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


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.

Download full-text


Available from: Shmuel Reis, Jun 26, 2014
    • "Using EHR could improve many aspects of medical practice and make the healthcare system safer and more efficient (Alvarez, 2004Committee on Identifying Priority Areas forQuality Improvement, 2003;Romanow, 2002). Several benefits of the EHR have been documented in the literature (Blumenthal, 2010;Buntin, Burke, Hoaglin, & Blumenthal, 2011;Cebul, Love, Jain, & Hebert, 2011;DesRoches et al., 2008;Hollingworth et al., 2007;Holroyd-Leduc, Lorenzetti, Straus, Sykes, & Quan, 2011;Samaan, Klein, Mansour, & DeWitt, 2009;Shachak, Hadas-Dayagi, Ziv, & Reis, 2009;Shekelle, Morton, & Keeler, 2006;Simon et al., 2007). Some studies emphasize that EHR could increase the quality of care through making essential health data accessible to different healthcare providers, thus improving the coordination of care (Canada Health Infoway, 2006;Cebul et al., 2011;DesRoches et al., 2008;Staroselsky et al., 2006) and efficiency of primary care practice (Greenhalgh, 2011;Pare et al., 2014;Raymond et al., 2015). "
    [Show abstract] [Hide abstract]
    ABSTRACT: In Canada, the healthcare system remains paper-laden, and EHR adoption by physicians lags behind many other industrial countries. Recent reviews identified individual and organizational factors as having the most important influence on EHR adoption and proposed taking a multidimensional perspective to study these adoption determinants. However, most studies have focused on physician EHR adoption measured at the individual level. Objectives First, we used a multilevel regression model to assess whether organizations' characteristics influenced physician behavioral intention to use EHR. Second, we sought to identify individual and organizational factors that explain physician intention. Methods We conducted a prospective cross-sectional study among physicians in 49 primary healthcare organizations in four regions of the province of Quebec (Canada). We first analyzed relationships between individual and organizational variables and intention. Second, we performed multilevel modeling to explore organizational characteristics' impact on physician intention to use EHR. Results 278 completed questionnaires were returned from the 31 organizations that had at least 5 participants (response rate: 39.8%). Questionnaires showed satisfactory psychometric properties. The multilevel modeling found no significant overall influence of organizational level on physician intention to use EHR. Second, six of the individual level constructs had a positive and strongly significant impact on physician intention. Conclusion In the Quebec context, organization-level seems to have no significant impact on EHR adoption by physicians. Hence, particular strategies are more likely to succeed if they target individual physicians rather than organizations.
    No preview · Article · Jun 2016
  • Source
    • "). For example, Shachak et al. (2009) surveyed 14 prior studies and found that often EHR increases the satisfaction of the medical staff (because of the information it provides). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Emergency department (ED) represents a distinctively challenging and critical work environment. While there is growing evidence for the positive role played by Electronic Health Record systems in hospitals, the evidence for their effectiveness in the ED setting has been inconclusive. The objective of this paper is to explore the moderating role played by diagnostic task complexity on the relationship between system use and quality of care in the emergency department setting. Our empirical investigation employs field data collected from the EHR systems (549,108 patient encounters) of the seven largest emergency departments within a single country. We consider the complexity of the medical diagnosis task using three sub-components and use Analytical Hierarchy Process to derive a composite score for complexity. While EHR system use has a positive impact on care quality under highly complex diagnostic tasks, interestingly system use has a negative impact on care quality for simple diagnostic tasks.
    Full-text · Conference Paper · Dec 2015
    • "On the other hand, patients may perceive the use of EHR as part of the provider's responsibilities and an important source of information at the point of care[3]. Moreover, some clinicians may be quite skilled at multitasking, enabling them to more successfully integrate their interactions with the computer and the patient[12]. Thus, their use of the computer might have positive or at least neutral effects on their communication with patients. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective Electronic health records (EHRs) have great potential to improve quality of care. However, their use may diminish “patient-centeredness” in exam rooms by distracting the healthcare provider from focusing on direct patient interaction. The authors conducted a qualitative interview study to understand the magnitude of this issue, and the strategies that primary care providers devised to mitigate the unintended adverse effect 20 associated with EHR use. Methods and Materials Semi-structured interviews were conducted with 21 healthcare providers at 4 Veterans Affairs (VAs) outpatient primary care clinics in San Diego County. Data analysis was performed using the grounded theory approach. Results The results show that providers face demands from both patients and the EHR system. To cope with these demands, and to provide patient-centered care, providers attempt to perform EHR work outside of patient encounters and create templates to streamline documentation work. 25 Providers also attempt to use the EHR to engage patients, establish patient buy-in for EHR use, and multitask between communicating with patients and using the EHR. Discussion and Conclusion This study has uncovered the challenges that primary care providers face in integrating the EHR into their work practice, and the strategies they use to overcome these challenges in order to maintain patient-centered care. These findings illuminate the importance of developing “best” practices to improve patient-centered care in today’s highly “wired” health environment. These findings also show that more 30 user-centered EHR design is needed to improve system usability.
    No preview · Article · Aug 2015 · Journal of the American Medical Informatics Association
Show more