Table 2 Definitions of computer use
Computer use activityReviewing and updating are episodic in nature, while ordering tests, referring and using other IT functions external to the EHR are usually single occasional tasks. We found the use of prescribing to be either a singleton or complex episodic task depending on how prompting and alerting occurred.
BoutWe observed a bout of computer use beginning with the GP turning to the computer to accomplish a particular task and ending when their attention was directed away from computer use by speaking or listening to the patient or attending to another task.
Reviewing recordThe activity starts with looking at the screen(s) and is enacted at different phases in the consultation: preparing for seeing the patient; checking information during history/examination/counselling; looking at prescriptions/therapy with no evident intention to prescribe and preparing for ordering tests or making referrals. It may also occur between bouts of updating post-consultation where this is more than just checking what has been updated.
Ordering testsThis activity is observed during the interaction or before the patient record is closed. It usually begins with a keystroke or menu action and includes different types of test, for example: (i) pathology (bloods, urine etc.); (ii) assessments (e.g. audio/visual tests and questionnaires). The amount of time spent on the computer doing the task is measured up to submission of produced forms: if a paper form is printed the activity ends at the time of taking the (last) page off the printer.
Referring patientThis is identified usually by stated intention of the GP and can take place (a) during consultation, (b) after consultation or (c) later, outside the consulting session. The duration is observed for how long the clinician spends doing the task from beginning of observed function to return of context to the previous. It may be Choose and Book functionality (application functionality that enables the GP to book an appointment time for the patient in an outpatient clinic within the consultation) or a dictation for later letter writing. If a paper form is printed, referring is deemed to end at the time of submitting a message or taking the (last) page off the printer where a form is printed.
PrescribingThis starts with the observed stated intention to prescribe (in conjunction with using the computer) and ends with the doctor picking up the prescription for signing; it may be interspersed with other activities in which case the bout is ended and a subsequent bout observed. It includes review of prescription history preparatory to prescribing specific medicine(s), but if there is no indicated intention to add or modify prescriptions, then previous looking at prescription history counts as reviewing.
Updating recordThis takes place at different stages in the consultation with the most common practice being a large block of updating after at the end of the patient consultation. Updating is defined as any data entry that involves input to the system as free text or selected codes. It includes: entry of readings such as blood pressure or temperature; additions to patient’s medical history; notes and memos on treatment and miscellaneous actions, e.g. coding and flagging templates.
Using other/external ITThis is used to note particular computer tasks undertaken for the patient that do not necessarily involve the EHR, through there may be soft key links from it to invoke the functions. These tasks include: printing information leaflets (using Web Mentor or equivalent), dictating letters/instructions (but not referrals) or access of alternate systems for information.
Episodic computer usesDefinition: separate sections of interactions with computer which are less frequent in duration and more predictable or relatively easy to observe. Execution involves use of any: (i) coded data entry; (ii) free text data entry; (iii) navigation; (iv) prompts and alerts; (v) interruptions or (vi) screen sharing.28
Singleton computer usesThese generally occur once and include: (i) blood pressure measurement; (ii) prescribing; (iii) referral or (iv) physical examination.28