Related Projects

Full Title

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

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 record.

EPR projects - the practicalities of implementing an EPR project

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.

Contractual issues

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


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