Document Type


Degree Name



Dept. of Medical Informatics and Clinical Epidemiology


Oregon Health & Science University


Human factors methods are rapidly being adopted by the medical informatics community to explore the safety, efficiency, and effectiveness of health information technology (HIT). Although our understanding of how these technologies affect large healthcare organizations is improving, less is known about the context and real-world work practices found in independent primary care practices. This manuscript contains a comprehensive literature review and the results of original research conducted in four primary care practices in Oregon. The goal was to learn: What socio-technical factors shape the way small primary care practices handle external clinical information, and what are the implications for the design of supportive systems? Four independent primary care practices were selected to include a range of size and complexity. Each used a commercial electronic health record in addition to receiving patient-specific clinical information on paper, by fax, and through verbal communications. Data were collected using semi-structured interviews, participant observations, and by studying artifacts and documents. Data were analyzed and compared using Cognitive Work Analysis (CWA), a comprehensive analytic framework adapted from Cognitive Systems Engineering (a sub-discipline of Human Factors). 2 A complete CWA was done for each site, resulting in formal representations and a cross-site comparison of: the domain-specific purpose, priorities, and resources; information handling functions and general work situations; descriptions of physical, cognitive, and automated work tasks; key decisions and cognitive strategies; and the social organization of information tasks. The use of CWA resulted in a rigorous description and comparison of how multiple socio-technical factors and the environment shape actual work practices for handling external clinical information. Specific work practices could be explained by the unique and common domain constraints including the sequence and allocation of tasks and choices between different media, equipment, and information technologies. In addition to a rich description of the work domain, the framework of CWA yielded general design considerations for replacing systems or workflows. First, designers must be aware of existing environmental and media-specific affordances. Second, individual and team situation awareness often depends on subtle perceptual cues and multiple communication channels. Last, staff and clinicians must be able to adjust and adapt new technologies to their local contexts. This research also showed that CWA is a feasible and informative approach to analyzing the context and details of information work in small primary care settings. In addition to producing a comprehensive description of the 3 work domain and a framework for comparison, CWA can also inform the design and improvement of work practices and technologies.




School of Medicine



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