Integrated Care Record … Integrated Care Practice
Geraldine Fitzpatrick
Interact Lab, Dept of Informatics, University of Sussex, Brighton UK BN1 9QH
Keywords: patient charts, telemedicine, clinical practice, electronic records
Extended Abstract
Introduction
While accepting the well-documented limitations of the paper chart and the significant potential
offered for healthcare through the ICRS initiative, the conceptualisation of ‘record’ that
underpins the ICRS implicitly constrains work practice implications of a care record service. I
suggest that the ICRS conceptualises the record as passive information archive deleting, by
omission, another equally important conceptualisation of the record at work in the practical
doing of care work.
The ‘record as archive’ view is evident in the way that the a priori features and functionalities
of the ICRS have already been prescribed in the RFPs. The ICRS documentation does argue,
laudably, for the importance of a patient-centric and clinician-centric service and to this end
patient and clinician representatives are being engaged through broad consultation processes.
The work practice and change management implications are also noted in the ICRS, with calls
on the Modernisation Agency and requests for training/implementation plans. While again it is
laudable that consortia are being asked to address these issues, they tend to inform the post-hoc
deployment and adoption of the ICRS not the design of the ICRS itself.
In this presentation I will use two hospital-based case studies to present stories of ‘integrated’
clinical practice and reflect on these with respect to the ICRS initiative. 1
Case Study – Patient Charts
The first is a qualitative case study of how paper charts were used in a medical ward of a large
metropolitan hospital, showing how the very nature of the paper chart is integrally and actively
embedded into the ‘doing’ of health care [1]. Firstly, it suggests there is no such entity as the
While not all explicitly included, I will draw on my own clinical practice background, involvement in
different health-technology projects, studies of clinicians at work, and working in industry as a
1
record in practice – the working chart is a distributed collection of inter-related forms, papers
and documents, all of which are meshed with the social, spatial and organisational milieu of the
hospital. While the patient chart serves as a focal point, and is the persistent archival trace of the
working record, it is not the totality of that record. This points to opportunities for the
organisational implementation of an ICRS to provide clinician-managed multi-layered
temporally-relevant views around a core persistent data set.
Secondly, the tangible physical nature of the paper record affords particular kinds of support for
communication and coordination, as has been well documented [2]. In particular for clinical
practice, it enables overlaid functionality so that conversations can be located at the point of
care and the relationship between paper and space can help make the status of work more
visible. This points to complementary ICRS functionality that could be provided to support the
communicative and coordinative role of the paper chart.
Case Study - Telemedicine
The second study reports on the experiences gained over of a two year period during which
three intensive care units were connected by a telehealth service [3]. The lessons point to the
level of effort involved in getting even simple off-the-shelf technologies appropriately deployed
and the even greater effort involved in bringing about changes in clinical practice whereby
using the telehealth system was as ‘natural’ as using the phone. Strategies to promote adoption
included having a full-time clinician at each site to facilitate use of the system and treating the
technology as yet another tool, not just to call a colleague for remote consultation but for a
variety of other uses such as cross-site education, grand rounds, management meetings and so
on. The system had significant impacts not just on patient outcomes but also on professional
practice and peer networks.
Summary
These studies suggest that a conceptualisation of the record at work rather than as archive can
help identify new opportunities for the support of clinicians and clinical practice that will, by
their very relevance to practice, help promote successful adoption. By understanding the
consultant for one of the companies bidding for an ICRS LSP contract.
perspective of integrated care – as opposed to care records divorced from their ‘mundane’ use
– we can make more informed decisions about how to evolve good clinical practices that are
enabled by, and drive forward, the design of good supportive clinical environments made up of
a mix of information systems, electronic tools, paper, and space as appropriate.
Acknowledgement
The support and cooperation of the staff at the metropolitan hospital and at the three intensive
care units is greatly appreciated. The work reported on here was carried out by the author while
at the University of Queensland and the Distributed Systems Technology Centre Australia.
References
1. Fitzpatrick, G. “Understanding the Paper Health Record in Practice: Implications for
EHRs”, in Proceedings of Health Informatics Conference (HIC’2000), Adelaide, 2000.
ISBN 0 9585370 5 4.
2. Sellen A & Harper R. (2002) The Myth of the Paperless Office. MIT Press, Cambridge.
3. R. Whiting, R.., Hayes, L., Fitzpatrick, G., Bryant, J. and Bailey, G. “TARDIS Project
Report”, in Proceedings of Health Informatics Conference (HIC’99), Hobart, 1999.