Article

Primary care physicians' use of an electronic medical record system: a cognitive task analysis.

Galil Center for Telemedicne, Medical informatics and Personalized Medicine, The R&B Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Journal of General Internal Medicine (Impact Factor: 3.42). 02/2009; 24(3):341-8. DOI: 10.1007/s11606-008-0892-6
Source: PubMed

ABSTRACT To describe physicians' patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular.
Cognitive task analysis using semi-structured interviews and field observations.
Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel.
The comprehensiveness, organization, and readability of data in the EMR system reduced physicians' need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient's chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians' communication skills also helped.
There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians' offices and by enhancing physicians' computer and communication skills.

0 Followers
 · 
85 Views
  • Source
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The objectives of this study were to (a) review electronic medical record (EMR) and related electronic health record (EHR) interface usability issues, (b) review how EMRs have been evaluated with safety analysis techniques along with any hazard recognition, and (c) formulate design guidelines and a concept for enhanced EMR interfaces with a focus on diagnosis and documentation processes. A major impact of information technology in health care has been the introduction of EMRs. Although numerous studies indicate use of EMRs to increase health care quality, there remain concerns with usability issues and safety. A literature search was conducted using Compendex, PubMed, CINAHL, and Web of Science databases to find EMR research published since 2000. Inclusion criteria included relevant English-language papers with subsets of keywords and any studies (manually) identified with a focus on EMR usability. Fifty studies met the inclusion criteria. Results revealed EMR and EHR usability problems to include violations of natural dialog, control consistency, effective use of language, effective information presentation, and customization principles as well as a lack of error prevention, minimization of cognitive load, and feedback. Studies focusing on EMR system safety made no objective assessments and applied only inductive reasoning methods for hazard recognition. On the basis of the identified usability problems and structure of safety analysis techniques, we provide EMR design guidelines and a design concept focused on the diagnosis process and documentation. The design guidelines and new interface concept can be used for prototyping and testing enhanced EMRs. © 2015, Human Factors and Ergonomics Society.
    Human Factors The Journal of the Human Factors and Ergonomics Society 03/2015; DOI:10.1177/0018720815576827 · 1.29 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This paper describes a metric called "performance efficiency," and its use in cognitive task analysis. This metric provides a means of determining the learning efficiency of instructional conditions. Performance efficiency will be described in the context of recording technologies that are often used in software usability studies. While usability is often considered in the programming of software environments, the "learnability" of these environments is more the concern of instructional designers. The advantages and disadvantages of these types of metrics and methodologies will be discussed in detail. Thus the purpose of this paper is to consider the applications of the "performance efficiency" metric to the design of instructional materials. Introduction Educational researchers have used a medical model to develop instructional materials; that is we hope to design instruction, which is both efficient and effective (Lewis & Barron, 2009). Gagné (1964) was one of the earliest educators to describe these two general categories of dependent variables. He proposed most educators are concerned with (1) "the rate of attainment of some criterion performance" (efficiency) and (2) "the degree of correctness of this performance" (effectiveness) (Gagné, 1964, p.295). It is an underlying theme of this paper that when these variables are applied to the design of instructional materials, we are considering the "learnability" of the instruction. Nielsen (1993) defined usability by developing several subcomponents (learnability, efficiency, memorability, errors, and satisfaction). Soloway, Guzdial, and Hay (1994) called for Norman's "user-centered" design philosophy to be more "learner-centered." Nielsen's (1993) definition of learnability "How easy is it for users to accomplish basic tasks" is a subjective measure of "perceived usability," rather than a more objective measure. However, Nielsen (2001) proposed we should consider the user's opinions and suggestions, but only after actually watching them work with the software. That is we must start by observing learners before considering their perceptions. It's interesting that if we were to look to the international standards organization (ISO) for a definition of usability, we would find that they also chose to use Gagné's variables (ISO 9241-11, 1998). While cognitive load may not seem related to usability, similarities reveal themselves if you consider the measures underlying this theoretical framework. Cognitive load theory is an instructional theory that is concerned with the learnability of instructional materials. This theoretical framework has become quite influential within the field of instructional design (Ozcinar, 2009; Paas, van Gog, & Sweller, 2010). Cognitive load theory is primarily concerned with procedural knowledge, task performances and problem-solving. Cognitive load measures are a combination of subjective data (mental-effort ratings) and performance scores (Tuovinen & Paas, 2004). These measures have been found to be reliable and correlated with error rates (Ayres, 2006) but not all cognitive load theorists agree with the use of subjective measures, and have proposed we consider more direct or objective measures (Brünken, Plass, & Leutner, 2003; Whelan, 2007). This concern has led to the impetus for this paper and the "performance efficiency" metric described in the next couple of sections. This type of research (task analysis) has a rich history and is certainly a metric to be used in cognitive task analysis. Task Analysis Task analysis researchers have used observation or photography/videography as a means of data collection for decades (Clark & Estes, 1996; Gilbreth & Gilbreth, 1917). Some of the earliest task analysis studies were made with stopwatches and the newly developed technology of chronocyclegraphy (Gilbreth & Gilbreth, 1917). This was the use of long exposure photography, which allowed for the detection of movements over time. While the Gilbreths were early pioneers of time motion studies, even they were aware of the underlying rationale for this type of research. They state it when they say "that the learner shall be taught the best way immediately, that is, from the beginning of his practice" (Gilbreth & Gilbreth, 1917, p.82). So they were amongst the first to promote efficient instruction, for it allows a learner to be more efficient with their time, and simply learn more.

Full-text (2 Sources)

Download
18 Downloads
Available from
Jul 4, 2014