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

Ethnographic study of ICT-supported collaborative work routines in general practice

<p>Abstract</p> <p>Background</p> <p>Health informatics research has traditionally been dominated by experimental and quasi-experimental designs. An emerging area of study in organisational sociology is routinisation (how collaborative work practices become business-as-usual). There is growing interest in the use of ethnography and other in-depth qualitative approaches to explore how collaborative work routines are enacted and develop over time, and how electronic patient records (EPRs) are used to support collaborative work practices within organisations.</p> <p>Methods/design</p> <p>Following Feldman and Pentland, we will use 'the organisational routine' as our unit of analysis. In a sample of four UK general practices, we will collect narratives, ethnographic observations, multi-modal (video and screen capture) data, documents and other artefacts, and analyse these to map and compare the different understandings and enactments of three common routines (repeat prescribing, coding and summarising, and chronic disease surveillance) which span clinical and administrative spaces and which, though 'mundane', have an important bearing on quality and safety of care. In a detailed qualitative analysis informed by sociological theory, we aim to generate insights about how complex collaborative work is achieved through the process of routinisation in healthcare organisations.</p> <p>Discussion</p> <p>Our study offers the potential not only to identify potential quality failures (poor performance, errors, failures of coordination) in collaborative work routines but also to reveal the hidden work and workarounds by front-line staff which bridge the model-reality gap in EPR technologies and via which "automated" safety features have an impact in practice.</p

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study

Objective To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality

The polypharmacy challenge: time for a new script?

National Institute for Health Research (NIHR) through a Clinician Scientist Award (Swinglehurst)

Caring for the patient, caring for the record: an ethnographic study of 'back office' work in upholding quality of care in general practice

© 2015 Swinglehurst and Greenhalgh; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Additional file 1: Box 1. Field notes on summarising (Clover Surgery). Box 2. Extract of document prepared for GPs by summarisers at Clover Surgery. Box 3. Fieldnotes on coding incoming post, Clover (original notes edited for brevity).This work was funded by a research grant from the UK Medical Research Council (Healthcare Electronic Records in Organisations 07/133) and a National Institute of Health Research doctoral fellowship award for DS (RDA/03/07/076). The funders were not involved in the selection or analysis of data nor did they make any contribution to the content of the final manuscript

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

Recovering the self: a manifesto for primary care.

Huge political, ideological and organisational changes are engulfing primary care, placing intense pressures on the sense of self for both patient and doctor within the consultation.A recent Health Foundation report urges us to develop care practices rooted in a philosophy of people as ‘purposeful, thinking, feeling, emotional, reflective, relational, responsive beings’.1 GPs are encouraged to work collaboratively with patients, fostering shared decision-making and promoting self-management. This assumes that patients (and doctors) have agency and capacity, the ability to make their own choices and decisions and the power to take action in a given situation. But these assumptions are problematic when you are running 15 minutes late during a morning surgery with 18 patients, most of whom are unknown to you, and your QOF screen pop-up urges you to update the patient’s CVD risk assessment score and take action to reduce their HbA1c levels.We wish to give clinicians ‘permission’ to do person-centred care by offering a language of self that they can use to describe and defend their practice. Our principal motivations in establishing the centrality of the self in primary care are to offer hope to those entering the field, encourage those jaded by their current experience in practice, and provide vital underpinning to the generalist cause

Caring for quality of care: symbolic violence and the bureaucracies of audit.

BACKGROUND: This article considers the moral notion of care in the context of Quality of Care discourses. Whilst care has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is centrally involved in the governance of UK health care, relates to practice. DISCUSSION: This paper presents a social and ethical analysis of Quality of Care in the light of the moral notion of care and Bourdieu's conception of symbolic violence. We argue that Quality of Care bureaucracies show significant potential for symbolic violence or the domination of practice and health care professionals. This generates problematic, and unintended, consequences that can displace the goals of practice. SUMMARY: Quality of Care bureaucracies may have unintended consequences for the practice of health care. Consistent with feminist conceptions of care, Quality of Care 'audits' should be reconfigured so as to offer a more nuanced and responsive form of evaluation