Document Type


Degree Name



Department of Medical Informatics and Clinical Epidemiology.


Oregon Health & Science University


EHR adoption rates rose sharply in the early 2000s as a result of federal incentives and wide acclaim for the potential positive effects of EHRs on physician efficiency, quality care delivery, and patient safety. In light of untoward effects on patient care that were observed following EHR implementations, questions arose regarding EHRs’ true impact on clinical workflow and medical care. In particular, lagging adoption rates among pediatricians and specialists compared to generalists suggested inequities in the ability of EHRs to meet all physicians’ information needs. Furthermore, end-user behavior and training were found to be highly variable despite the need for clinicians to be able to access the same key clinical data. First, we used a case study approach, studying the field of pediatrics, to investigate physicians’ typical EHR usage and workflow when evaluating a new patient across a variety of practice settings and clinical specialties (Aim 1a). We also broadened this scope to look at work environment: inpatient versus ambulatory, specialist versus generalist, proceduralist versus non-proceduralist (Aim 1b). Second, we evaluated physicians’ perceptions of EHR usefulness and current barriers to information access when evaluating a new patient across a variety of practice settings and clinical specialties (Aim 2). Third, we explored and characterized distinct information-gathering workflow patterns in practicing hospitalists (Aim 3). Our research found that significant variability exists in how physicians use the EHR in their sequence of providing patient care, how long they took to do so, and what sections of the EHR they preferred or found helpful. There were clear distinctions in these parameters based upon practice setting and type. Overall, however, certain core elements of the EHR were universally valued; these elements, such as chief complaint, past medical history, and history of present illness, are irrefutably essential to most any patient narrative. We found that physicians access information and create documentation using at least two different types of workflows. Further research is needed to evaluate the multitude of characteristics that providers’ workflows have. Effective EHR design must afford for a variety of workflow types to be widely usable. Lastly, documentation in the EHR is a burdensome practice for physicians to both create and extract meaningful information from. This burden must be alleviated in order for physicians to be able to focus on building therapeutic relationships with their patients. This research lays some of the foundational knowledge necessary to engage in the provider-centered design process.




School of Medicine



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