Documenting for care: Evaluating an EMR for primary care providers

Healthcare providers generate a large volume of patient documentation. Healthcare facilities adopt EMRs as one strategy to store and manage the data generated by providers, however these systems do not allow for easy information input or extraction. We conducted a cognitive walkthrough study to understand the user interface and interactions with the EMR system. Our qualitative observational study of 10 providers, which collected 52 hours of data, found that providers do not always interact with meaningful patient information. Follow-up interviews with 7 of those providers verified our findings from the observational studies. We analyzed our data and report different places, processes, tools and motivations for creating documentation of patient encounters. Providers either document in the exam room or in their pod office space. Providers either document a patient encounter during one sitting or iterate on the note over several sessions. The various ways providers document have different strengths and weaknesses, but a single theme persists - providers attempt to document to improve the care of the patient, but often struggle because their duties require them to document for billing. From this understanding we present a reconceived model of the EMR that better supports patient information input and retrieval. This model would center around linking patient information, then presenting that information to the provider. The goal for information presentation would be delivering only the information they need, when they need it. In addition to presenting a long-term design goal, we also recommend short-term solutions to improve EMR usage and provider workflows. In the short term, additional staff should be utilized to offload administrative tasks for providers and paper documents designed for patient care should be scanned into the EMR