005).

HIT tools can cause communication andcollaboration to become creative, lead to an increase in cognitive acuity, andgenerate new psychic formations that can give rise to new motives and renewedobjects. As Tikhomirov argues, motives are “not just conditions for developingactual intellectual activity, but also factors influencing its productivity andstructure” (Tikhomirov, 1999, p. 350). For this reason, technologies thatsupport clinical activity can assist in stabilizing cognitive need and theformation of new goals in the subject’s activity, which Tikhomirov holds asbeing one of the fundamental acts in the structure of creative activity (1999).

Distributed creativeactivity

In a most practical way, Tikhomirov’sview of “joint practical activity” is grounded in Vygotsky’s universal law ofdevelopment, which posits that the function of the human mind first emerges associally distributed, i.e., that cognition is both distributed and embodiedsystemically (Tikhomirov, 1999). For example, in healthcare, joint activity ismediated by distributed cognition in predicting clinical events, planningcourses of action, and diagnosing conditions (Cohen et al., 2006; Cook, Woods,& Miller, 1998; Hutchins, 1995; Nemeth, 2008). In brief, these clinical activitiesenable a shift from individual intelligence to a distribution ofcreative activity across both minds and technologies, and provide insightinto how clinical intelligence is shared and transformed from a socio-culturalperspective. Clinical activity includes the distribution of clinical knowledgeas part of cultural-historical development. Hence, the social distribution ofcognition (in the context of the ICU) results in a unique development of theintensivist mind, and of the relationship between people and artifacts, whichhas a direct impact on diagnostic outcomes and the transformation of the socio-culturalrole of every clinician.

What arises from this process is distributedcreative activity (DCA): the inter-cognitive distribution of creativeintelligence among clinicians and HIT (subjects and technologies). The theoryholds that the creative augmentation of clinical cognition plays a central rolein diagnostic healthcare, where intelligence is distributed across a creativeactivity system — between clinicians, patient, and technologies. As such,creative intelligence is jointly embodied and activity is systemic, where cognitionis not mere information or computational processing, but a distribution ofintelligence and a sharing of socio-cultural development.

In application, the clinician and HITparticipate qualitatively in an intelligence ecosystem, where computers mediatethe distribution of cognition, sharing those functions that the mind is unableto perform due to limits in its computational complexity and speed.[7] As such, the distributionand analysis of patient data becomes a shared repository from which clinicianscan combine their diagnostic skills and resident knowledge with HIT to arriveat diagnostic conclusions more accurately and efficiently.

In DCA, shared knowledge is not onlypart of an activity system, but also a distribution of cognition in the socialworld of clinical care. Cultural mediation here implies more than thedistribution of cognition or the mediation of activity through artifacts,humans, and context, but a greater augmentation of cognition and distributionof higher thinking due to a distributed work that includes the use ofinformation technology (Salomon, 1993, p. 13). For example, the MIVA systemconstructs visual signs that have powerful mediating effects on cognition (Rindet al., 2013; Spence, 2002). Human information processing is often limited andconstrained by speed, memory, and a range of personal cognitive disabilities. Toaddress these limits and irregularities, MIVA can be used to amplify cognitionin ways that support the brain’s ability to make complex associations andextrapolations, thus identifying extended knowledge, meaning, and visualintelligence (Cowan, 2000; Vygotsky, 1978/1934; Wise, 1999).

Future work

Ongoing studies on critical careactivity continue to provide significant evidence to suggest that distributedcognitive activity underlying clinical performance should not focus onindividuals, but on complex social systems that constitute joint clinicalactivity. Previous research has found support for the claim that the majorityof intensivists engaging in collaborative activity in the ICU, usingcommunication IT such as wireless e-mail, improve team relationships, as wellas staff satisfaction and patient care (O’Connor et al., 2009). This has beenfound to improve communication speed by 92%, communication reliability by 92%,coordination by 88%, reduce staff frustration by 75%, and result in faster(90%) and safer (75%) patient care. We believe that clear, rapid, appropriate,and accurate communication is essential to delivering safe patient care, fromwhich real joint activity among intensivists is vital for patient care and jobsatisfaction (O’Connor et al., 2009).

The theoretical model of DCA proposedin this paper is grounded in traditional activity theory, with an extendedtheoretical component that is applied to HIT (as illustrated in Figure 1). Assuch, future work includes the evaluation of this model through observation ofDCA in the ICU. This specific study will identify and compare intensivistcognitive load, workflow, and clinical decision support (CDS) system use. Ourobjective is to: 1) identify the root causes and underlying mechanisms of ICUerror related to the effects of diagnostic tools/systems on clinical work andcognitive load; with the long term goal of designing transformative CDSs thatincrease protection of patients from adverse events and provide greater safety,while reducing intensivists’ time, effort, work, and cognitive resources. Therationale for our work is to provide a more complete and advanced understandingof the individual, interrelated, and interactive factors of CDS, cognitive workflow,and inter-team clinical communication that contributes to medical error in theICU. Our project will inform the further design and development of an ICUclinical visualization, communication and decision support tool that providesICU staff with capabilities of greater control over data andintra-communication at the point of care.

Conclusion

Healthcare is one of the mostpreeminent environments to observe creative activity in real time, as themind’s social and historical development transform before us. For this reason,the purpose of observing clinical work from a distributed cognition perspectiveis to understand joint activity and the flow of knowledge between eachcollaborative agent, whether technological or human. Tikhomirov’s quest tobetter understand “how computers affect the development of intellectualactivity” is explicitly revealed in the clinical environment. In particular,his efforts to understand the positive effects of computers on the developmentof creative activity provide valuable instruction to activity theorists, especiallywith respect to their influence on new goal formation (Tikhomirov, 1972, pp.186-87) as it might apply in critical care environments. As he notes, “newneeds and new motives are important sources of creative activity” because it isa “unit of life that includes the generation of new psychic formations, thereal function of which is giving humans the opportunity to generate a new worldof objects” (Tikhomirov, 1988, Tikhomirov, 1999, pp. 349-351). However, throughHIT (in particular MIVA), complex clinical activity becomes asuper-augmentation of interpersonal cognition in ways that underpin creativediagnosis in healthcare. For these reasons, distributed creative activity bringsan extended meaning to creative activity and an advanced notion aboutthe social distribution of cognition in socio-cultural development with respectto the context of public health and the care of the critically ill.

Acknowledgements

Special thanks to my graduate studentresearch team (Yamini Karanam (Ph.D. Cand.), David Chartash (Ph.D. Cand.),Michael Zhang (M.S. Student), and Elliot Li (M.S. Student)) for their work withme in developing the working model of clinical activity as illustrated byFigure 1, including the work of creating the graphic. Also, many thanks to mygraduate student, Preethi Srinivas (Ph.D. Cand.) for her editorial comments.All graduate students are supported through a Solution Center Grant and theIndiana University School of Informatics and Computing, IUPUI, Indianapolis, INUSA.

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Notes

[1] Tikhomirov definesinterpersonal cognition as “forming concepts about another person’s way ofthinking.” This includes the style, influence, and an understanding of their:1) “goals and motives” and the problem to be solved, and 2) “capacity to lookat an object-related situation and determine the true meaning of another’sactivity, especially in conflict situations...” (Tikhomirov, 1988, pp.154-155).

[2] Optimizing intensive-careworkflow while maximizing safety and quality of care remains at the forefrontof the medical industry in the US, Europe, and Russia. In the intensive careunit (ICU), critically ill patients require frequent intervention andcontinuous and coordinated monitoring. Clinical workflow in the ICU isidentified as the most complex environment in healthcare. With more than sixmillion ICU admissions annually in the US, ICUs have both the highest annualmortality rate (12-17%) and the highest costs in healthcare, accounting for4.1% of the $2.6 trillion in annual healthcare spending, or nearly $107 million.More-over, one quarter of all patients die in the ICU, of which 8% die due tomisdiagnosis. More startling are the findings that ICU patients are the mostmonitored, tested, and examined of all hospital patients, yet the criticalsigns of a potentially deadly medical condition are sometimes missed.

[3] For the ICU, bedsidedevices send continuous streams of data through the electronic medical recordsystem, through which the clinical team (e.g., nurses, cardiologists,pulmonologists, anesthesiologists, and pharmacologists, etc.) interact witheach other and HIT to diagnose the patient’s condition.

[4] Intensivist refers toboard-certified physicians who are additionally certified in the subspecialtyof critical care medicine, which could also include neurointensivists,anesthesiologiests, as well as those working in pediatrics and surgery. It canalso refer to all clinicians, e.g., critical-care nursing staff, whoseworkspace is concentrated in the intensive care unit or other forms of criticalcare. In this paper, the author often uses the word “clinician” and“intensivist” interchangeably. However, in using the word “intensivist” he isgiving special attention to clinical activity and clinician cognitive workflowin the ICU.

[5] Intensivists work in highlystressful environments in which they monitor several critically-ill patientssimultaneously, usually within a suite of ICU rooms. In such critical carespaces, there are considerable demands on their time and physiological andpsychological reserves. The contextual outcome of patient monitoring, with theanalysis of both numeric and textual data, and the treating of complex medicalproblems, is labor intensive and time-consuming, with cognitive loads oftenexceeding mean expectations for clinical support. Synchronous and asynchronouscommunication (for the purposes of expediting and increasing the ac- curacy ofdecision-making) with fellow intensivists is limited by available technologies.

[6] The theory of distributedcognition was developed by Hutchins (1995), and addresses cognitive processesnot confined to the thinking of an individual, but rather distributed amongseveral individuals by means of any variety of external artifacts (i.e., analogor electronic) or internal cognitive functions (i.e., short or long-termmemory). Together, the external and internal resources contribute to a greatercomposited computational system, with a much broader capacity than anyindividual could be constituted (Cohen et al. 2006).

[7] Studies show that humansdo not have sufficient means of storing information; we only poses “smallamounts of rapid-access storage,” short-term memory (Simon, 1998, p. 61).