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Cited by 188Electronic Health Records SystemsClinical Reasoning and Diagnostic SkillsTechnology and Human Factors in Education and Health

Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis

Open access
Shachak, Aviv, Hadas-Dayagi, Michal, Ziv, Amitai, Reis, Shmuel·2009·Journal of General Internal Medicine
DOI 10.1007/s11606-008-0892-6PMC PMC2642564
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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.

Integrity signals

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Crossref · 10.1007/s11606-008-0892-6

Cites

49 of 49 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 19 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    EMR use interfered with patient-doctor communication.

    “EMR use interfered with patient-doctor communication.”
    • Also stated in: § EMRs and Patient-Doctor Communication · plain
      “Of the study participants, 92% felt EMR use disturbed communication with their patients.”
    Quote in the paperSubstantial claim
  • Findingown data

    The main strategy physicians used to overcome EMR interference with communication was to separate EMR use from time spent communicating with patients.

    “The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients.”
    • Also stated in: § EMRs and Patient-Doctor Communication · plain
      “The main strategy entailed separating EMR use from time spent communicating with patients (Fig. 1).”
    Quote in the paperSubstantial claim
  • Findingown data

    Automaticity in EMR use sometimes led to errors, including choosing the wrong medication or entering data into the wrong patient's chart.

    “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.”
    Quote in the paperSubstantial claim
  • Findingown data

    EMR use reduced the cognitive load physicians experienced for clinical tasks.

    “Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks.”
    • Also stated in: § EMRs and Cognitive Load · plain
      “Overall, study participants felt the EMR system reduced their cognitive loads.”
    • Also stated in: § DISCUSSION · hedged
      “findings from the present study suggest that EMR use reduced physicians' cognitive loads associated with more demanding clinical tasks.”
    Quote in the paperSubstantial claim
  • Findingown data

    Observations did not detect well-defined patient-visit stages.

    “During our observations we did not detect well-defined patientvisit stages.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 25
  • Classified as probably not a substantial claim. 18

  • May combine two claims.

    Findingown data

    The EMR system's data comprehensiveness, organization, and readability lessened physicians' need to remember information and made handwritten records easier to read.

    “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.”
    • Also stated in: § EMRs and Cognitive Load · plain
      “These aspects minimized the need to recall information from memory and eliminated the difficulty of reading handwriting.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Computer mastery and improved communication skills also helped physicians overcome EMR interference with communication.

    “Computer mastery and enhanced physicians' communication skills also helped.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Skills such as touch typing and using shortcuts or templates lessened typing demands and freed time for communication.

    “Computer skills, especially blind typing and the use of keyboard shortcuts and templates, reduced the burden of typing and, therefore, allowed more time for communication (Table 2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In several observed instances, interruptions caused participants to open a second chart, but they closed it before going back to the current patient.

    “In several instances, study participants opened second charts as a result of interruptions; however, they always closed those charts before returning to their visiting patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Seventeen participants described the same stages of an encounter, though the order sometimes differed.

    “Seventeen study participants reported the same encounter stages, although the sequence of events sometimes varied among physicians.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    One common wrong-chart scenario involved opening a chart by typing the patient's name rather than using the HMO-issued magnetic card, which sometimes led to selecting the wrong person from a list.

    “Typing in a patient's name opened a list of patients, and physicians sometimes accidentally selected the incorrect individual.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Expertise elements seemed to vary by individual and not to depend on accreditation, training stage, or years of experience.

    “Elements of expertise appeared to be individual rather than related to physician accreditation, formal educational stage, or years of experience.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Physicians reported that the EMR's decision-making aids improved the quality of patient care.

    “They also said that the system's decisionmaking aids improved the quality of patient care.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Most participants ensured complete documentation by typing into the EMR; two said they created templates for frequent problems or exams and used them as checklists for history completeness.

    “They usually achieved this element by typing data into their EMR systems; however, two study participants reported preparing comprehensive templates for common problems or examinations and using them as checklists to ensure anamnesis completeness.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Both patients and EMR systems demand focused attention from physicians.

    “both patients and EMR systems require physicians' focused attention”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Physicians were satisfied with the EMR system, particularly its data comprehensiveness, organization, and readability.

    “They were satisfied with the EMR system, especially with its data-related comprehensiveness, organization, and readability.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    EMR use had both positive and negative impacts on patient safety.

    “EMR use exerted both positive and negative impacts on patient safety.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The communication skills that mattered most included reading aloud during typing, keeping eye contact, showing attention and empathy through body language, using humor to ease tension, and stepping away from the computer for important or sensitive discussions.

    “The most influential skills observed were reading aloud while typing, maintaining eye contact, using body language to show attention and empathy, using humor to reduce tension, and leaving the computer completely and turning to the patient when conveying important information or discussing sensitive issues.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    A participant reported that the automaticity linked to shortcuts and templates could lead to errors.

    “one participant commented that the automaticity associated with shortcuts and templates could induce errors”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Except for one physician, participants kept eye contact with patients and turned away from their computers.

    “With one exception, physicians maintained eye contact with their patients and turned away from the computers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    More experienced users may be more likely to make EMR-related errors.

    “the fact that more experienced users may be prone to EMR-related errors”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Other strategies and enabling factors included office spatial organization, blind typing, computer navigation, and communication skills.

    “Other strategies and enabling factors were spatial organization of the office, blind typing, computer navigation, and communication skills”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Automatic actions are fast and efficient, but automaticity can lead to errors when actions that require attention become habitual.

    “Because they require little guidance or monitoring, automatic actions are fast and efficient.27 However, when actions that require attention become habitual, automaticity can lead to errors.[28][29][30]”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [27] Wheatley T, Wegner DM. Automaticity of action, psychology of. In: Smelser NJ, Baltes PB, eds. International Encyclopedia of the Social & Behavioral Sciences. Oxford: Pergamon; 2001:991–993. source

      Not checked in the free run.

    • cites [28] Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res. 2005;18(4):211–216. source

      Not checked in the free run.

    • cites [29] Green M. Error and injury in computers & medical devices. 2004. Available at: http://www.expertlaw.com/library/computers/computer_negligence.html . Accessed: Sep 18, 2008.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The researchers kept collecting data until they reached theoretical saturation.

    “Data collection continued until theoretical saturation 35 was reached.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] Strauss AL, Corbin JM. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park (CA): Sage; 1990.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    This conclusion aligns with most prior studies, which report that EMRs improve information exchange but often reduce patient-centeredness.

    “This conclusion is consistent with the majority of previous studies, which report that EMRs have a positive impact on information exchange but that they often negatively affect patient-centeredness”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Analysis began as data accumulated, and initial results shaped further data collection and analysis.

    “Analysis began as soon as data were accumulated, and the results of initial data analysis shaped further data collection and analysis”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The reduction in cognitive load from EMR use arose from data availability, readability, organization, and some decision support.

    “This beneficial result arose as a result of data availability, readability, and organization, as well as, to some extent, decision support.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Many published accounts describe errors linked to automaticity and suggest that interruptions may contribute to medical errors.

    “The literature is replete with descriptions of automaticity-related errors as well as observations on the potential role of interruptions in causing medical errors.29,30,41,42”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [29] Green M. Error and injury in computers & medical devices. 2004. Available at: http://www.expertlaw.com/library/computers/computer_negligence.html . Accessed: Sep 18, 2008.

      Not checked in the free run.

    • cites [30] Green M. Nursing error. 2004. Available at: http://www.visualexpert.com/Resources/nursingerror.html Accessed: September 18, 2008.

      Not checked in the free run.

    • cites [41] Collins S, Currie L, Patel V, Bakken S, Cimino JJ. Multitasking by clinicians in the context of CPOE and CIS use. Medinfo. 2007;12(Pt 2):958–962.

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    EMR use negatively influenced communication, and this problem can be partially addressed by improving office spatial organization and enhancing physicians' computer and communication skills.

    “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.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Earlier research suggested that patient-doctor communication in EMR settings varies with physician style, experience, and baseline communication skills.

    “Some previous research has suggested that patient-doctor communication in EMR settings varies depending on physician style, experience, and baseline communication skills.18,20,21,45”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [18] Booth N, Robinson P, Kohannejad J. Identification of high-quality consultation practice in primary care: the effects of computer use on doctor–patient rapport. Inform Prim Care. 2004;12(2):75–83. source

      Not checked in the free run.

    • cites [20] Ventres W, Kooienga S, Marlin R, Vuckovic N, Stewart V. Clinician style and examination room computers: a video ethnography. Fam Med. 2005;37(4):276–281.

      Not checked in the free run.

    • cites [21] Rouf E, Whittle J, Lu N, Schwartz MD. Computers in the exam room: differences in physician–patient interaction may be due to physician experience. J Gen Intern Med. 2007;22(1):43–48. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A recent viewpoint article raised similar concerns about automaticity and shortcuts or templates.

    “Similar concerns have been expressed in a recent viewpoint article 37”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] Simborg DW. Promoting electronic health record adoption. Is it the correct focus? J Am Med Inform Assoc. 2008;15(2):127–129. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    This study's results may differ from earlier work because Clalit has used EMRs for a long time and its users are generally highly expert.

    “The difference between our findings and those of other studies of computerized medical information systems may therefore be due to the long period of EMR use at Clalit and users' generally high level of expertise.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Two researchers independently reviewed transcripts and observation summaries; their initial agreement on themes was 83%, and they discussed disagreements until consensus.

    “Initial agreement between researchers was high (83% on themes), and open discussions were held until consensus was reached.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Earlier work reported that CPOE and EMR systems leave many tasks unsupported, which raises cognitive load and forces users to change how they manage information.

    “Previous studies have noted that CPOE and EMR systems do not fully support many tasks, thus increasing cognitive load and requiring users to adapt their information management strategies to the new technology.39,40”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [39] Weir CR, Nebeker JJ, Hicken BL, Campo R, Drews F, Lebar B. A cognitive task analysis of information management strategies in a computerized provider order entry environment. J Am Med Inform Assoc. 2007;14(1):65–75. source

      Not checked in the free run.

    • cites [40] Borycki EM, Lemieux-Charles L. Does a hybrid electronic-paper environment impact on health professional information seeking? Stud Health Technol Inform. 2008;136:505–510.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A study reported a high rate of risky copying and pasting of examination data.

    “reflected in a study that found a steep rate of high risk copying and pasting of examination data.43”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43] Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform. 2007;76 Suppl 1:122–128. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    The identified challenges, best practices, and elements of expertise could give physicians a broad set of tools and strategies for flexible use during consultations.

    “Many of the challenges, best practices, and elements of expertise identified would provide physicians with a broad set of tools and strategies that may be employed flexibly during consultation”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The study suggests that using EMR systems should be viewed beyond technical aspects, encompassing benefits, risks, and principles of high-quality use during patient visits.

    “The present study suggests it is important to go beyond these technical aspects of using EMR systems to a broader view of the benefits, risks, and principles of highquality use during patient visits”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Few requirements exist for high usability standards.
    • Rests on an assumption: Currently, EMR implementation and training tend to emphasize technical features like system functionality and capabilities.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationnone given

    Some problems found in this study may be specific to the system, while others are shared by many computerized medical information systems and devices.

    “Some of the problems uncovered in this study may be system-specific.Others are common to many computerized medical information systems and devices”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    These findings align with the literature.

    “These findings, too, are consistent with the literature.16,17,[44][45][46]”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [16] Makoul G, Curry RH, Tang PC. The use of electronic medical records: communication patterns in outpatient encounters. J Am Med Inform Assoc. 2001;8(6):610–615. source

      Not checked in the free run.

    • cites [17] Ventres W, Kooienga S, Vuckovic N, Marlin R, Nygren P, Stewart V. Physicians, Patients, and the electronic health record: an ethnographic analysis. Ann Fam Med. 2006;4(2):124–131. source

      Not checked in the free run.

    • cites [44] Frankel R, Altschuler A, George S, Kinsman J, Jimison H, Robertson NR, et al. Effects of exam-room computing on clinician–patient communication: a longitudinal qualitative study. J Gen Intern Med. 2005;20(8):677–682. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Computerized systems often undergo evaluation and are sometimes certified for functionality and interoperability.

    “Computerized systems are often evaluated and sometimes certified for functionality and interoperability.47”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Classen DC, Avery AJ, Bates DW. Evaluation and certification of computerized provider order entry systems. J Am Med Inform Assoc. 2007;14(1):48–55. source

      Not checked in the free run.

35 of 35

  • The paper relies on this without support.

    In Israel, physicians must provide patients with printed prescriptions by hand, even when the prescription is generated electronically.

    “in Israel, paper prescriptions are mandatory even when generated by an EMR system”
    “Israeli law requires primary care physicians to print and physically hand prescriptions to their patients.”

  • The paper relies on this without support.

    Few requirements exist for high usability standards.

    “Generally, however, there are few requirements for high usability standards”

  • The paper relies on this without support.

    Currently, EMR implementation and training tend to emphasize technical features like system functionality and capabilities.

    “To date, EMR implementation and training usually focus on technological aspects, such as the functionality and capabilities of systems”
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Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • The same interview-protocol source has two reference numbers

    Minor

    The methods cite Militello and Hutton as reference 33, while the appendix cites them as reference 32. The reference list identifies 32 as their paper and 33 as an EMR-system website.

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Related

Authors
Shachak, A., Hadas-Dayagi, M., Ziv, A., & Reis, S.
Affiliations
  • Technion – Israel Institute of Technology (IL)
  • Sheba Medical Center (IL)
Corresponding author
Shachak, Aviv
ORCID
Venue
Journal of General Internal Medicine
Publisher
Springer Science and Business Media LLC
Published
2009-01-07
Volume
24
Issue
3
Pages
341-348
ISSN
  • 0884-8734 (ISSN-L)
  • 1525-1497
DOI
10.1007/s11606-008-0892-6
PMC
PMC2642564
OpenAlex
W2007554419
Semantic Scholar
14dcf4e304be438d4ad6d101d2ae977e0d1f53b4
Cited by
188
References
51
Citations by year
2026: 2 · 2025: 4 · 2024: 7 · 2023: 6 · 2022: 10 · 2021: 9 · 2020: 8 · 2019: 14 · 2018: 20 · 2017: 11 · 2016: 19 · 2015: 13 · 2014: 16 · 2013: 18 · 2012: 4
FWCI
21.86
Type
journal article
Language
en
Open access
Licence
www.springer.com/tdm (tdm)
Locations
  • Journal of General Internal Medicine (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Technology and Human Factors in Education and Health
Keywords
electronic health records, primary care physicians, cognitive task analysis, cognitive load, patient-doctor communication, medical errors, automaticity, interruptions, computer skills, physician expertise, health maintenance organizations
MeSH terms
Attitude to Computers, Female, Health Maintenance Organizations, Humans, Interviews as Topic, Israel, Male, Physician-Patient Relations, Physicians, Family, Professional Competence, Task Performance and Analysis, Cohort Studies, Medical Records Systems, Computerized

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