Table 3.

Impact of Operational Failures on Primary Care Physicians’ Work and Examples Associated With These Impacts

Impact of Operational Failure on Primary Care Physicians	Examples
1. Additional steps required to complete task	• Double documentation; duplicating, and repeating notes if no link between notification system and patient’s record • Work shifting to primary care physicians that was previously done by others (eg, filling in forms, scheduling patients, updating patient contact information) • “Looping” of tasks between clinical and nonclinical teams due to uncertainty over roles within practice • Separating prescription items into those that can be prescribed electronically and those needing “wet-signatures”
2. Required workarounds	• Contacting other professionals, insurance, or billing systems for missing information or patients themselves for answers if information in record is thought to be inaccurate or is difficult to find • Using paper-based tracking systems of ordered tests, prescriptions issued, abnormal test results, etc because electronic health record does not facilitate this tracking • Copying and pasting text from patient’s previous notes if system does not auto-populate new templates • Printing out notes owing to difficulties in switching between computer screens • Disabling or ignoring electronic health record functions • Hand-writing prescriptions or test requests if information technology networks go down or if want to add additional details that are not permitted within electronic systems
3. Consumed time	• Manually inputting information if poor interoperability between systems • Opening information systems that freeze or lock physician out • Removing repetitive or unnecessary alerts • Searching for missing test results or repeating tests
4. Disruptions	• Interruptions to consultation from staff, other patients, phone calls • Interference to workflow by computer decision support alerts taking physician into other tasks • Having to leave room to get necessary equipment, find paper for the printer, or use a different printer • Not having access to required examination rooms
5. Delayed decision making	• Lack of information feedback from and difficulty reaching other health care clinicians • Missing or delayed test results • Trying to determine who should undertake pending tests • Not being able to locate necessary information in the notes
6. Interfered with physician-patient relationship	• Poorly designed electronic health records shifts physicians’ focus away from the patient • Addressing clerical or administrative questions with patients during consultations shifts focus away from their presenting complaint, and consumes time
7. Cognitive burden	• Information overload due to multiple streams of incoming patient information, with most relevant information obscured by repetitive or unnecessary information • Decision support systems creating unhelpful signal-noise ratio with clinically irrelevant alerts and alert fatigue
8. Dissatisfaction	• Frustration associated with delayed or missing critical information from other clinicians, laboratories, etc • Stress arising from disruptions during the consultation, inefficient practice organization, and hectic schedules • Dissatisfaction associated with large volumes of non-clinical tasks • Time pressure and work pace leading to stress and burn-out