Abstract
OBJECTIVE
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.
DESIGN
Cognitive task analysis using semi-structured interviews and field observations.
PARTICIPANTS
Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel.
RESULTS
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.
CONCLUSIONS
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.
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Acknowledgements
We would like to thank the primary care physicians who took part in the study. We also greatly appreciate the administrative assistance of Mrs. Ivette Trujillo-Mordetzki. The first author was supported by a fellowship from the Israel Council of Higher Education and Galil Center. This study was supported by a research grant from Israel National Institute of Health Policy and Health Services Research. Roshtov, an EMR vendor, provided their platform (which is used by our study participants) for the research team to examine during the development of the research protocol and analysis of findings. Preliminary results of this study were presented at the annual meeting of the Israeli Association for Information Systems (ILAIS), 2006, and at Human Factors Engineering in Health Informatics conference, Arhus, Denmark, 2007.
Conflict of Interest
Shmuel Reis was a consultant for GMN (PHR provider) until August 2006. Roshtov, an EMR vendor, provided their platform (which is used by our study participants) for the research team to examine during the development of the research protocol and analysis of findings. We do not see any financial implications for these companies from this publication.
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Appendices
APPENDIX A: Cognitive Task Analysis (CTA)
CTA is a methodology for characterizing and describing the cognitive elements underlying goal generation, decision-making, reasoning, and information processing. It also permits the identification of the role of expertise in performing complex tasks.33,49,50 Typically, CTA involves interviews, or a combination of interviews and observations, with six to eight Subject Matter Experts (SMEs). In the present study a specific variant of CTA was employed—Applied Cognitive Task Analysis (ACTA)33—with some modifications. The CTA involved a combination of semi-structured interviews and direct observations that we then used to create a task diagram, identify potential errors, and study the effects of EMR use on patient–doctor communication.
APPENDIX B: Interview questions
Adapted from Militello and Hutton32.
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1.
Background details
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a.
Demographics: gender, specialty, years since graduation of medical school, time since finishing residency (for residents: stage of residency).
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b.
Observe the spatial organization of the doctor’s office: where do the doctor and patient sit? Where are the computer and the screen? Is the screen constant or mobile?
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c.
Please define your level of experience in using the EMR (if the interviewee has difficulty answering this question offer a scale: non-user, novice, experienced user, expert user?). How long have you been using the EMR?
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a.
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2.
Task diagram
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a.
Please describe the main stages of a typical patient visit and how you use the EMR in it? (The purpose is to get a broad picture of the visit, without getting into too many details. You may ask the physician to demonstrate how s/he uses the EMR.)
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b.
Of the steps you have just identified, which require difficult cognitive skills? By cognitive skills I mean judgments, assessments, problem solving skills, etc.
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c.
If the interviewee does not refer to these issues, use probes like: Which stages especially require consciousness and attention? Which actions are done automatically? At what stages have you made errors in the past? Can you give an example? At which stages have you paid close attention to communication with the patient?
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a.
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3.
Knowledge audit
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a.
Experienced/expert users: what advice would you have for a resident who just started working with the EMR? OR
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b.
Resident/novice users: What advice can you give others about using the EMR?
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c.
During the time you have been working with the EMR, are there ways of working smart or accomplishing more with less that you have found especially useful?
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d.
Can you think of a time when you realized you would have to change the way you were working with the EMR? Follow-up probes: to avoid medical errors? To improve communication with patients?
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e.
Were there times when you had to rely on experience to avoid being led astray by the EMR? Probe: can you give me an example?
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f.
Would you like to add anything?
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a.
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Shachak, A., Hadas-Dayagi, M., Ziv, A. et al. Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis. J GEN INTERN MED 24, 341–348 (2009). https://doi.org/10.1007/s11606-008-0892-6
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DOI: https://doi.org/10.1007/s11606-008-0892-6