Understanding Physicians at Work: Insights into Users, User Tasks, Environment, and Medical Information
Understanding health care providers at work is clearly a daunting challenge for most usability professionals with limited medical knowledge. Your own individual experience with doctors and nurses gives us some limited understanding of what they really do. A visit to the local clinic with a sore throat will serve as a convenient baseline.
Visiting the Clinic
If you wake up tomorrow morning with a sore throat and a fever, you might decide to see a doctor. Here are typical steps you might follow:
- Call for appointment. Good news. They can fit you in at 3 p.m.
- You appear at the clinic at 3 p.m. and start filling out paperwork: health insurance information, medical history including surgeries, family history of ailments, and current medications. You also watch TV and browse the magazines.
- The nurse sees you at 3:30 p.m. and takes your temperature, blood pressure, heart rate, and measures your height and weight. He or she also asks what's wrong and how long you've had symptoms.
- The doctor appears at 3:40 p.m. He or she looks at your throat, up your nose, and in your ears. "The flu is going around, and you've probably got it. I'm going to prescribe a new anti-flu medicine, Tamiflu. Which pharmacy do you use?"
- On the way out the door, you stop at the receptionist to write a check for the co-pay on your insurance.
Let's look at this from the doctor's perspective. Specifically, Figure 4 shows a task analysis for a doctor of internal medicine who is seeing a patient in an outpatient setting. During the clinic visit, you actually experienced three of the 16 subtasks, circled in orange in Figure 4, that the provider typically completes. You also experienced several administrative subtasks not related to medical care, i.e., filling out forms and paying for the visit, along with many minutes of reading old magazines, watching TV, and browsing colorful brochures on osteoporosis and circumcision.
Figure 4. Task Analysis for a doctor of internal medicine
Understanding medical systems starts with understanding the tasks that providers typically complete, as shown in Figure 4. At the highest level, there are the following six major tasks that providers complete for each patient encounter:
- Nursing or physicians assistant (PA) pre-work
- Review patient chart
- Interact with patient
- Order labs, procedures, medications, and consultations with specialists
- Compose the note
- Record billing
Tasks two through five can be done in almost any order, and each provider typically has his or her own favorite order. I observed an oncologist start with step 3 (interact with patient), go to step 2 (review patient chart), and finish with step 4 (order labs, procedures, and medications). Naturally, if the patient had questions, he would jump back to step 3 and could go anywhere from there, depending on the patient interaction, what appeared in the patient's chart, and what problem-solving approach he pursued. At the end of the day he composed the note.
The patient encounter starts when a nurse first sees the patient in the exam room. Here the nurse typically measures and records the patient's vitals, including height, weight, heart rate, and blood pressure. The nurse also asks, "So, what brings you into the clinic today?" Whatever the patient says next will be translated into the chief complaint and is typically recorded in the system.
The physician often reviews the patient's chart next for two reasons. First, the patient may be here as a follow-up to a prior visit, which is documented in the chart. Second, the patient's current health problem is typically related to prior health problems, e.g., diabetics typically have related health problems including retinopathy, neuropathy, and renal failure.
Interacting with the patient will inform the physician's next steps. It is part examination and part conversation. The examination involves a physical examination of the patient, sometimes reviewing all major systems, i.e., circulatory, skeletal, gastrointestinal, etc. The discussion involves understanding the patient's current problems and discussing alternative treatments.
Ordering is an internal process whereby the physician orders other parts of the clinic to complete work on or for the patient. For example, the physician can order blood tests (labs), an MR scan (procedure), a prescription for penicillin (medications), a consultation with a specialist in ENT (consult), and a follow-up visit.
Each time a physician meets with a patient, the physician must record what happened in a note. Notes come in different sizes, but essentially it is a written record of the vitals, the chief complaint, the current medications, any lab results, the results of the examination, the diagnosis, and the orders placed for labs, procedures, medications, etc. Composing the note often takes more time with a computerized system than with the old paper-based system.
Finally, the physician must record the work done so that the clinic can get paid. This involves identifying the Evaluation and Management (E/M) code and recording any procedures completed. Billing for services is an enormously complicated process and beyond our scope.
This understanding of the tasks and task flows completed by physicians was essential to our analysis of EMR usability. It is also central to good user-centered design. With this solid understanding of users' tasks, we can now revisit the challenges that physicians face with EMRs to look for ways to improve their EMR experiences.