title: User Manuals for a Primary Care Electronic Medical Record System: A Mixed Methods Study of User- and Vendor-Generated Documents.
abstract: OBJECTIVE
  Tutorials and user manuals are important forms of impersonal support for using software applications including electronic medical records (EMRs). Differences between user- and vendor documentation may indicate support needs, which are not sufficiently addressed by the official documentation, and reveal new elements that may inform the design of tutorials and user manuals.
  
  
  OBJECTIVE
  What are the differences between user-generated tutorials and manuals for an EMR and the official user manual from the software vendor?
  
  
  METHODS
  Effective design of tutorials and user manuals requires careful packaging of information, balance between declarative and procedural texts, an action and task-oriented approach, support for error recognition and recovery, and effective use of visual elements. No previous research compared these elements between formal and informal documents.
  
  
  METHODS
  We conducted an mixed methods study. Seven tutorials and two manuals for an EMR were collected from three family health teams and compared with the official user manual from the software vendor. Documents were qualitatively analyzed using a framework analysis approach in relation to the principles of technical documentation described above. Subsets of the data were quantitatively analyzed using cross-tabulation to compare the types of error information and visual cues in screen captures between user- and vendor-generated manuals.
  
  
  CONCLUSIONS
  The user-developed tutorials and manuals differed from the vendor-developed manual in that they contained mostly procedural and not declarative information; were customized to the specific workflow, user roles, and patient characteristics; contained more error information related to work processes than to software usage; and used explicit visual cues on screen captures to help users identify window elements. These findings imply that to support EMR implementation, tutorials and manuals need to be customized and adapted to specific organizational contexts and workflows. The main limitation of the study is its generalizability. Future research should address this limitation and may explore alternative approaches to software documentation, such as modular manuals or participatory design.
authors.affiliation: Faculty of Information and Institute of Health Policy, Management and Evaluation, University of Toronto. Address: Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada; ;
authors.forename: Aviv
authors.initials: A
authors.lastname: Shachak
authors.affiliation: Faculty of Information, University of Toronto. Phone.
authors.forename: Rustam
authors.initials: R
authors.lastname: Dow
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada;
authors.forename: Jan
authors.initials: J
authors.lastname: Barnsley
authors.affiliation: Institute for Clinical Evaluative Sciences; Department of Family and Community Medicine, University of Toronto, Toronto Western Hospital Family Health Team, Address: G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; Phone:: 416-480-4055 Ext. 3871.
authors.forename: Karen
authors.initials: K
authors.lastname: Tu
authors.affiliation: Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave. #A120, Toronto, ON M4N 3M5, Canada; Ext. 3930.
authors.forename: Sharon
authors.initials: S
authors.lastname: Domb
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto; Centre for Global eHealth Innovation and Centre for Health, Wellness and Cancer Survivorship, University Health Network and University of Toronto. Address: Centre for Global eHealth Innovation, Toronto General Hospital, R. Fraser Elliott Building 4th Floor, 190 Elizabeth St., Toronto, ON M5G 2C4, Canada; Ext. 6903.
authors.forename: Alejandro R
authors.initials: AR
authors.lastname: Jadad
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada;
authors.forename: Louise
authors.initials: L
authors.lastname: Lemieux-Charles
keywords: Electronic medical record; minimalism; tutorial; user manual; user-generated documentation; workflow