Shachak A et al. 2009 "Primary care physicians' use of an electronic medical record system: a cognitive task analysis."

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 2009;24(3):341-348.
"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."
"To describe [Israeli primary care] 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."
Type Clinic
Primary care
Type Specific
Family practice, and pediatrics
Small, medium and large
Urban, suburban, and rural
Other Information
The Israeli health maintenance organization (HMO) Clalit has 3.7 million members. Multiple clinics were selected including urban and rural and varying clinic size.
Type of Health IT
Electronic medical records (EMR)
Context or other IT in place
An electronic medical record (EMR) system had been in place since 1993.
Workflow-Related Findings
"I can find out in seconds if the patient has taken a vaccination...whether I asked about smoking...when she last took a mammography test, etc."
"Overall, study participants felt the EMR system reduced their cognitive loads. They were satisfied with the EMR system, especially with its data-related comprehensiveness, organization, and readability."
"To some extent the EMR system also provided clinical decision aids.
Physicians considered the system simple to use, and even those who had been using it for only 3-5 months reported completing many actions automatically. [S]tudy participants quickly and nearly automatically [perform] system-related actions such as opening and closing charts, navigating between fields, and selecting items from lists."
"The physicians who participated in the study were able partially to overcome the negative impact of EMRs on communication by using various strategies and enabling factors. The main strategy entailed separating EMR use from time spent communicating with patients.... [During observations] a clear separation between time spent inputting data into EMRs and time spent consulting with patients was noted. With one exception, physicians maintained eye contact with their patients and turned away from the computers. Most also did not touch their keyboards during conversations with their patients."
"One of the observed pediatricians used a predefined template for all physical examinations. Prior to an examination he would type a keyboard shortcut to insert the template and then, while the patient settled down after the examination, he would alter the data based on his findings."
Physicians "appreciated that [the EMR] made reviewing patients' medical histories and test results easier.... These aspects minimized the need to recall information from memory and eliminated the difficulty of reading handwriting."
Physicians "said that the system's decision-making aids improved the quality of patient care. These as well as other features of the EMR system - such as alerts of potential adverse drug interactions - were perceived to enhance patient safety."
"EMR use provoked new types of medical errors. Typical errors reported by most study participants (>60%) were typos, adding information to the wrong patient's chart, and unintentionally selecting an erroneous item (diagnosis or medication) from a scroll-down list located above or below the desired item...Study participants described two common scenarios for adding to the wrong chart. The first arose when they opened a chart by typing a patient's name instead of using his or her unique magnetic card provided by the HMO. Typing in a patient's name opened a list of patients, and physicians sometimes accidentally selected the incorrect individual. Some of the more experienced physicians reported knowing most of their patients by
name. To save time, they reported, they would open such a person's chart as soon as he or she entered the office and glance at the record before beginning the clinical interview. The second reported scenario arose when, in response to an interruption (e.g., a nurse asking about another patient or
taking a telephone call from a patient), a physician would open another patient's chart, forget to close it, and then type into it information about the visiting patient."
"A number of study participants reported discovering they had written in the wrong patient's chart only after a pharmacist alerted them that the name on a prescription differed from the presenting patient's name (in Israel, paper prescriptions are mandatory even when generated by an EMR system). Similarly, study participants sometimes realized they had prescribed the wrong medication when concerned pharmacists asked whether they really had intended to prescribe a particular drug."
"The findings indicate that study participants were aware of these potential errors. In all the cases observed, study participants reviewed printed prescriptions before signing and handing them to their patients. 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."
"The most influential skills [to reduce the negative impact of EHR use on communication] 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."
To ensure documentation completeness, "two study participants reported preparing comprehensive templates for common problems or examinations and using them as checklists."
"The computer interferes with communication, no doubt. At least half of the visit my attention is to the screen and not to the patient."
"[P]hysicians' average screen gaze lasted from 25% to 55% of the visit time."
"92% [of study participants] felt EMR use disturbed communication with their patients."
"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."
Study Design
Only postintervention (no control group)
Study Participants
Twenty-five primary care physicians from Clalit's Northern District were studied.