Abstract
BACKGROUND: To support physicians in focusing on relevant information during melanoma treatment, it is essential to design information systems (ISs) that integrate into their workflow. OBJECTIVE: This study aimed to identify the work steps, knowledge sources, and key information during tumor board registration, revealing the physician's cognitive workflow and task conceptualization. METHODS: We applied the concurrent think-aloud method with 10 dermatologists from the University Hospital Essen's skin cancer unit, providing direct insights into their work. Participants had varying levels of experience, from a few weeks to over a decade in the department, and differing levels of previous patient knowledge. Voice and screen recordings were transcribed and inductively annotated across 3 categories: "work step," "information in focus," and "program used." Furthermore, 4 annotators from medical informatics and social psychology conducted the annotation process. These annotations were used to map the workflow model via a sequence diagram, alongside a quantitative analysis of code occurrences and overlaps. RESULTS: Patient-related data in clinical IS are distributed across nested submodules, requiring physicians to extract key information through extensive system interactions. The workflow consists of 4 distinct phases with 10 work steps, taking on average 13 minutes to complete. Physicians switched between 3 programs approximately 25 times, requiring a minimum of 16 interactions to access essential information from the hospital IS. The analysis identified 7 fundamental pain points: time-intensive login and patient selection (consuming 7% of workflow time), need for multiple system instances, data fragmentation across systems, hierarchical information modularization, interface structures hindering simultaneous viewing, repetitive data insertion (27% of time), and inappropriate input fields forcing external text editor use (28% of time). Collectively, approximately 55% of workflow time was dedicated to system interactions and manual data compilation rather than clinical decision-making. Physicians frequently copied information from various reports to compile a free-text case summary, representing an extensive workaround addressing data fragmentation. External editing of the case summary was highly iterative, with an average of 3.5 repetitions. The workflow phase "updating the knowledge" showed the greatest variety in step sequences, with physicians accessing radiology reports, laboratory values, tumor board protocols, and progress documentation in varying orders. CONCLUSIONS: These insights offer a deeper understanding of physicians' intentions when handling medical information and their challenges with current clinical IS. The workflow can be understood as a comprehensive workaround due to data distribution, with physicians compensating through experience-based adaptations. This understanding of physicians' task conceptualization forms the basis for designing software solutions that better support workflows at the point of care by organizing and presenting relevant data more effectively.