Graduation Date

Summer 8-14-2015

Document Type


Degree Name

Doctor of Philosophy (PhD)


Biomedical Informatics

First Advisor

John R. Windle

Second Advisor

James C. McClay

Third Advisor

Ann Fruhling


Electronic health record (EHR) systems have been studied for over 30 years, and despite the benefits of information technology in other knowledge domains, progress has been slow in healthcare. A growing body of evidence suggests that dissatisfaction with EHR systems was not simply due to resistance to adoption of new technology but also due to real concerns about the adverse impact of EHRs on the delivery of patient care. Solutions for EHR improvement require an approach that combines an understanding of technology adoption with the complexity of the social and technical elements of the US healthcare system. Several studies are presented to clarify and propose a new framework to study EHR-provider interaction. Four focus areas were defined - workflow, communication, medical decision-making and patient care. Using Human Computer Interaction best practices, an EHR usability framework was designed to include a realistic clinical scenario, a cognitive walkthrough, a standardized simulated patient actor, and a portable usability lab. Cardiologists, fellows and nurse practitioners were invited to participate in a simulation to use their institution’s EHR system for a routine cardiac visit. Using a mixed methods approach, differences in satisfaction and effectiveness were identified. Cardiologists were dissatisfied with EHR functionality, and were critical of the potential impact of the communication of incorrect information, while displaying the highest level of success in completing the tasks. Fellows were slightly less dissatisfied with their EHR interaction, and demonstrated a preference for tools to improve workflow and support decision-making, and showed less success in completing the tasks in the scenario. Nurse practitioners were also dissatisfied with their EHR interaction, and cited poor organization of data, yet demonstrated more success than fellows in successful completion of tasks. Study results indicate that requirements for EHR functionality differ by type of provider. Cardiologists, cardiology fellows, and nurse practitioners required different levels of granularity of patient data for use in medical decision-making, defined different targets for communication, sought different solutions to workflow which included distribution of data input, and requested technical solutions to ensure valid and relevant patient data. These findings provide a foundation for future work to optimize EHR functionality.

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