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: (0191) 243 6181 Fax: (0191) 243 6101
neil.jenkings@ncl.ac.uk
©2003 Sowerby Centre for Health Informatics at Newcastle
Aims
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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.
©2003 Sowerby Centre for Health Informatics at Newcastle
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
©2003 Sowerby Centre for Health Informatics at Newcastle
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:
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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.
©2003 Sowerby Centre for Health Informatics at Newcastle
The Problem of Fitness for Purpose
• “Ready-to-Hand” “Unready-to-Hand”
• “At such times, inspection and practical problemsolving 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
©2003 Sowerby Centre for Health Informatics at Newcastle
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-forpurpose
©2003 Sowerby Centre for Health Informatics at Newcastle
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.
©2003 Sowerby Centre for Health Informatics at Newcastle
The problem of gatekeepers
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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.
©2003 Sowerby Centre for Health Informatics at Newcastle
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
©2003 Sowerby Centre for Health Informatics at Newcastle
Discussion
Five interrelated problems
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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
©2003 Sowerby Centre for Health Informatics at Newcastle