Wu Robert C, Orr M Scott, Chignell Mark, Straus Sharon E
Knowledge Translation Program, University of Toronto, Canada.
Inform Health Soc Care. 2008 Jun;33(2):139-49. doi: 10.1080/17538150802127223.
Point of care access to electronic medical records may provide clinicians with the information they want when they need it and may in turn improve patient safety. Yet providing an electronic medical record on handheld devices presents many usability challenges, and it is unclear whether clinicians will use them.
An iterative design process for the development and evaluation of a prototype of a mobile electronic medical record was performed. Usability sessions were conducted in which physicians were asked to 'think aloud' while working through clinical scenarios using the prototype. Verbal protocol analysis, which consists of coding utterances, was conducted on the transcripts from the sessions and common themes were extracted.
Usability sessions were held with five family physicians and four internists with varying levels of computer expertise. Physicians were able to use the device to complete 52 of 54 required tasks. Users commented that it was intuitive (9/9), would increase accessibility (5/9) but for them to use it, it would need the system to be fast and time-saving (5/9). Users had difficulty entering information (5/9) and reading the screen (4/9). In terms of functionality, users had concerns about completeness of information (6/9), details of ordering (5/9) and desired billing functionality (5/9) and integration with other systems (4/9).
While physicians can use mobile electronic medical records in realistic scenarios, certain requirements likely need to be met including a fast system with easy data selection, easy data entry and improved display before widespread adoption occurs.
即时获取电子病历可为临床医生在需要时提供他们想要的信息，进而可能提高患者安全。然而，在手持设备上提供电子病历存在许多可用性挑战，尚不清楚临床医生是否会使用这些设备。
对移动电子病历原型进行了开发和评估的迭代设计过程。开展了可用性测试，让医生在使用原型处理临床场景时进行“大声思考”。对测试记录进行了言语协议分析，即对话语进行编码，并提取了共同主题。
与五位家庭医生和四位内科医生进行了可用性测试，他们的计算机专业水平各不相同。医生们能够使用该设备完成54项所需任务中的52项。用户评价该设备直观（9/9），会增加可及性（5/9），但要让他们使用，系统需要快速且节省时间（5/9）。用户在输入信息（5/9）和阅读屏幕（4/9）方面存在困难。在功能方面,用户担心信息完整性（6/9）、医嘱细节（5/9）、所需计费功能（5/9）以及与其他系统的集成（4/）。
虽然医生可以在实际场景中使用移动电子病历，但在广泛采用之前可能需要满足某些要求，包括具备快速系统、易于数据选择、便于数据录入和改进显示。
