Problems Encountered in Electronic Health Record Research

1
Problems Encountered in Electronic Health Record
Research

• K. Neil Jenkings
• Sowerby Centre for Health Informatics at the
  University of Newcastle,
• University of Newcastle-upon-Tyne,
• Tel [phone] Fax [phone]
• neil.jenkings_at_ncl.ac.uk

2
Aims

• Introduction
• The Problem of Fitness for Purpose
• The Problem of Modelling
• The Problem of Previous Research Strategies
• The Problem of Gatekeepers
• The Practical Problem of Data Representation
• Discussion.

3
Introduction

• This paper attempts to highlight what some of the
  problems for researchers, other than purely
  technological capabilities, are that can be
  encountered in electronic health records
  research.
• EHR Scope

4
EHR Scope

• large multi-disciplinary health and social care
  environment
• not under the management of a single authority
• differing bodies have both formal and informal
  structures and working patterns and communication
  structures
• legacy systems
• not confined to communication hardware and
  software
• formal and informal work organization
• personnel
• organisational memory
• previous initiatives and experience of work
  collaboration
• and current pilot initiatives not sponsored by
  Electronic Health Record projects.

5
The Problem of Fitness for Purpose

• Ready-to-Hand Unready-to-Hand
• At such times, inspection and practical
  problem-solving occur, aimed at repairing or
  eliminating the disturbance in order to get
  going again. In such times of disturbance, our
  use of equipment becomes explicitly manifest as
  a goal-orientated activity, and we may then try
  to formulate procedures or rules. (Suchman 1987
  p53)
• Requirement for detailed descriptions of work
• But we arrive with legacy systems in place and,
  more significantly, legacy rationalisations of
  why those systems do not operate in the desired
  fashion.
• The problem being their ability to set the agenda
  for EHR requirements and design

6
The Problem of Modelling

• Models that do not adequately reflect the
  everyday world
• Producing products where readiness-to-hand is
  absent.
• Risk of producing reality disjunctures on users
• The disjuncture between the ideal and reality
  may be so significant that it generates
  significant dissonance and conflict, leading to
  abuse, misuse and disuse of tools and systems
• May only produce adaptation and coping strategies
• In either case inadequate description can lead to
  unreadiness-to-hand products that are not
  fit-for-purpose

7
The Problem of Previous Research Strategies

• Imperative that we have detailed information as
  to what occurs at these sites and why
• Actual activities official and unofficial
• the why question not being predetermined by
  official or formal accounts whose versions
  are designed to fit in with service provision
  protocols
• A whole industry has grown up providing
  quantitative services to, and within, the NHS.
• Design and implementation activities have relied
  upon non-existent or inadequate gloss
  descriptions of the actual activities of
  healthcare professionals they wish to support or
  transform.
• The problem being a preference for quantitative
  strategies has now become a legacy of previous
  strategies.

8
The problem of gatekeepers

• Users as Guardians of privacy
• Powerful professional bodies
• Hierarchical Organisation
• Gatekeepers determining access and hence
  methodology
• Respondents who speak on behalf of (but in
  effect, instead of) their employees, i.e. those
  who handle much of the inter-healthcare
  organisation and patient communication, and talk
  authoratively about work practices which they do
  not do and often have never done.

9
The practical problem of data representation

• process model approach almost a universal
  standard for NHS managers at all levels
• Consequently a major resource for the designers
  of EHRs technologies.
• Need to accommodate this preference
• Models need not be information poor
• Problem of prose representation
• Lengthy and inaccessible
• The challenge is not only to collect detailed
  information, but also to be able to represent it
  to an audience with a preference for process
  model representations of the world

10
Discussion

• Five interrelated problems
• The Problem of Fitness for Purpose
• The Problem of Modelling
• The Problem of Previous Research Strategies
• The Problem of Gatekeepers (methodology)
• The Practical Problem of Data Representation
• Ethnographic dimension of our work is not a
  substitute for the managerial or architectural
  perspectives but that these three perspectives
  have to be combined appropriately if the concept
  of EHR is to result in tools that are
  ready-to-hand and thus meet political and
  clinical needs