The clinician in the driver's seat: part 2 - intelligent uses of space in a drag/drop user-composable electronic health record
User-composable approaches provide clinicians with the control to design and assemble information elements on screen via drag/drop. They hold considerable promise for enhancing the electronic-health-records (EHRs) user experience. We previously described this novel approach to EHR design and our illustrative system, MedWISE. The purpose of this paper is to describe clinician users' intelligent uses of space during completion of real patient case studies in a laboratory setting using MedWISE. Thirteen clinicians at a quaternary academic medical center used the system to review four real patient cases. We analyzed clinician utterances, behaviors, screen layouts (i.e., interface designs), and their perceptions associated with completing patient case studies. Clinicians effectively used the system to review all cases. Two coding schemata pertaining to human-computer interaction and diagnostic reasoning were used to analyze the data. Users adopted three main interaction strategies: rapidly gathering items on screen and reviewing ('opportunistic selection' approach); creating highly structured screens ('structured' approach); and interacting with small groups of items in sequence as their case review progressed ('dynamic stage' approach). They also used spatial arrangement in ways predicted by theory and research on workplace spatial arrangement. This includes assignment of screen regions for particular purposes (24% of spatial codes), juxtaposition to facilitate calculation or other cognitive tasks ('epistemic action'), and grouping elements with common meanings or relevance to the diagnostic facets of the case (20.3%). A left-to-right progression of orienting materials, data, and action items or reflection space was a commonly observed pattern. Widget selection was based on user assessment of what information was useful or relevant. We developed and tested an illustrative system that gives clinicians greater control of the EHR, and demonstrated its feasibility for case review by typical clinicians. Producing the simplifying inventions, such as user-composable platforms that shift control to the user, may serve to promote productive EHR use and enhance its value as an instrument of patient care.