Rose AF et al. 2005 "Using qualitative studies to improve the usability of an EMR."

Rose AF, Schnipper JL, Park ER, et al. Using qualitative studies to improve the usability of an EMR. J Biomed Inf 2005;38(1):51-60.
"The adoption of electronic medical records (EMRs) and user satisfaction are closely associated with the system's usability. To improve the usability of a results management module of a widely deployed web-based EMR, we conducted two qualitative studies that included multiple focus group and field study sessions. Qualitative research can help focus attention on user tasks and goals and identify patterns of care that can be visualized through task modeling exercises. Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. We used the findings of these studies to recommend design changes to the user interface of the results management module."
To describe the usability of EMR based on information from physicians and nurses of primary care practices associated with Brigham and Women's Hospital and Massachusetts General Hospital.
Type Clinic
Primary care
Other Information
Participating primary care practices were affiliated with Brigham and Women's Hospital (BWH) and Massachusetts General Hospital (MGH).
Type of Health IT
Electronic medical records (EMR)
Type of Health IT Functions
The EMR is "a web-based application that facilitates the management of patient information, provides clinical messaging, and standardizes methods of data entry and retrieval...[O]ur focus for this particular study is on ResultsManager, a component that assists users with follow-up tasks for patient laboratory test results. It collects test results ordered by a physician and presents them from one centralized location."
Workflow-Related Findings
"During their observed usage of Results Manager, all seven participants in the task analysis study accessed [the] Patient Summary feature at least once.... Users of this feature can quickly glance at a selected patient's problems, medications, visits, notes, family history, and allergies. Despite the convenience of Patient Summary, however, many participants were quick to point out that its layout feels cluttered in the 800 · 600 display and the Notes, Visits, and Medications components require horizontal as well as vertical scrolling."
"Test participants noted the Results Manager's liberal usage of color and low contrast with data objects that are in their 'selected' state.... Secondly, although the Alerts and Guidelines box is displayed with bright red borders, the task analysis test participants paid little attention to it, suggesting that it used color ineffectively, or may require more prominent placement on the screen."
"Many physicians often used their own letters and found the predefined letter templates of Results Manager to be inadequate for all their workflow needs. Three test participants cited bigger default font sizes for letters to elderly patients and the ability to import prior test results as desirable features. The additional steps of having to copy and paste from previous notes and to continuously adjust fonts add to the user's time on task."
"The majority of participants in both studies used Results Manager during specific blocks of time they reserved during the week, typically 30 min to an hour. It was often the case that these users only had a single block of time each week to spend acknowledging laboratory results and printing patient letters. However, there were some users who attempted to complete these tasks in between their patient encounters and other daily responsibilities, using either Results Manager, or a manual method such as hardcopies of laboratory slips.... One observed participant checked for updates throughout the day and wrote preliminary notes as separate results came in. Batch printing of patient letters was also common across test participant workflows, as not every user was within close proximity to a printer."
"[M]ost of the task analysis participants said they would not need to invoke Popup to access the Medications module if they could edit the patient's medication list directly from Results Manager. Currently, they can only add a new medication from within the Results Manager screen."
"The navigation...was described as 'awkward' by participants from both qualitative studies who also indicated 'too many clicks and screen flips' were required to complete the task of acknowledging and informing patients of laboratory results. This particular workflow required frequent access to other modules of the [EMR], most notably Patient Summary, Medications, and Notes. If the information required to support this workflow was not immediately present in the Results Manager screen, it became necessary for users to temporarily shift their focus to other parts of [the EMR], making it harder to maintain system context."
"Our test participants wanted immediate access to information: 'If it's not on the screen, it better not be more than one click away,' as summarized by one observed user during our task analysis research. However, physicians also complained when too much information was on a screen, making it 'too busy' and problematic when trying to perform tasks quickly."
"All participants observed during the task analysis study...expressed the need for quicker access to [the EMR's] Notes module (where previous outpatient visit notes are kept) from within the Results Manager. Currently, this can be done using the 'Popup' menu feature on [the] main navigation bar..., which launches a new 'child' window on top of the active browser window to view other...modules. However, even experienced users found continued frustration with this indirect approach as Notes is not listed as a selection under the Popup menu. Another sub-menu item, such as Health Maintenance, must be selected first, and then the user can navigate to Notes. Another alternative is to stay within the main browser window and leave the Results Manager module, which adds the additional tasks of temporarily saving data and moving to another screen."
"A physician participant in the task analysis study (who also participated in the focus groups) demonstrated a different workaround to address the ... navigation issues - he kept multiple browser windows open and switched back and forth between different patient records and...modules. While waiting for the system to process one patient record, he created his own navigation system to be more productive. However, while this may seem like a clever solution, it can undermine patient safety. When asked if he ever got confused during multiple window switching, this physician responded, 'Yes, all the time.'"
Study Design
Only postintervention (no control group)
Study Participants
Five physicians and two nurses participated in the task analysis. The focus groups involved 26 physicians (2 interns, 11 residents, and 13 attendings).