DESCRIPTION (provided by applicant): To date, there is little quantitative research on how providers use Electronic Health Record (EHR) systems in real clinical settings, and on the methodology and metrics to assess EHR usability: the effectiveness, efficiency, and satisfaction with which users can achieve intended tasks. Such research can identify candidate components for redesign. In particular, documentation of the patient encounter and information retrieval of existing patient data are complementary tasks of the clinical workflow at the point of care. Documentation is often in narrative form stored as unstructured text documents. Providers also retrieve information from previous notes. Lack of EHR automation and poor user interfaces can contribute to the introduction of redundant information into the patient record (eg, information copy/pasted from other areas of the EHR) as well as to inefficient workflows such as the duplicative work that results when clinicians enter orders through structured menus and subsequently manually document these orders in progress notes. In our previous research on time-motion studies in an outpatient setting (PACE study), we found the following: (1) inefficiencies in EHR workflow during the constrained time frame of office consultations. These can be classified as resulting from (a) navigation: providers move across screens to retrieve and then mentally integrate scattered patient information; (b) order entry: driven by nested pull-down menus and other inefficient interfaces, and (c) documentation: notes contain redundant information copy/pasted from earlier notes or other parts of the EHR, duplicative documentation of orders entered, poorly searchable notes, and boilerplate- generating templates. These contribute to information being lost in a "sea of text." (2) The CPRS/VistA Notes function accounts for about half of total EHR activity and is quantifiably a central nexus of activity because providers repeatedly navigate back to Notes for reference (together, Notes and order entry tasks account for 20 ~75% of workflow activity, based on time-at-task, mouse activity and navigation patterns). Therefore, Notes is a promising candidate for redesign. (3) We observed wide variation in providers' EHR workflow and in how they organize information in progress notes, which deserves further study. The proposed project has 3 specific aims: (1) To measure longitudinally the degree of redundancy (primary outcome measure) introduced over time in patient documentation, and to perform baseline content analysis to study variation in how clinicians organize and segment their notes into major sections (eg, SOAP). We will also study lexical and terminology variation across providers. This aim is based on sequence alignment and manual coding of time-indexed archival CPRS/VistA progress notes from two VA sites. Clinician interviews (Stimulated Recall) will provide context for the findings. (2) To quantitatively profile how prima...