Institutional logics of the EMR and the problem of 'perfect' but inaccurate accounts

ABSTRACT

Electronic Medical Records promise to simultaneously enhance coordination and provide transparency and accountability in work process. As such, EMR are purported to benefit both hospitals and patients. In this paper we use grounded empirical data to explore how this promise plays out in the everyday tasks of healthcare providers. Building on the small body of CSCW literature that suggests that the accounting functions of EMR are impinging on the ability of medical personnel to coordinate work, we draw on the theoretical lens of new institutionalism to outline how certain institutional logics around safety and accountability are shaping the experience of EMR systems in situ. We suggest that the institutional logics that currently characterize U.S. healthcare are embedded in the EMR design itself, structuring how institutional values such as 'safety' are achieved and evaluated. Using over one year of ethnographic research in an obstetrical unit, we find that the institutional logics of 'safety' embedded in the EMR create negative organizational outcomes, effectively undermining coordination and necessitating inaccurate accounts of work. We provide design implications to address these issues in the current institutional environment and envision how systems might be designed to promote alternate logics of safety that are social, dynamic, and cast humans as expert agents in the system.

References

1. Abraham, J. and M. Reddy (2008). Moving patients around: a field study of coordination between clinical and non-clinical staff in hospitals. Proc. CSCW 2008, ACM Press, 225--228.
2. Anderson, J.G., Aydin, C.E., and Jay, S.J (1994). Evaluating Health Care Information Systems: Methods and Applications. Sage Publications, Thousand Oaks, CA.
3. Bardram, J. E., and Bossen, C. Mobility work: the spatial dimension of collaboration at a hospital. Computer Supported Cooperative Work (2005). 14(2), 131- 160.
4. Bates, D.W., and Gawande, A.A. (2003). Improving safety with information technology. NEJM, 348, 2536--253
5. Berg, M., and Bowker, G. The multiple bodies of the medical record: toward a sociology of an artifact. The Sociological Quarterly. (1997). 38(3), 513--537.
6. Berg, M. (2001). Implementing information systems in health care organizations: myths and challenges. International Journal of Medical Informatics, 64, 143--15
7. Bjørn, P., and E. Balka. Health care categories have politics too: unpacking the managerial agendas of electronic triage systems. Proc. ECSCW 200 Limerick: Springer (2007), 371--390.
8. Bossen, C. (2006). Representations at work: a national standard for electronic health records. Proc. CSCW 2006. ACM, 69--7
9. Bossen, C. (2011). Accounting and co-constructing: the development of a standard for electronic health records. Computer Supported Cooperative Work, 20, 473--495.
10. Bowker, G.C. and Star, S. L. (1999). Sorting Things Out: Classification and Its Consequences, Cambridge, MA: MIT Press.
11. 1Dekker, S. W. A. (2006). The Field Guide to Understanding Human Error. Aldershot, UK: Ashgate Publishing Co.
12. DiMaggio, P.J., and W.W. Powell, (1991). Introduction. In The New Institutionalism in Organization Analysis. WW Powell and P.J. DiMaggio (eds.) Chicago: University of Chicago Press.
13. Chen, Y. (2010). Documenting transitional information in EHR. Proc. CHI 2010. ACM Press,1787--1796.
14. Dickerson, K., & Manheimer, E. The Cochrane Collaboration: evaluation of health care and services using systematic reviews of the results of randomized controlled trials. Clin Obst & Gyn, (1998). 41(2), 315--331.
15. Dourish, P. Process descriptions as organisational accounting devices: the dual use of workflow technologies. Proc. GROUP 2001, ACM Press (2001), 52--60.
16. Emerson, R.M., Fretz, R.I., and Shaw, L.L. Writing Ethnographic Fieldnotes. (1995). Chicago: The University of Chicago Press.
17. Fitzpatrick, G. Integrated care and the working record. Health Informatics Journal, (2004), 10(4), 291--302.
18. Fitzpatrick, G., and G. Ellingsen. A Review of 25 Years of CSCW Research in Healthcare: Contributions, Challenges and Future Agendas. Computer Supported Cooperative Work (21 June 2012), 1--57.
19. Greenhalgh, T, H., W.W. Potts, G. Wong, P, Bark and D. Swinglehurst (2009). Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method. The Milbank Quarterly, 87(4), 729--788.
20. Hartswood, M., R. Procter, M. Rouncefield and R. Slack (2003). Making a case in Medical Work: Implications for the Electronic Patient Record. Computer Supported Cooperative Work, 12, 241--266.
21. 2Heath, C. and P. Luff. (996). Documents and Professional practice: 'bad' organisational reasons for 'good' clinical records. Proc. CSCW 1996. ACM Press (1996), 354--363.
22. 2Hilligoss, B., and M. Cohen. (2011). Hospital handoffs as multifunctional situated routines: implications for researchers and administrators. Advances in Health Care, 11, 91--132.
23. Institute of Medicine. (1999). To Err is Human: Building a Safer Healthcare System. Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds). Washington DC: National Academies Press.
24. Kellogg, K.C. (2009). Operating room: relational spaces and microinstitutional change in surgery. The American Journal of Sociology, 115(3), 657--711.
25. Lyndon, A., and Kennedy, H.P. (2010). Perinatal safety: from concept to nursing practice. J Perinat Neonatal Nurs.; 24(1): 22--31
26. Meyer, J.W., & Rowan, B. (1977). Institutional organizations: formal structure as myth and ceremony. American Journal of Sociology, 83, 340--63.
27. Østerlund, C. S. Documents in place: demarcating places for collaboration in healthcare settings. Computer Supported Cooperative Work (2007) 17, 195--225.
28. Powell, W.W., and J.A. Colyvas. (2008). Microfoundations of institutional theory. In The SAGE Handbook of Organizational Institutionalism, eds. Greenwood, R., Oliver, C., Sahlin, K., & Suddaby, R. Thousand Oaks, CA: Sage.
29. Pratt, W., Reddy, M.C., McDonald, D.W., Tarczy-Hornoch, P., Gennari, J.H. (2004). Incorporating ideas from Computer Supported Cooperative Work. Journal of Biomedical Informatics, 37, 28--37.
30. Reddy, M., P. Dourish and W. Pratt. (2001). Coordinating heterogeneous work: Information and representation in medical care. Proc. ECSCW 2001. 239--258.
31. 3Rochlin GI. (1999). Safe operation as a social construct. Ergonomics, 42(11):1549--1560.
32. 3Scott, W.R. (2001). Institutions and Organizations. Thousand Oaks, CA: Sage, 2nd ed.
33. 3Scott, W.R. (2003). Organizations: Rational, Natural and Open Systems. Prentice-Hall: Upper Saddle River, NJ. 5th ed.
34. Shekelle, P.G., and Goldzweig. C.L. (2009). Costs and Benefits of Health Information Technology: An Updated Systematic Review. London: Health Foundation for Southern California Evidence-Based Practice Center, RAND Corporation.
35. Steinbrook, R. (2009). Health care and the American Recovery and Reinvestment Act. New England Journal of Medicine, 360(11), 1057--1060.
36. Suchman, L. Making Work Visible. Communications of the ACM, (1995). 38 (9), 56--61.
37. 3Tang, C., and S. Carpendale (2007). An observational study on information flow during nurses' shift change. Proc. ACM CHI 2007, ACM Press, 219--228
38. 3Timmermans, S., and Berg, M. The gold standard: the challenge of evidence-based medicine and standardization in health care. (2003). Philadelphia: Temple University Press.
39. 3Valentine, M.A., and Edmondson, A.C. (2013). Team scaffolds: how minimal team structures enable role-based coordination. HBS Working Paper 12-062.
40. Wiener, C. L. The Elusive Quest: Accountability in Hospitals. (2000). New York: Walter de Gruyter.
41. 4Winthereik, B. R., and S. Vikkelsø (2005). ICT and integrated care: some dilemmas of standardising inter-organisational communication. Computer Supported Cooperative Work,14, 43--67.
42. 4Zhou, X., M. Ackerman and K. Zheng (2011). CPOE workarounds, boundary objects, and assemblages. In Proc. CHI 2011. ACM Press, 3353--3362.

Index Terms

• Human-centered computing

  • Collaborative and social computing