June 2008

Document Type


Degree Name



Dept. of Medical Informatics and Clinical Epidemiology


Oregon Health & Science University


Objective: Computerized Provider Order Entry (CPOE) is an important component of the electronic health record, but there has been some difficulty with user acceptance, and this is often due to poor computer interface usability which disrupts clinician workflow. This qualitative research employed usability engineering methods to study community hospital physicians using commercial CPOE systems while in a naturalistic context. Methods: Using Norman’s Theory of Action as a framework for analysis, this study sought to understand any disparity between the users’ mental models and the representations and behavior of the computer system as the basis for usability problems. Community-based physicians from three health systems were observed entering patient admission orders in real time on commercial CPOE systems. Using think-aloud methods, the users’ words, video images and computer display activity were recorded. These data were analyzed from cognitive, human-computer interaction and grounded theory perspectives. Results: Numerous usability problems were uncovered with these observations. Users demonstrated cognitive problems when they were unable to specify the actions needed to enter orders and when they had difficulty perceiving and interpreting the display. They were noted to have problems locating items on the display and remembering details of their respective systems and they expended excessive time and effort entering data. The users occasionally were resigned to actions that were not initially intended, guessed at the next steps to take and often ignored items on the display. Specific CPOE interface issues that caused usability problems were inappropriate alerts and default values, overly long lists and a lack of synonyms. Order sets were generally a benefit to usability. Conclusion: Field usability testing should be considered in all institutions implementing CPOE or other clinical computer applications as a means of identifying problems important to the user so that one might improve the usability and acceptance of those systems.




School of Medicine



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