Journal of General Internal Medicine

, Volume 24, Issue 3, pp 341–348 | Cite as

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

  • Aviv Shachak
  • Michal Hadas-Dayagi
  • Amitai Ziv
  • Shmuel Reis
Original Article



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.


Cognitive task analysis using semi-structured interviews and field observations.


Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel.


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.


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.


Electronic Medical Record (EMR) primary care physician cognitive task analysis 



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.


  1. 1.
    Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348(25):2526–2534.PubMedCrossRefGoogle Scholar
  2. 2.
    Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742–752.PubMedGoogle Scholar
  3. 3.
    Lejbkowicz I, Denekamp Y, Reis S, Goldenberg D. Electronic medical record systems in Israel’s public hospitals. Isr Med Assoc J. 2004;6:583–587.PubMedGoogle Scholar
  4. 4.
    Laerum H, Ellingsen G, Faxvaag A. Doctors’ use of electronic medical records systems in hospitals: cross sectional survey. BMJ. 2001;323(7325):1344–1348.PubMedCrossRefGoogle Scholar
  5. 5.
    Mikulich VJ, Liu YC, Steinfeldt J, Schriger DL. Implementation of clinical guidelines through an electronic medical record: physician usage, satisfaction and assessment. Int J Med Inform. 2001;63(3):169–178.PubMedCrossRefGoogle Scholar
  6. 6.
    Patel VL, Kushniruk AW, Yang S, Yale JF. Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning. J Am Med Inform Assoc. 2000;7(6):569–585.PubMedGoogle Scholar
  7. 7.
    Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547–556.PubMedCrossRefGoogle Scholar
  8. 8.
    Ash JS, Sittig DF, Dykstra RH, Guappone K, Carpenter JD, Seshadri V. Categorizing the unintended sociotechnical consequences of computerized provider order entry. Int J Med Inform. 2007;76 Suppl 1:21–27.CrossRefGoogle Scholar
  9. 9.
    Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506–1512.PubMedCrossRefGoogle Scholar
  10. 10.
    Sullivan F, Wyatt JC. How computers help make efficient use of consultations. BMJ. 2005;331(7523):1010–1012.PubMedCrossRefGoogle Scholar
  11. 11.
    Sullivan F, Wyatt JC. How computers can help to share understanding with patients. BMJ. 2005;331(7521):892–894.PubMedCrossRefGoogle Scholar
  12. 12.
    Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–235.PubMedCrossRefGoogle Scholar
  13. 13.
    Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. 2008. Available at: Accessed: September 18, 2008.
  14. 14.
    Shachak A, Reis S. The impact of electronic medical records on patient–doctor communication during consultation: a narrative literature review. J Eval Clin Pract 2008, in press.Google Scholar
  15. 15.
    Margalit RS, Roter D, Dunevant MA, Larson S, Reis S. Electronic medical record use and physician–patient communication: an observational study of Israeli primary care encounters. Patient Educ Couns. 2006;61(1):134–141.PubMedCrossRefGoogle Scholar
  16. 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.PubMedGoogle Scholar
  17. 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.PubMedCrossRefGoogle Scholar
  18. 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.PubMedGoogle Scholar
  19. 19.
    Miettola J, Mantyselka P, Vaskilampi T. Doctor–patient interaction in Finnish primary health care as perceived by first year medical students. BMC Med Educ. 2005;5(1):34.PubMedCrossRefGoogle Scholar
  20. 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.PubMedGoogle Scholar
  21. 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.PubMedCrossRefGoogle Scholar
  22. 22.
    Chandler P, Sweller J. Cognitive load theory and the format of instruction. Cogn Instr. 1991;8(4):293–332.CrossRefGoogle Scholar
  23. 23.
    Simon HA, Chase WG. Skill in chess. Am Sci. 1973;61(4):394–403.Google Scholar
  24. 24.
    Eysenck MW. Psychology: an International Perspective. New York: Psychology Press; 2004.Google Scholar
  25. 25.
    Sweller J. Cognitive load during problem-solving: effects on learning. Cogn Sci. 1988;12(2):257–285.CrossRefGoogle Scholar
  26. 26.
    Fernandez-Duque D, Johnson ML. Attention metaphors: How metaphors guide the cognitive psychology of attention. Cogn Sci. 1999;23(1):83–116.CrossRefGoogle Scholar
  27. 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.Google Scholar
  28. 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.PubMedCrossRefGoogle Scholar
  29. 29.
    Green M. Error and injury in computers & medical devices. 2004. Available at: Accessed: Sep 18, 2008.
  30. 30.
    Green M. Nursing error. 2004. Available at: Accessed: September 18, 2008.
  31. 31.
    Dreyfus S, Dreyfus H. A Five-stage Model of the Mental Activities Involved in Directed Skill Acquisition. Berkeley: University of California; 1980.Google Scholar
  32. 32.
    Benner P. Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bull Sci Technolo Soc. 2004;24(3):188–199.CrossRefGoogle Scholar
  33. 33.
    Militello LG, Hutton RJ. Applied cognitive task analysis (ACTA): a practitioner’s toolkit for understanding cognitive task demands. Ergonomics. 1998;41(11):1618–1641.PubMedCrossRefGoogle Scholar
  34. 34.
    Clicks®—medical information system. Available at: Accessed: Sep 18, 2008.
  35. 35.
    Strauss AL, Corbin JM. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park (CA): Sage; 1990.Google Scholar
  36. 36.
    Shuval K, Shachak A, Linn S, Brezis M, Reis S. Evaluating primary care doctors’ evidence-based medicine skills in a busy clinical setting. J Eval Clin Pract. 2007;13(4):576–580.PubMedCrossRefGoogle Scholar
  37. 37.
    Simborg DW. Promoting electronic health record adoption. Is it the correct focus? J Am Med Inform Assoc. 2008;15(2):127–129.PubMedCrossRefGoogle Scholar
  38. 38.
    Walker JM, Carayon P, Levenson N, Paulus RA, Tooker J, Chin H, et al. EHR safety: the way forward to safe and effective systems. J Am Med Inform Assoc. 2008;15:272–277.PubMedCrossRefGoogle Scholar
  39. 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.PubMedCrossRefGoogle Scholar
  40. 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.PubMedGoogle Scholar
  41. 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.Google Scholar
  42. 42.
    Collins S, Currie L, Bakken S, Cimino JJ. Interruptions during the use of a CPOE system for MICU rounds. AMIA Annu Symp Proc. 2006:895.Google Scholar
  43. 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.CrossRefGoogle Scholar
  44. 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.PubMedCrossRefGoogle Scholar
  45. 45.
    McGrath JM, Arar NH, Pugh JA. The influence of electronic medical record usage on nonverbal communication in the medical interview. Health Inform J. 2007;13(2):105–118.CrossRefGoogle Scholar
  46. 46.
    Chan W-S, Stevenson M, McGlade K. Do general practitioners change how they use the computer during consultations with a significant psychological component? Int J Med Inform. In press [corrected proof]. Epub 2007 Nov 22.Google Scholar
  47. 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.PubMedCrossRefGoogle Scholar
  48. 48.
    Kushniruk A, Borycki E, Kuwata S, Kannry J. Predicting changes in workflow resulting from healthcare information systems: ensuring the safety of healthcare. Healthc Q. 2006;9 Spec No.114–118.PubMedGoogle Scholar
  49. 49.
    Chipman S, Schraagen J, Shalin V. Introduction to cognitive task analysis. In: Schraagen J, Chipman S, Shalin V, eds. Cognitive Task Analysis. Mahwah (NJ): Lawrence Erlbaum Associates; 2000.Google Scholar
  50. 50.
    Kushniruk AW, Patel VL. Cognitive and usability engineering methods for the evaluation of clinical information systems. J Biomed Inform. 2004;37(1):56–76.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Aviv Shachak
    • 1
    • 4
  • Michal Hadas-Dayagi
    • 1
  • Amitai Ziv
    • 2
  • Shmuel Reis
    • 1
    • 3
  1. 1.Galil Center for Telemedicne, Medical informatics and Personalized Medicine, The R&B Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael
  2. 2.MSR-Israel Center for Medical Simulation, Sheba Medical CenterTel-HashomerIsrael
  3. 3.Departments of Medical Education and Family Medicine, The R&B Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael
  4. 4.Department of Health Policy Management and EvaluationUniversity of TorontoTorontoCanada

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