Unertl KM et al. 2007 "Variation in use of informatics tools among providers in a diabetes clinic."

Unertl KM, Weinger M, Johnson K. Variation in use of informatics tools among providers in a diabetes clinic. AMIA Annu Symp Proc; 2007: AMIA; 2007. p. 756-760.
"A goal of health information technology (HIT) is to help eliminate variation when it may compromise safety, efficiency, or quality of care. This study utilized direct observation and semi-structured interviews to examine variability in HIT use among four nurse practitioners and four physicians in an ambulatory diabetes clinic and to assess the impact of this variability on patient care. While use of informatics tools for information access and communication was similar among all users, variability existed in patterns of data entry into the [electronic medical record] EMR. The study provides direction for developing new functionality that may be needed in HIT and suggests changes to existing functionality. By designing tools that meet user needs and workflows, adoption of informatics applications may be enhanced and patient safety and user satisfaction improved."

To examine the use of health IT in a diabetes specialty clinic, "[provide] direction for developing new functionality that may be needed ... and [suggest] changes to existing functionality."

Tools Used
Type Clinic
Specialty care
Type Specific
Diabetes care
Small and/or medium
Other Information
The study was conducted in "Vanderbilt Eskind Diabetes Clinic, an ambulatory specialty clinic" at Vanderbilt University Medical Center, with 6,000 adult and pediatric patients.
Type of Health IT
Electronic medical records (EMR)
Workflow-Related Findings
"[All] providers took handwritten notes while with the patient and consulted these notes later while entering information into the EMR." "Anecdotal reports from staff and providers in the clinic indicated that some providers in the clinic also completed handwritten notes that were later scanned into the patient's record, although this practice was not directly observed."
"Some of the providers viewed the EMR more as an information repository, while others more fully integrated the available tools into their practices."
"When accessing information in the EMR, a few providers frequently used graphical display options to view patients' HbA1c values, cholesterol levels, and weight over time. Providers who used this functionality often used it as an educational tool for patients, to more clearly show patients their historical values compared to their current status."
"All of the physicians had access to and made use of dictation software to varying degrees. Some physicians used the software for large portions of their notes, while others used it for small sections of their notes. The dictation software was not available to the nurse practitioners for administrative reasons, although two of the four nurse practitioners stated that they would have liked to use it."
"Use of informatics tools varied both within each group of providers and between the physician and nurse practitioner groups." All physicians and nurse practitioners used the EHR to look up information in and outside of the exam room. One physician and one nurse practitioner routinely examined data in graphical form. Nurse practitioners routinely corrected data in the electronic record while in the exam room; physicians did this sometimes. Only nurse practitioners "started their notes while in the exam room with patients."
Both nurse practitioners and physicians used the "message basket" tool for communication within the clinic and with staff and providers in other clinics. One physician and one nurse routinely used the EHR for e-prescribing; one nurse practitioner occasionally used this functionality. All providers used the patient portal to communicate with patients. Only nurse practitioners used non-secure email for patient communication, because in the patient portal, patients could not attach files to transmit several days of self-performed glucose readings.
"One provider who stated that the [messaging] functionality was useful and decreased phone calls also described it as a 'time sucking pit' because of the time and effort involved in keeping up with messages."
"[The patient] portal allows patients to exchange secure messages with their provider and to retrieve laboratory results. The providers noted that the portal was useful for many patients, but one physician stated that it had been 'a disaster' with some of her older patients. Other providers were concerned about the time required to use this new communications tool."
"Several providers admitted to spending extensive time outside of normal work hours completing notes. One nurse practitioner commented, 'I'm ending up at the end of the day, if I've seen 11 or 12 patients, I may have 6-7 unfinished notes. And I'm taking it home and doing it. It's not good.' Providers also frequently completed EMR documentation during their lunch hour and at other free times during the day."
"Cognitive artifacts such as the binder maintained by nursing staff [describing] individual provider preferences [for paper documentation provided to use in the exam room] demonstrate unanticipated system-level workarounds and potential inefficiencies and signify areas where the EMR might not function as intended."
"All of the providers suggested that the ability to see the entire patient chart and information from other providers was a valuable benefit of the system. However, several providers noted difficulties finding specific pieces of data among the volumes of information in some patient charts. The existing informatics tools may meet the institutional need to gather patient documentation in a single record, but the sorting and searching functions do not fully support clinician needs to retrieve and synthesize longitudinal data."
Study Design
Study Participants
Participants were four nurse practitioners in 18 patient encounters, four physicians in 25 patient encounters, and nurses, nurse educators and dieticians in 16 hours of observations.