Electronic Patient Records
trust; EPR; integration; IT projects; contracts
DIRC research on dependability in healthcare settings has
had a particular focus on the issue of information management and integration
- in particular looking at patient records. Our work has looked at:
Paper records, their creation, keeping and use have been
the subject of research for some time, documents and document work are
often a principal locus for cooperative work, but this interest has
been given a new momentum by the move towards computerization and electronic
records. DIRC research involved an ethnographic examination of record
keeping, organisational change and issues of trust. 'Trust' here relates
to the generalised ability to "take for granted, to take under
trust, a vast array of features of the social order". As records
and record keeping proliferate, and as the technology and organisational
culture changes, with organisations becoming increasingly distributed,
so issues of trust and related notions such as risk become notable.
Put simply, our interest is particularly in 'how' (rather than 'why')
people in organizational life often appear to place great trust in the
often less than pristine, and heavily and (allegedly) illegibly annotated
pieces of paper.
Our interest has been in trying to understand in detail
how and in what ways and in what precise circumstances artefacts such
as records and the various representations they contain come to be trusted
or trustable. What features of the record and the work that surrounds
it and goes into its production, do we need to understand, capture and
represent in order to maintain or develop trust? How do documents get
worked up and enter into everyday work as trustable, reliable artifacts?
What emerges from our observations is the tie between the location of
the records as a collection, and the particular activities carried out
on the ward, and variations in the organisation of the records as a
collection depending on the activity. The record as a central focus
of activity entails brings members involved in different activities
associated with the patient into alignment. Furthermore, the obligations
and rituals associated with the keeping and sharing of records allow
members to demonstrate a regard for each other's work and to maintain
the impression of the work as a collaborative, team effort, carried
out by members with notionally different statuses. Furthermore, the
emphasis on paper, as it is in so many other organisations, is closely
linked to the need for an audit trail and to questions of accountability
should these arise. The supposed 'completeness' of the paper record
is part of its 'trustability' and permits it to act as an audit trail;
providing an outline of, and justification for various decisions.
Electronic Patient Records
Current health and social care policy initiatives in the
UK and many other western countries make significant claims about the
desirability of integrated services for better health and social care,
predicated on information integration being a precondition for service
integration. A key element of any healthcare information integration
strategy is the electronic medical record (EMR), but studies cast doubt
on how effectively IT in general, and the EMR in particular, can actually
deliver service integration.
DIRC research of information integration in the context
of the provision of UK psychiatric healthcare services suggested that,
within the particular setting studied and contrary to many expectations,
the EMR would do relatively little to further service integration goals.
They reveal important discrepancies between the presumptions of the
role of the EMR and the ways in which healthcare professionals actually
use and communicate information. More generally, we concluded that it
may be some considerable time before technologies like the EMR can deliver
their promised benefits, and will only do so if processes used in their
development and implementation become significantly more user-led.
DIRC research suggests that the practices that underpin
the use of patient records may have a range of important implications
for the general design of systems to support collaborative work. Firstly,
given the emphasis on obtaining and presenting 'readings' of the record,
it suggests that information gathering is not, and probably cannot be,
supported solely or simply by an EPR. Secondly, it documents way in
which the everyday, routine work of staff involves far more than mere
information gathering and that forms of awareness, relationship and
'liaising' work get interleaved into the process of obtaining and presenting
information. Taken together, these problematise presumptions about how,
in practice, the EPR might facilitate the greater integration and cohesion
of healthcare services, suggesting instead that such a goal could actually
be hindered by the integration of information via the EPR through reducing
the opportunities and affordances for "interpreting" the patient
EPR projects - the practicalities of implementing an
This DIRC research considers some of the everyday practicalities
of delivering an electronic health record project within an NHS Hospital
Trust. Using ethnographic, observational, data we document how and in
what ways the orderly character of project work is achieved against
a background of battles and negotiations to deliver the project within
and despite various organisational contingencies and constraints.
Satisfying the growing demand for improved coordination
and cooperation between healthcare providers presents a major challenge
for healthcare planners. DIRC research has focused specifically on the
everyday issues involved in integrating new EPR systems into 'workaday'
concerns of medical and administrative practices and systems. These
are problems that are relatively well known - and yet remain stubbornly
persistent. Our concern was less with the technical issues involved
in integration than with a wide range of human and social factors. Using
ethnographic, observational, techniques we document how and in what
ways issues of integration are addressed.
DIRC research examined various features of contractual
issues in everyday user-designer relations in order to consider what
designing with and for users means in the context of electronic patient
record (EPR) development. In so doing we sketch out some neglected issues
both in user-designer relations specifically and in project management
more. We use our ethnographic observations of how contractual issues
feature as part of everyday discourse and negotiation to contribute
to the longstanding debate on 'users' and the design process, pointing
to ways in which contractual issues exacerbate the well known complexities
of determining exactly who the users are and how they can be represented
and accommodated within the design process.
Hartswood, M., Procter, R.N., Rouncefield, M., Slack, R.
(2003). 'Making a Case in Medical Work: Implications for the Electronic
Medical Record'. - in Computer-Supported Cooperative Work (CSCW) Journal.Vol
12, Issue 3, pp241-266.
Clarke, K., Hartswood, M., Procter, R. And Rouncefield, M.
(2003) 'Trusting The Record. Methods of Information in Medicine, 2003.
42: pp 345-352.
Clarke, K, Hartswood, M., Procter, R. And Rouncefield, M
(2001) The Electronic Medical Record and Everyday Medical Work. In Proceedings
of the 6th International Symposium on Health Information Management Research,
Greece, May, 2001, p. 279-83.
Clarke, K., Hartswood, M., Procter, R., Rouncefield, M. And
Sharpe, M. The Electronic Medical Record and Healthcare Integration: Some
Observations of Inter-organisational Working. In Bryant, J. (Ed.) Proceedings
of the BCS Conference on Healthcare Computing, Harrogate, March 18th-20th,
2002. Pp 205-211.
K. Clarke, J. Hughes, D. Martin, M. Rouncefield, A. Voß,
R. Procter, R. Slack, M. Hartswood (2005) . 'Dasein of the Times': Temporal
Features of Dependability In Mackie, J and Rouncefield. M. (2005) (eds)
Proceedings of the 5th Annual DIRC Research Conference. Pp56-63
Dave Martin and Mark Rouncefield 'That's How The Bastille
Got Stormed': Issues of Responsibility in User-Designer Relations In Mackie,
J and Rouncefield. M. (2005) (eds) Proceedings of the 5th Annual DIRC
Research Conference. pp82-91