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Accounting and Co-Constructing: The Development of a Standard for Electronic Health Records

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Abstract

Patient records are central, constitutive parts of health care and hospitals. Currently, substantial sums are being invested in making patient records electronic, in order to take advantage of IT’s ability to quickly accumulate, compute, and propagate data to multiple sites, to enhance coordination of health care services and cooperation among staff, and make patient records immediately accessible to distributed actors. Investors also aim to increase health care services’ accountability and integration, and improve quality and efficiency. This paper analyses a Danish national standard for electronic health records, on the basis of an application prototype test designed to that standard. The analysis shows that, inscribed in the standard is an ambition to increase the accountability of staff and health care services at the cost of increased work, loss of overview, and fragmentation of patient cases. Significantly, despite the standard having been conceived and developed in a process of co-construction involving clinicians, clinicians did not find it adequate for their work. This analysis argues this was the result of the model of work embedded in the standard coming from a stance external to practice. Subsequently, a flip-over effect occurred, in which the model of work became a model for work. Hence, this paper argues that co-construction processes should not only include users as representatives of a profession, but strive to produce experiences and knowledge intrinsic to practice.

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Notes

  1. For a comprehensive overview of the literature on EHRs, see Greenhalgh et al. 2009. For overviews of national initiatives, see for example, Chantler et al. 2006 (UK); Dorda et al. 2008 (Austria); Berner et al. 2005, Singer 2009 (USA); and Ellingsen and Røed 2010 (Norway).

  2. ‘Emancipatory’ will be used as an inclusive term here, for concerns about quality of life, quality of work, democracy, dominance, and different possible futures.

  3. Procter et al., 2009, distinguish between context, timing, scale and purpose of engagement, and user experience.

  4. Computerized problem-oriented records have been used at the Vermont Hospital (1970–74) in the U.S. (Schultz 1988) and the Karolinska Hospital in Sweden (1968–71) (Mellner, Selander et al. 1976). A CPOMR for general practitioners was in use in Norway from 1984 to 2008 (Botsis et al 2010).

References

  • Asp, L., & Petersen, J. (2003). A conceptual model for documentation of clinical information in the EHR. From http://www.sst.dk/upload/papermie2003_asp013_dk.pdf.

  • Atkinson, P. (1995). Medical talk and medical work. London: Sage.

    Google Scholar 

  • Berg, M. (1999). Accumulating and coordinating: occasions for information technologies in medical work. Journal of Computer Supported Cooperative Work, 8(4), 373–401.

    Article  Google Scholar 

  • Berg, M. (2001). Implementing information systems in health care organizations: myths and challenges. International Journal of Medical Informatics, 64(2–3), 143–156.

    Article  Google Scholar 

  • Berner, E. S., Detmer, D. E., & Simborg, D. (2005). Will the wave finally break? A brief view of the adoption of electronic medical records in the United States. Journal of the American Medical Informatics Association, 12(1), 3–7.

    Article  Google Scholar 

  • Bijker, W. E., & Law, J. (Eds.) (1992). Shaping technology/building society. Cambridge (Mass) & London: MIT Press

  • Blomberg, J., & Kensing, F. (1998). Participatory design: issues and concerns. Journal of Computer Supported Cooperative Work, 7, 167–185.

    Article  Google Scholar 

  • Bossen, C., Dindler, C., & Iversen, O. S. (2010). User gains and PD aims: assessment from a participatory design project. Proceedings of the 11th Biennial Participatory Design Conference. (pp. 141–150). Sydney, Australia: ACM.

  • Bowers, J., Button, G., & Sharrock, W. (1995). Workflow from within and without: technology and cooperative work on the print industry shopfloor. In H. Marmolin, Y. Sundblad, & K. Schmidt (Eds.), Proceedings of the fourth European conference on computer-supported cooperative work (pp. 51–66). Dordrecht: Klüwer Academic Publishers.

    Chapter  Google Scholar 

  • Chantler, C., Clarke, T., & Granger, R. (2006). Information technology in the english national health service. Journal of the American Medical Association, 296(18), 2255–2258.

    Article  Google Scholar 

  • Cotton, P., Fraser, I. M., & Hill, W. Y. (2000). The social audit agenda—primary health care in a stakeholder society. International Journal of Auditing, 4(1), 3–28.

    Article  Google Scholar 

  • Danish Institute for Health Services Research. (2001). Test of conceptual model for electronic health records, DSI, Copenhagen [In Danish: Aftestning af Begrebsmodel for Elektronisk patientjournal].

  • Donnelly, W. J., & Brauner, D. J. (1992). Why SOAP is bad for the medical records. Archives of Internal Medicine, 152, 481–484.

    Article  Google Scholar 

  • Dorda, W., Duftschmid, G., Gerhold, L., Gall, W., & Gambal, J. (2008). Austria’s path toward nationwide electronic health records. Methods of Information in Medicine, 47(2), 117–123.

    Google Scholar 

  • Dourish, P. (2001). Process description as organisational accounting devices: the dual use of workflow technologies. In C. Ellis & I. Zigurs (Eds.), Proceedings of the 2001 international ACM SIGGROUP conference on supporting group work (pp. 52–60). New York: ACM Press.

    Chapter  Google Scholar 

  • Ellingsen, G., & Røed, K. (2010). The role of integration in health-based information’ infrastructures. Journal of Computer Supported Cooperative Work, 19(6), 557–584.

    Article  Google Scholar 

  • Feinstein, A. R. (1973a). The problems of the ‘problem-oriented medical record’. Annals of Internal Medicine, 78(5), 751–762.

    Google Scholar 

  • Feinstein, A. R. (1973b). An analysis of diagnostic reasoning. I. The domains and disorders of clinical macrobiology. The Yale Journal of Biology and Medicine, 46, 212–232.

    Google Scholar 

  • Feinstein, A. R. (1973c). An analysis of diagnostic reasoning. II. The strategy of intermediate decisions. The Yale Journal of Biology and Medicine, 46, 264–283.

    Google Scholar 

  • Feinstein, A. R. (1974). An analysis of diagnostic reasoning III. The construction of clinical algorithms. The Yale Journal of Biology and Medicine, 47(1), 5–32.

    MathSciNet  Google Scholar 

  • Gärtner, J., & Wagner, I. (1996). Mapping actors and agendas: political frameworks of systems design and participation. Human Computer Interaction, 11(3), 187–214.

    Article  Google Scholar 

  • Glouberman, S., & Mintzberg, H. (2001a). Managing the care of health and the cure of disease—Part I: differentiation. Health Care Management Review, 56–69.

  • Glouberman, S., & Mintzberg, H. (2001b). Managing the care of health and the cure of disease—Part II: integration. Health Care Management Review, 70–84.

  • Goldfinger, S. E. (1973). The problem-oriented record: a critique from a believer. The New England Journal of Medicine, 288(12), 606–608.

    Article  Google Scholar 

  • Greenhalgh, T., Potts, H. W., Wong, G., Bark, P., & Swinglehurst, D. (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.

    Article  Google Scholar 

  • Hammersley, M., & Atkinson, P. (1997). Ethnography. Principles in practice. New York: Routledge.

    Google Scholar 

  • Hanseth, O., & Monteiro, E. (1997). Inscribing behaviour in information infrastructure standards. Accounting, Management and Information Technologies, 7(4), 183–211.

    Article  Google Scholar 

  • Hartswood, M., Procter, R., Slack, R., Voss, A., Büscher, M., Rouncefield, M., et al. (2008). Co-realization: towards a principled synthesis of ethnomethodology and participatory design. In M. S. Ackerman, C. A. Halverson, T. Erickson, & W. A. Kellogg (Eds.), Resources, co-evolution and artifacts (pp. 59–94). London: Springer.

    Chapter  Google Scholar 

  • Heath, C., & Luff, P. (1996). Documents and professional practice: ‘bad’ organisational reasons for ‘good’ clinical records. In M. S. Ackerman (Ed.), Proceedings of the 1996 ACM conference on Computer Supported Cooperative Work (pp. 354–363). New York: ACM Press.

  • Ho, L. M., McGehee, S. M., Hedley, A. J., & Leong, J. C. Y. (1999). The application of a computerized problem-oriented medical record system and its impact on patient care. International Journal of Medical Informatics, 55(1), 47–59.

    Article  Google Scholar 

  • Hurst, J. W. (1971). Ten reasons why lawrence weed is right. The New England Journal of Medicine, 284(1), 51–52.

    Article  Google Scholar 

  • Kalra, D. (2006). Electronic health record standards. In R. Haux & C. Kulikowski (Eds.), IMIA Yearbook of medical informatics 2006 (pp. 136–144). Stuttgart: Shattauer.

    Google Scholar 

  • Kirsh, D. (1995). The intelligent use of space. Artificial Intelligence, 73(1–2), 31–68.

    Google Scholar 

  • Latour, B. (1992). Where are the missing masses? The sociology of a few mundane artifacts. In W. E. Bijker & J. Law (Eds.), Shaping technology/building society (pp. 225–258). London: MIT Press.

    Google Scholar 

  • Lave, J. (1988). Cognition in practice: Mind, mathematics, and culture in everyday life. New York: Cambridge University Press.

    Book  Google Scholar 

  • Lilley, S. (1996). Refining accountabilities: Opening the black box of management systems success. In R. Munro & J. Mouritsen (Eds.), Accountability. Power, ethos and technologies of managing (pp. 118–143). London: Thomson Business Press.

    Google Scholar 

  • Lorenzi, N. M., & Riley, R. T. (2004). Managing technological change: Organizational aspects of health informatics. New York: Springer Verlag.

    Google Scholar 

  • Martin, D., Mariani, J., & Rouncefield, M. (2009). Practicalities of participation: Stakeholder involvement in an electronic patient records project. In A. Voss, M. Hartswood, R. Procter, M. Rouncefield, R. Slack, & M. Büscher (Eds.), Configuring user-designer relations: Interdisciplinary perspectives (pp. 133–155). London: Springer.

    Chapter  Google Scholar 

  • Mediq. (2004). Use BEHR in clinical practice. Copenhagen [In Danish: ‘BRUG-GEPKA projektet i Københavns Amt’].

  • Mellner, C., Selander, H., & Wolodarski, J. (1976). Computerized problem-oriented medical record at Karolinska hospital: format and function, users’ acceptance and patient attitude to questionnaire. Methods of Information in Medicine, 15(1), 11–20.

    Google Scholar 

  • National Board of Health. (2000). National strategi for IT i sygehusvæsenet 2000–2002 [National Strategy for IT in Health Care]. Copenhagen: National Board of Health.

    Google Scholar 

  • National Board of Health. (2003). National IT Strategy 2003–2007 for Danish Health Care Service. Copenhagen: Ministry of Interior and Health.

  • National Board of Health. (2004). Beskrivelse af GEpj—på begrebsniveau [In English: Description of BEHR—on conceptual level. Version 2.0].’ from http://www.sst.dk/applikationer/epj/gepj/020_20040416/index.html.

  • Power, M. (1997). The audit society. Rituals of verification. Oxford: Oxford University Press.

    Google Scholar 

  • Robinson, M., & Bannon, L. (1991). Questioning representations. In L. Bannon, M. Robinson, & K. Schmidt (Eds.), ECSCW´91. Proceedings of the European conference on computer supported cooperative work (pp. 219–233). Amsterdam: Klüwer Academic Publishers.

    Chapter  Google Scholar 

  • Rolland, K. H., & Monteiro, E. (2002). Balancing the local and the global in infrastructural information systems. The Information Society, 18(2), 87–100.

    Article  Google Scholar 

  • Schmidt, K. (1997). Of maps and scripts. The status of formal constructs in cooperative work. Proceedings of the International ACM SIGGROUP Conference on Supporting Group Work: the Integration Challenge (pp. 138–147). Phoenix: ACM.

    Book  Google Scholar 

  • Schmidt, K., & Simone, C. (1996). Coordination mechanisms: towards a conceptual foundation of CSCW systems design. Journal of Computer Supported Cooperative Work, 5(2–3), 155–200.

    Article  Google Scholar 

  • Singer, E. (2009). A digital health-care revolution: twenty billion dollars might finally turn the U.S. health-care system digital. Technology Review, Massachusetts Institute of Technology, http://www.technologyreview.com/biomedicine/22026/ (accessed September 2010).

  • Star, S. L., & Griesemer, J. R. (1989). Institutional ecology, ‘translations’ and boundary objects: amateurs and professionals in Berkeley’s museum of vertebrate zoology, 1907–39. Social Studies of Science, 19(3), 387–420.

    Article  Google Scholar 

  • Strathern, M. (Ed.) (2000). Audit cultures: Anthropological studies in accountability, ethics and the academy. London: Routledge.

  • Suchman, L. (1987). Plans and situated actions. The problem of human-machine communication. Cambridge: Cambridge University Press.

    Google Scholar 

  • Suchman, L. (1993). Technologies of accountability: Of lizard and aeroplanes. In G. Button (Ed.), Technology in working order (pp. 113–126). New York: Routledge.

    Google Scholar 

  • Suchman, L. (1995). Making work visible. Communications of the ACM, 38(9), 56–63.

  • Suchman, L. (2005). Located accountabilities in technology production published by the Centre for Science Studies, Lancaster University, Lancaster LA1 4YN, UK, at http://www.comp.lancs.ac.uk/sociology/papers/Suchman-Located-Accountabilities.pdf.

  • Timmermans, S., & Berg, M. (2003). The gold standard. The challenge of evidence-based medicine and standardization in health care. Philadelphia: Temple University Press.

    Google Scholar 

  • Törpel, B., Voss, A., Hartswood, M., & Procter, R. (2009). Participatory design: issues and approaches in dynamic constellations of use, design, and research. In A. Voss, M. Hartswood, & R. Procter (Eds.), Configuring user-designer relations: interdisciplinary perspectives (pp. 13–29). London: Springer.

    Chapter  Google Scholar 

  • von Hippel, E. (2006). Democratizing innovation. Cambridge: MIT Press.

    Google Scholar 

  • Walker, H. K., Hurst, J. W., & Woody, M. F. (Eds.) (1973). Applying the problem-oriented system. New York: Medcom Press.

  • Weed, L. L. (1969). Medical records, medical education, and patient care. The problem-oriented record as a basic tool. Chicago: Year Book Medical Publishers.

    Google Scholar 

  • Wiener, C. L. (2000). The elusive quest: Accountability in hospitals. Hawthorne: Aldine.

    Google Scholar 

  • Winthereik, B. R., van der Ploeg, I., & Marc, B. (2007). The electronic patient record as a meaningful audit tool: accountability and autonomy in general practitioner work. Science, Technology & Human Values, 32(1), 6–25.

    Article  Google Scholar 

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Acknowledgements

Sincere thanks to the staff at the Endocrinology Department, and the three anonymous reviewers.

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Correspondence to Claus Bossen.

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Bossen, C. Accounting and Co-Constructing: The Development of a Standard for Electronic Health Records. Comput Supported Coop Work 20, 473–495 (2011). https://doi.org/10.1007/s10606-011-9141-3

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