Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Background: The extensive and rapidly expanding research literature on electronic patient records (EPRs) presents challenges to systematic reviewers. This literature is heterogeneous and at times conflicting, not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Aim: To map, interpret and critique the range of concepts, theories, methods and empirical findings on EPRs, with a particular emphasis on the implementation and use of EPR systems. Method: Using the meta-narrative method of systematic review, and applying search strategies that took us beyond the Medline-indexed literature, we identified over 500 full-text sources. We used ‘conflicting’ findings to address higher-order questions about how the EPR and its implementation were differently conceptualised and studied by different communities of researchers. Main findings: Our final synthesis included 24 previous systematic reviews and 94 additional primary studies, most of the latter from outside the biomedical literature. A number of tensions were evident, particularly in relation to: [1] the EPR (‘container’ or ‘itinerary’); [2] the EPR user (‘information-processer’ or ‘member of socio-technical network’); [3] organizational context (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); [4] clinical work (‘decision-making’ or ‘situated practice’); [5] the process of change (‘the logic of determinism’ or ‘the logic of opposition’); [6] implementation success (‘objectively defined’ or ‘socially negotiated’); and [7] complexity and scale (‘the bigger the better’ or ‘small is beautiful’). Findings suggest that integration of EPRs will always require human work to re-contextualize knowledge for different uses; that whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. Conclusions: The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. We offer this paper as a preliminary contribution to a much-needed debate on this evidence and its implications, and suggest avenues for new research

Displays of authority in the clinical consultation: A linguistic ethnographic study of the electronic patient record

AbstractThe introduction of computers into general practice settings has profoundly changed the dynamics of the clinical consultation. Previous research exploring the impact of the computer (in what has been termed the ‘triadic’ consultation) has shown that computer use and communication between doctor and patient are intricately coordinated and inseparable. Swinglehurst et al. have recently been critical of the ongoing tendency within health communication research to focus on ‘the computer’ as a relatively simple ‘black box’, or as a material presence in the consultation. By re-focussing on the electronic patient record (EPR) and conceptualising this as a complex collection of silent but consequential voices, they have opened up new and more nuanced possibilities for analysis. This orientation makes visible a tension between the immediate contingencies of the interaction as it unfolds moment-by-moment and the more standardised, institutional demands which are embedded in the EPR (‘dilemma of attention’). In this paper I extend this work, presenting an in-depth examination of how participants in the consultation manage this tension. I used linguistic ethnographic methods to study 54 video recorded consultations from a dataset collected between 2007 and 2008 in two UK general practices, combining microanalysis of the consultation with ethnographic attention to the wider organisational and institutional context. My analysis draws on the theoretical work of Erving Goffman and Mikhail Bakhtin, incorporating attention to the ‘here and now’ of the interaction as well as an appreciation of the ‘distributed’ nature of the EPR, its role in hosting and circulating new voices, and in mediating participants' talk and social practices. It reveals – in apparently fleeting moments of negotiation and contestation – the extent to which the EPR shapes the dynamic construction, display and circulation of authority in the contemporary consultation

The electronic patient record: a linguistic ethnographic study in general practice

PhDElectronic Patient Records (EPRs) are in widespread use in UK general practice. Although often taken-for-granted by clinicians, managers, administrators and patients, there is limited understanding of how EPRs shape care processes and healthcare interactions in this setting. The EPR is ubiquitous in practice, but its social impact remains under-researched. In this thesis I present a novel approach to examining the role of the EPR, which draws on ethnography and discourse analysis. My work is based on eight months of ethnographic observation in clinical and administrative areas of two general practices. This included observation of clinical consultations, with videorecording of the interpersonal interaction and contemporaneous screen capture of the EPR. This opens up the ‘EPR-in-use’ to detailed scrutiny. In my analysis, which draws particularly on the theoretical work of Goffman and Bakhtin, I pay close attention to the detail of local action and interaction, whilst maintaining sensitivity to the wider context of the general practice organisation. This makes an original contribution to the emerging field of linguistic ethnography. My analysis shows that the EPR contributes to shaping and regimenting interactions and care practices in profound ways, both within the consultation and more widely in general practice organisations. It creates new opportunities, but also creates new demands and tensions. In particular, it sharpens the tension between different ways of framing the patient – the patient as ‘individual’ and the patient as ‘one of a population’ – the latter a more institutional version of the patient. This creates what I have called a ‘dilemma of attention’ for clinicians engaged in patient care. I show ways in which the EPR contributes to the bureaucratisation of care, the construction and circulation of authority within and beyond the consultation, and the production of new notions of patienthood and professional habitus in contemporary general practice

Subtle Redistribution of Work, Attention and Risks: Electronic Patient Records and Organisational Consequences

Based on an actor-network study of the way in which medical work in a hospital has changed after the introduction of an electronic patient record system, the paper addresses the question of organisational consequences of ICT. It describes how the introduction of electronic patient records (EPR) has occasioned redistribution of work, of organisational attention, and of risks. By comparing these findings to the public expectations of EPR and to the literature on organisational effects of EPR, it is argued that we need to shift from a theory of improvement to a theory of distribution in order to understand the way in which ICT affects work practices. The paper further argues that this shift also has implications for the theoretical understanding and practical management of design, implementation, and evaluation of ICT

A KM perspective on implementing an electronic patient record within an NHS hospital

The Electronic Patient Record (EPR) is being developed by many hospitals in the UK and across the globe. We class an EPR system as a type of Knowledge Management System (KMS), in that it is a technological tool developed to support the process of knowledge management (KM). Healthcare organisations aim to use these systems to provide a vehicle for more informed and improved clinical decision making thereby delivering reduced errors and risks, enhanced quality and consequently offering enhanced patient safety. Finding an effective way for a healthcare organisation to practically implement these systems is essential. In this study we use the concept of the business process approach to KM as a theoretical lens to analyse and explore how a large NHS teaching hospital developed, executed and practically implemented an EPR system. This theory advocates the importance of taking into account all organizational activities - the business processes - in considering any KM initiatives. Approaching KM through business processes allows for a more holistic view of the requirements across a process: emphasis is placed on how particular activities are performed, how they are structured and what knowledge demanded and not just supplied across each process. This falls in line with the increased emphasis in healthcare on patient-centred approaches to care delivery. We have found in previous research that hospitals are happy with the delivery of patient care being referred to as their 'business'. A qualitative study was conducted over a two and half year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non- participant observation of meetings and documentary data. We believe that the inclusion of patients within the study may well be the first time this has been done in examining the implementation of a KMS. The theoretical propositions strategy was used as the overarching approach for data analysis. Here Initial theoretical research themes and propositions were used to help shape and organise the case study analysis. This paper will present preliminary findings about the hospital's business strategy and its links to the KMS strategy and process

Assessing the potential for integrating routine data collection on complementary feeding to child health visits: a mixed-methods study

There is no routine data collection in the UK on infant dietary diversity during the transition to solid foods, and health visitors (HVs) (nurses or midwives with specialist training in children and family health) have the potential to play a key role in nutrition surveillance. We aimed to assess items for inclusion in routine data collection, their suitability for collecting informative data, and acceptability among HVs. A mixed-methods study was undertaken using: (i) an online survey testing potential questionnaire items among parents/caregivers, (ii) questionnaire redevelopment in collaboration with community staff, and (iii) a survey pilot by HVs followed by qualitative data collection. Preliminary online questionnaires (n = 122) were collected to identify useful items on dietary diversity. Items on repeated exposure to foods, aversive feeding behaviors, flavor categories, and sugar intake were selected to correspond to nutrition recommendations, and be compatible with electronic records via tablet. HVs surveyed 187 parents of infants aged 12 months. Semi-structured interviews indicated that HVs found the questionnaire comparable with standard nutrition conversations, which prompted helpful discussions, but questions on eating behavior did not prompt such useful discussions and, in some cases, caused confusion about what was ‘normal.’ Lack of time among HVs, internet connectivity issues, and fear of losing rapport with parents were barriers to completing electronic questionnaires, with 91% submitted by paper. Routine nutrition data collection via child health records seems feasible and could inform quality improvement projects

An organisational semiotics inspired information architecture: pervasive healthcare as a case study

Information architecture (IA) is defined as high level information requirements of an organisation. It is applied in areas such as information systems development, enterprise architecture, business processes management and organisational change management. Still, the lack of methods and theories prevents information architecture becoming a distinct discipline. Healthcare organisation is always seen as information intensive organisation, moreover in a pervasive healthcare environment. Pervasive healthcare aims to provide healthcare services to anyone, anywhere and anytime by incorporating mobile devices and wireless network. Information architecture hence plays an important role in information provisioning within the context of pervasive healthcare in order to support decision making and communication between clinician and patients. Organisational semiotics is one of the social technical approaches that contemplate information through the norms or activities performed within an organisation prior to pervasive healthcare implementation. This paper proposes a conceptual design of information architecture for pervasive healthcare. It is illustrated with a scenario of mental health patient monitoring

Data spaces and the (trans)formations of data innovation and governance

In this thesis, I theorize data innovation and governance as simultaneous processes and account for the distinctive nature of data. Utilizing the concept of space, I show how data innovation and governance in multi-actor environments unfold across certain structures of possible forms, and how the realities data refer to condition the forms innovation and governance can take. The uniqueness of data entities has been of interest to information systems scholars, imparting distinct value-creation possibilities and dedicated governance approaches. In the literature on digital innovation, data have been referred to as semantic entities whose value can be open-endedly explored once assigned meaning by actors to fulfill various goals and purposes. Across the literature on data governance, data have been referred to as strategic assets that are governed by organizations. This duality of data – as valuable resources that at the same time require proper governance – has also been central in practical debates, such as the European Union’s aspirations for developing data spaces as shared infrastructures for innovating with data, while preserving European values, laws and regulations. Data innovation commonly requires recombining data that are produced, copied, shared, and used across multiple actors, requiring forms of governance extending beyond the boundaries of single organizations. In this thesis, I build on the process-oriented, realist ontology of assemblage theory to account for data’s distinctive nature and utilize the concept of space to theorize processes of innovation and governance in multi-actor environments. Data spaces, as argued in this thesis, are neither solely geometrical, nor networked; instead, provide forms across which processes of data innovation and governance can change their spatial configurations. Empirically, I study data spaces through an embedded case study in the highly regulated Norwegian healthcare sector dealing with personal and sensitive health data. The cases take an information infrastructure perspective on studying how health data (including electronic patient record data and patient-generated health data) were innovated with and governed across multiple public and private actors. Overall, the meta-analysis shows how innovation and governance with health data took on different forms as data were processed for various purposes across multiple intertwined data spaces. This thesis is aimed at theory-building and its contribution is two-fold. First, it shows how the concept of data spaces can be used to study processes of data innovation and governance as unfolding across various organizations, digital technologies, legal basis, and data sources, by changing their spatial configurations as certain thresholds are reached. Second, it shows how data do not simply decouple from the realities they refer to, rather, these realities condition the forms data innovation and governance can take and are shaped by these processes in return.publishedVersio

From Artefacts to Infrastructures

In their initial articulation of the direction of the CSCW field, scholars advanced an open-ended agenda. This continuing commitment to open-ness to different contexts and approaches is not, however, reflected in the contents of the major CSCW outlets. The field appears to privilege particular forms of cooperative work. We find many examples of what could be described as ‘localist studies’, restricted to particular settings and timeframes. This focus on the ‘here and now’ is particularly problematic when one considers the kinds of large-scale, integrated and interconnected workplace information technologies—or what we are calling Information Infrastructures—increasingly found within and across organisations today. CSCW appears unable (or unwilling) to grapple with these technologies—which were at the outset envisaged as falling within the scope of the field. Our paper hopes to facilitate greater CSCW attention to Information Infrastructures through offering a re-conceptualisation of the role and nature of ‘design’. Design within an Information Infrastructures perspective needs to accommodate non-local constraints. We discuss two such forms of constraint: standardisation (how local fitting entails unfitting at other sites) and embeddedness (the entanglement of one technology with other apparently unrelated ones). We illustrate these themes through introducing case material drawn on from a number of previous studies

INVESTIGATING THE POSSIBILITY FOR IS/IT TO SUPPORT THE DELIVERY OF CHINESE MEDICINE

As Chinese medicine (CM) has increased in popularity globally it now becomes imperative to investigate ways in which safe, efficient, effective and evidence-based approaches might be adopted into CM practice. In the case of western or more traditional healthcare delivery practice, IS/IT is often adopted and employed to assist in this regard and thus this paper examines how IS/IT might be used to support the delivery of CM. In particular, the paper investigates how IS/IT tools and techniques might be used in supporting CM clinics daily processes and thereby bring greater value to a country’s healthcare. In doing so, this paper studies the current global CM situation and provides a solid foundation for how to design and develop an enterprise wide CM clinical management system