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EMR Design as Socio-Technical Mosaic: A Multi-Lens
Approach to Emergency Department System Design
INTRODUCTION
Socio-techn...
highly collaborative and time-sensitive work in
which the the ED employees engage, but it also
allows for a somewhat chaot...
hierarchical in nature, with three levels: activities,
actions, operations, and it can be used to look at
processes that a...
portal site, eMedicine, etcetera), iPhone
applications such as Emera, text references like
the Pocket Pharmacopeia, and oc...
The needle stick case highlights the fact that each
patient’s case and the circumstances of the
environment are going to b...
within the organization. Further study
incorporating ideas from ST would help
illuminate the dynamics of the situation and...
the narrative is quite filtered and often
incomplete, since patient care needs come before
documentation. The incompletenes...
participatory, and frequent. Other forms of
communication, such as whiteboards, post-it’s,
scribbled notes, and phone call...
would provide a more direct form of remediation
than the current roundabout way of adding notes.
MULTITASKING
The final per...
social and organizational contexts in which the
technology will be used. It is my contention that
in-depth ethnographic st...
APPENDIX: PERSPECTIVE CHART
Framework/
Theory
View of system (or part of
system)
Data Observed/Collected Potential Implica...
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EMR Design as Socio-Technical Mosaic: A Multi-Lens Approach to Emergency Department System Design

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The purpose of this paper is to draw focus to how HIT systems design, and particularly systems for the emergency department (ED) can benefit from socio-technical thinking.

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EMR Design as Socio-Technical Mosaic: A Multi-Lens Approach to Emergency Department System Design

  1. 1. EMR Design as Socio-Technical Mosaic: A Multi-Lens Approach to Emergency Department System Design INTRODUCTION Socio-technical studies of Health Information Technology (HIT) and Electronic Medical Record (EMR) systems have received a growing amount of attention in recent years. The International Journal of Medical Informatics notes that papers focusing on socio-technical approaches to HIT doubled between 2004-2006 and 2007-2009. [1] Despite the expanding interest, those who actually develop information systems for the healthcare sector have done little to incorporate the crucial insights that derive from this type of work. With government reimbursement plans meant to encourage implementation of EMR systems nationwide by 2014, hospitals are racing to make the transition. Unfortunately, most of these systems focus more on the technical aspects, such as synchronization, interoperability integration, and productivity, and less on the social, organizational, and human aspects of the work done through systems. The purpose of this paper is to draw focus to how HIT systems design, and particularly systems for the emergency department (ED) can benefit from socio-technical thinking. This paper presents research conducted in the ED of a large urban hospital that is currently in the process of implementing a new $100 million system. I chose a variety of frameworks through which to analyze the system and ED work to see what each can elucidate and how insights derived from each can be translated into recommendations for system design or organizational structuring. The lenses I used include action theory, distributed cognition, situated action, structuration theory, boundary objects, articulation work, genre repertoire, remediation and multitasking. Through the research, I found that almost every theory or perspective gave new insight. The challenge was to also see how these insights could potentially fit into the development of real systems. This paper is meant to merely be a survey of what a variety of socio-technical perspectives can add to our understanding of the work done in ED’s. These theories span a broad landscape of socio-technical approaches, and, combined together form a mosaic to view the various and overlapping ways a system can account for social and organizational practices. It was out of the scope of this paper to go into depth with any one framework, but this exploration reveals a brief overview of what each can add to EMR design in practice, not just in theory. RESEARCH SETTING & METHODOLOGY Setting and Participants In order to understand how each of the various theoretical frameworks might provide insight into healthcare information system design, I conducted an ethnographic study in the ED at GTH1, a large Chicago-area hospital. The ED of the hospital is a busy, 40-bed Level II trauma center that typically cares for 25 or more patients at any one time. It is a highly collaborative, open setting in which physicians, physician assistants, nurses, techs, secretaries, and a variety of ancillary staff work together. There are at least two attending physicians available all hours of the day, with a third “fast-track” physician seeing patients with lower-level triage needs from 10am to 10pm each day. Once a patient is moved into the ED from triage, virtually all of their chart information is input into the hospital’s EMR system by the attending physician. This is done at one of two computer banks centrally located in the ED at a large counter by the nurses’ station. The area is open and heavily trafficked by the physicians, nurses, ancillary medical staff, cleaning staff, orderlies, and others. This open space helps facilitate the 1 1 This is a pseudonym. Julia Haines School of Information and Computer Science University of California, Irvine Irvine, CA 92697 hainesj@uci.edu
  2. 2. highly collaborative and time-sensitive work in which the the ED employees engage, but it also allows for a somewhat chaotic environment. The EMR system that GTH’s ED uses has been in place for the past 5 years; however, within the next 12 months, the entire hospital will be transitioning to a new system. The new system is a major object of focus for all employees at GTH and most of the ED staff is involved in meetings about the new system. The primary participants throughout the research process were two ED physicians. Both have been working at GTH for over three years, but have also used a variety of systems at other hospitals, and both have experience with paper charting. All ED physicians rotate through various shift cycles including morning, day/evening, and night shifts. Each of these shifts was observed. Method The study was comprised of observation sessions during a variety of shift cycles and a series of interviews with the physicians over a period of a month and a half. Three observation sessions were conducted during various shifts with the two physicians. Each session occurred entirely at the physician’s computer bank and lasted approximately six to seven hours, starting one to one and a half hours after a physician shift change and ending at least one hour before the next physician shift change to accommodate the ED’s needs during the chaotic hour overlap between shifts. Thus, observation of patient hand- off and transition between shifts was limited. Each of the three sessions was informally divided to specifically focus on looking at the work of the ED through three different frameworks. This was meant only to provide the time to focus on employing methods and observing artifacts and activities important to each of the frameworks. It was not meant as a concrete dividing line between one framework and another. On the contrary, the mosaic of frameworks used meant that observations pertinent to one or more frequently overlapped and interleaved with others. Thus, phenomena observed throughout all the sessions were useful in thinking about the system and the ED organization. A series of interviews with the participating physicians allowed for further insight and enabled more appropriate methodological approaches to underlie the theoretical perspectives. One interview was held prior to the initial observation session and one followed each session, with a fifth and final interview by phone occurring a couple weeks later. Interviews were semi-structured and intended to explore a variety of topics. All were recorded and partially transcribed. Additionally, a number of printed and handwritten artifacts were analyzed following the observation sessions in which they were utilized. While most data was qualitative in nature, there was quantitative data gleaned from observations of multitasking. This data was collected using a stopwatch function. It was only minimally analyzed due to the limited scope of the observation. More specific information about methodology is discussed in the sections that follow. Each section that follows briefly describes each lens, its previous use in studies of HIT or EMR systems, if any, the glimpse it provided into the system or organization, what was encountered, and what the potential implications are for system design or organizational structuring. ACTIVITY THEORY Activity theory (AT) enables the study of people and social groups by looking at the development, structure, and processes of their activities. The theory’s emphasis on the primacy of activity and its focus on the agency of living things set it apart from other frameworks. According to Kaptelinin and Nardi [14], action theory differs from traditional HCI in that it focuses on higher-level, meaningful actions in the use of technology over longer spans of time, rather than simply looking at the the tasks of users and systems in a small slice of time. Seemingly, this would make AT a very useful framework through which to study work in an ED, yet it hasn’t been a very prominent perspective in socio-technical studies of HIT or EMR systems. Bardram [3] has looked at hospital systems as mediators, bridging the gap between planning and working, and has also presented the concept of Activity-Based Computing, an approach to support clinical work in which parallel activities and interruptions make collaborative healthcare work even more complex. [4] However, outside of this work, only a few have used AT as a lens through which to study medical systems and practices. [6, 9] The basic principles of the theory are that it is focused on subject-object relationships, it is 2
  3. 3. hierarchical in nature, with three levels: activities, actions, operations, and it can be used to look at processes that are internal-external and/or individual-collective in dimension. Through the lens of AT, I looked at activities, actions, operations, and goals in the ED and how the system plays a role as a mediating tool in the collaborative process of caring for patients. Overview of approach and data In this view, it was clear that the system facilitated processes that were internal-external and bridged the individual-collective dimension. Internal thoughts and assumptions of the physician and others involved were made explicit in the chart, and the various roles of individuals in the work community combined together to make a collective repository of information used in meeting the goals of patient care. The system itself could be seen as a tool that aided in these actions and activities. The EMR system aided in division of labor, as it enabled the coordination of orders for ancillary tests, ordering drugs, etcetera. The system also guided activity as a planning tool, prompting for certain protocols to be followed and specific information to be included conditional to other information. The system also loosely served as a means of accomplishing multiple objectives to reach the polymotivated goals of the ED, which include patient outcomes, making profit, and exhibiting standards of care. Insight for system design From observation through this lens, it was clear that, unlike Bardram’s system study [3], this system did not provide a mechanism through which to reach the seemingly disparate goals of having smooth workflow and staying on track. Accountability did inhibit workflow in many areas and seemed to be held as a more important goal than smooth workflow. Additionally, as a planning tool, the system did not help monitor deviations from plans well, requiring articulation work on the part of the physician to ensure that an accurate account and narrative of the patient visit was made. Finally, low-level actions in putting data into the system often required a great deal of effort. Rather than being automatic and on the operational level, the system needs forced the physician to pay attention to certain tasks that could have required less effort, such as the need to input normal characteristics rather than that being the default. Further studies using AT as a lens could help identify ways the system can work to mediate multiple activities for multiple goals at one time and simplify the hierarchy of processes to aid in workflow. DISTRIBUTED COGNITION In contrast to AT, distributed cognition (DCog) has been used in HIT and EMR studies to a great extent. Patel et al. [19] and Nemeth et al. [16] in particular have done a great deal of research in this area. DCog differs from other approaches in that it extends what is considered ‘cognitive’ to interactions outside of the individual, looking at both internal and external processes. These cognitive processes are defined by the functional relationships among elements, not their spatial colocation. Hollan et al. [13] note that three kinds of cognitive processes become evident when observing people: processes distributed amongst a social group, processes coordinated between internal and environmental/physical structures, and processes distributed through time, wherein earlier events effect later ones. All three of these cognitive processes are vital to ED work. Two of the most important functions in the creation of an organizational product like the chart are the decontextualization and recontextualization of information, which Ackerman and Halverson [2] describe in their study of organizational memory. Through the lens of DCog, then, the EMR is both an organizational product that helps create organizational memory and part of the larger cognitive system as well. Using this framework, I took a high-level look at the gathering and synchronization of information for the patient chart and how decontextualization and recontextualization play a role in creating organizational memory and the organizational product of the chart. Overview of approach and data In looking at the components of the overall cognitive system (not to be confused with the physical EMR system) it was clear that sources of information for each patient case are vast and varied, but certain patterns do emerge across cases. I looked at the physical, functional, and temporal relationships between the physician and the artifacts/components of the system, including: the patient’s presenting symptoms or complaint, the patient history (as told by patient), input from other physicians, nurses, techs, and ancillary staff, ancillary testing (including lab tests and radiology), online reference sources (GTH’s 3
  4. 4. portal site, eMedicine, etcetera), iPhone applications such as Emera, text references like the Pocket Pharmacopeia, and occasionally patient EMR’s from previous visits. Other components were no doubt used in other cases not observed. The constellation of components highlights that the processes are distributed amongst the social group of the ED, coordinated between internal and external structures, such as ancillary tests, and distributed through time. Surrounded by this multiplicity of resources, the physician acts as the agent, for the most part choosing the resources that become the components of the system, and then decontextualizes and recontextualizes information from these resources and past experience with patients to create the organizational product of the EMR and treat the patient. For each new patient or patient visit, the organizational product created is distributed and interwoven in a variety of objects and processes; similar patient cases reveal patterns for what must necessarily be part of the system. For instance, any indication of chest pain from the patient necessitates inclusion of an EKG in the system. The information from the EKG must undergo the process of decontextualization and recontextualization to help “interpret the equation”, as one physician put it, and create a true narrative of the patient visit. Insight for system design Through the lens of DCog, it is clear that there are innumerable components that could be included in the cognitive system. However, it is also clear that certain components, such as input from other staff and ancillary tests are almost always part of the system in some way. Thus, perhaps the EMR system design should focus more on enabling a more collaborative narrative, rather than one assembled by the physician. System design could look for ways to better integrate those components into the system to facilitate faster and easier processing. Additionally, in an interview, one physician estimated that fewer than half of patients seen in GTH’s ED have a medical record there, and amongst those who do, the record is only useful in less than a quarter of patients. Part of the reason prior EMR’s are not helpful is that there is no interactive response with factors input for presenting symptoms or history. If there were even some small measure of term, pattern, or feature matching with prior EMR’s, it could help in generating a differential diagnosis for the patient by identifying information to include in the cognitive system. In moving forward with HIT research through the lens of DCog, perhaps like Hollan et al. suggest, “ethnographically natural” experiments that test ideas such as pattern matching for differential diagnosis could aid in design of better system. SITUATED ACTION Through the lens of situated action (SA), context is everything. In explaining her concept of SA, Suchman [22] looked at workflow in an accounting office to show that organization work comes from what people do informally, not from some procedural model. Likewise, in the environment of the ED, workflow comes from what needs to be done on a moment-to-moment basis, not from some protocol. In healthcare and in the ED in particular, workflow is all about “practical action,” yet most studies of the ED neglect the importance of its emergent and improvised activities and instead focus on higher- level patterns. EMRs are an end with a variety of means to get there, and thus can be viewed as a tool to facilitate and enhance the actual informal work being done. Overview of approach and data Looking at the system through this low-level lens, I observed the emergent goals and actions of a case involving a woman who had been stuck by a needle. In this view, the EMR system is a tool used in improvising that plays a different role in each unique situation, and the collaboration amongst those involved determines the workflow. The patient who had been stuck by the needle came immediately through triage, and the attending physician, nurses, and techs involved scrambled to determine what to do first and then next as no protocol for treating a needle stick could be found immediately. Thus, they moved forward with certain actions to meet immediate goals of care and reacted to results to treat the patient, with the goals for the next activity emerging from the previous. After some time, a protocol for testing and treatment was found, but much of the testing and treatment had already been done. The record was retroactively edited to fulfill the requirements of the protocol and account for the necessary procedures. Insight for system design 4
  5. 5. The needle stick case highlights the fact that each patient’s case and the circumstances of the environment are going to be unique, so the structure of the work cannot be informed entirely a priori. Additionally the flow of the work is going to be impacted by triage needs and a constellation of factors involved in the patient case. While there are protocols and decision trees for certain complaints or patterns of symptoms, its clear that the workflow in the ED must be practical and not procedural, particularly when it comes to cases with particular urgency or gravity. Through this lens, it can be seen that goals do arise in action and the work must be adjusted to meet the new goals. Yet, the charting system observed is very structured and fairly linear in terms of charting one patient and following one flow of work. Suchman’s point about “innovation in design” as it relates to “innovation in the underlying conception of the activity that the design supports” is very salient here. The context of each case is very important, and while there are larger patterns that suit many cases, there should be more flexibility in the system to enhance the actual work being done rather than force certain steps in a procedure. It should also help adapt procedure to changing goals, for instance allowing a quick change in orders if the constellation of symptoms changes rather than forcing documentation about what changed. This is especially important in the view that an EMR is supposed to be a narrative of the patient visit; it should follow that narrative rather than forcing it. Further socio-technical study of EMR and workflow in the ED should use the lens of SA to look at how the system can support changing goals, interruptions, and a variety of workflows to support different situations. STRUCTURATION THEORY Structuration theory (ST) has been used more frequently than many other lenses in the study of technology in healthcare. Barley [5] looked at how CT scanners played a role in changing the social order of radiology departments. Similarly, others studies have looked at how the implementation of EMR systems have changed the structure of organization in hospitals. [24] On the other hand, it appears few have looked at the dialectical interplay and mutual shaping between organizational structure and technology that Orlikowski has described. [18] In this view, technology is structural as well as socially constructed. While the changes in organizational structure from implementation of EMR’s are more visible, the potential flexibility of technology should enable its modification for organizational needs as well. Overview of approach and data Taking the framework of ST, I attempted to understand how the EMR system and the ED structure had shaped each other. In this view, I postulated the move from paper charts to EMR technology impacted organizational structure and interactions, particularly those related to power. Since this had already occurred some years before, I relied on interview data to understand this impact. From the interviews, it was clear that, from the physician’s perspective, the institution of EMR’s have changed the structure of the work and organization. The physician must spend more time charting on the computer than in front of the patient. With a paper charting system the physician can do the charting in the patient room, enabling closer patient contact. It is also faster because it does not necessitate closing out charts, logging in and out, waiting for pages to load, etcetera. This has implications for structure of the patient visit, as there is now less face time with physicians, and consequently more face time with nurses and technicians. At the same time, this has also changed the structure of hierarchy in the organization, putting more power and responsibility on the physician while limiting the power of nurses and technicians. In paper charting, there are almost no boundaries as to who can write on the chart; nurses can document and make orders. In the electronic system, however, the majority of charting is limited to the physician. Nurses now have to come to the physician for almost everything they want to order or enter into the chart for a patient. They have limited ability to order certain tests and chart things, with most non-physician access limited to triage. Thus, the technology and its restrictiveness has fundamentally changed some of the nurse- physician dynamics, as well as the patient- physician and patient-nurse dynamics. Insight for system design The system itself could remedy hierarchy issues by distributing input into the chart over multiple users. This could also potentially be remedied 5
  6. 6. within the organization. Further study incorporating ideas from ST would help illuminate the dynamics of the situation and the mutual shaping between organizational structure and technology. While the impact of the technology on the organization was pronounced, it was less clear how the staff of the ED have modified the technology to better fit their needs. A longer-term study incorporating more observation would help. The implementation of the initial EMR system at hospitals is an interesting case to study, as the move from paper to electronic records has massive implications for the structure of work. At the same time, many older EMR systems are being replaced with newer EMR systems, which will invoke further changes. The hospital is currently working to have a new system implemented by the end of next year and all levels of employees are contributing to the clinical content development process, so in some formal ways they are already working to shape the system. However, most of the work going into design relies on focus-group type activities. Empirical studies of actual work in the ED would be incredibly valuable to understanding the impact on and use of the EMR technology. BOUNDARY OBJECTS The concept of boundary objects has been used (and misused) in a wide variety of ways since Star and Griesmer first described how boundary objects help translate between different social worlds. [21] More recently, Star made clear what is not a boundary object [20]; the utility of the concept relates largely to the level of scope and scale. Within HIT, there are many boundary objects to consider, some of which help translate between different medical disciplines and some that link the work in healthcare to other social worlds. One paper looked at material artifacts, such as records, whiteboards, and x-rays, and immaterial artifacts, such as rules, standards, and customs used in coordinating action in the hospital as boundary objects. [10] Another study viewed victims of incidents as boundary objects emergency medical care work. [15] The ED is rife with potential boundary objects for study. Looking particularly at those that shape important translations of between social worlds can aid in system design by emphasizing the important aspects of the object for translation. Overview of approach and data Using the concept of boundary objects, I looked at the different social worlds involved in the creation of and subsequent use of the EMR. In the creation of the EMR, the patient (and specifically their complaint or symptoms) is the primary boundary object around which care is coordinated. The patient’s health and condition are of specific importance to individual players in their hospital visit and the information about the patient must be translated between these healthcare workers. The information about the patient derived from a radiologist’s scans will say something very different than blood work done in the lab, but all this information must be translated across different groups to create a full record. Once the record is created, the system and the information contained in each record served as boundary objects to translate and negotiate between different social worlds that must use information about the patient, such as diagnosis. Thus, the narrative the physician creates in the chart is an important boundary object, as it impacts the patient, billing, insurance, primary care, specialists, pharmacists, rehabilitation, and even potentially lawyers, which is one reason why accountability in the record is of the utmost importance. The record shows the level of care indicated by the physician and the chosen diagnosis/ complaint, which is propagated throughout the system and used for different purposes by say, specialists, as opposed to billing. Coders help in translation for billing and insurance purposes and jargon changes in the process. Insight for system design What a certain symptom in a patient means or what an overall record means is strongly structured in use within each world and weakly structured in common use between groups. If a patient suffers a heart attack, the definition of what that means for follow up from a cardiologist is quite different that what it means for insurance. But both of these are informed by the record created from the patient visit. Therefore, completeness and detail level of the narrative are of the utmost importance. As witnessed in observations of the work at GTH, the charting system and the workflow of the organization are often in conflict, which limits the ability to produce a strong narrative. Additionally, because the physician is required to input almost all data, 6
  7. 7. the narrative is quite filtered and often incomplete, since patient care needs come before documentation. The incompleteness of the narrative created then impacts what is ultimately translated amongst the various social worlds. Thus, system design and organizational structuring for charting should take into account ways to make the record more thorough for subsequent use of the record. ARTICULATION WORK When Gerson and Star investigated due process in the workplace, they looked at how problems are solved through tacit knowledge and articulation work. [11] They suggested the most important points in designing information systems to meet requirements of the workplace are that the system must account for multiple viewpoints, complex information and categories, incomplete representations, and the empirical situation of the workplace. In the ED, articulation work is important because of the uniqueness of each case, yet little research appears to have been done in this area. Overview of approach and data In the view of Gerson and Star, a system cannot anticipate all possible conflicts and contexts, so tacit knowledge and articulation work must be used. In taking this view of due process, I looked at the various conflicts, errors, and workarounds for completing the record and caring for patient simultaneously. Since there is a great deal of complexity in each individual case, subtasks and gathering a variety of resources is needed for patient care. In order to create a strong narrative of the patient visit, the physician must use free text, since charting options in other areas of the record do not adequately represent the complexity of the information. Since the physician is the only one with access to do this sort of open narrative, the system is very limiting in terms of the viewpoints it provides. And when multiple viewpoints are possible, it can sometime create conflict. One clear example of articulation work related to this is the creation of discrepancy files when test results are over-read. The radiologist and the attending physician over-read the results of x-rays, CT scans, and MRI’s. When they disagree on the results, a discrepancy file must be created for further review from an outside party, with the record later adjusted based on the decision made. Insight for system design From this perspective, the current charting software is not great at enabling the work that needs to be done to realize due process. Most articulation work is done through the physician adding free text to the record; however, because the physician does all the entry, the system is not necessarily taking into account any conflicting perspectives. The system design should try to account for multiple viewpoints, complex information and categories, incomplete representations, and the empirical situation of the workplace. The new system being implemented at GTH should allow for more collaboration in charting and more flexibility in the system input. It is likely that the system will not take into account the articulation work and tacit knowledge of those using the system, however, because those that do the work are frequently not involved until late stages in development and are usually only involved by means of focus groups and interviews, not engaging means like participatory design. Almost two years into the move to implement the new system at GTH, no empirical research into the work of the ED has been done. Further study into the low-level work needed to complete records would help inform the design in a way that meets the organizations needs. COMMUNICATION GENRES Orlikowski and Yates looked at what genres used in organizational communication tell us about the organization’s processes, calling the overall set of genres the organization’s genre repertoire. [17] In relation to ED work, many studies have looked at particular forms of communication, such as the whiteboard [23], but literature review reveals that none have looked at the full genre repertoire of an ED to understand its communicative processes in whole, nor have any studies looked at genre variants and changes in the ED. Overview of approach and data I attempted to identify all of the various forms of communication and their general frequency of use, outside of communication occurring within the confines of patient rooms, which this study was not privy to. Most communication is verbal: radiologists call attending physicians to give readings on tests, technicians tell physicians patient statuses, and coordination with the charge nurse occurs in conversation. This shows that most collaboration is very informal, highly 7
  8. 8. participatory, and frequent. Other forms of communication, such as whiteboards, post-it’s, scribbled notes, and phone calls reinforce the idea of temporality and informality. In combination, this gives a good sense of the collaborative nature of the work, the mobility and distribution of those involved, and the time urgency of activities. By contrast, the formality of the final chart shows that most of this communication is less for the purposes of the group creating it and more for documentation purposes for parties outside of the current group and for other social worlds. It also shows something about hierarchy because communications for charting purposes are usually one-to-one between the physician and someone else. The temporality of communication forms used in collaboration contrasted with the permanency of the resulting record indicates a disconnect in process. This is reinforced by the discrepancy between participation in momentary communications versus permanent ones. The system seems to be enforcing hierarchy in communicative processes for permanently recorded information while the actual communication involved in collaborating on patient care is much more evenly spread. Insight for system design From this lens of genre repertoire, system redesign should take into account these forms of temporal communication in creating the record to see how the system can be accommodating or reflective of the organizing process of the ED. A new system design could look for ways to simplify and incorporate informal communication genres to create a more full narrative of encounter in the record, rather than forcing a hierarchical structure to create the formal, permanent record. Other forms of temporal communication, such as instant messages and emails, as well as functionality like speech-to-text could be integrated. These genre forms need not be forced, but offered so that the system provides a way for genres to evolve, whether they are deliberately chosen or inadvertently change over time. REMEDIATION In the same vein as communication genres, remediation looks at the changing forms of media and our use and reuse of previous forms of media in new forms. Bolter suggests that every form of new media depends on earlier media in the experience they provide. [7] Much like genre repertoire, few studies have actually looked at the types of media that go into forming the EMR or the transparency or “hypermediacy” of the various forms of EMR available. Overview of approach and data Through the lens of remediation, the system at GTH is a hypermedia combination of analogue predecessors (the paper chart) and other digital media (radiology scans, etcetera), although the design of the archived EMR tries to erase remediation and appear transparent. That is to say the text and visuals resulting from the active chart appear in a way that looks like they were all simply typed into the system, rather than based on other often temporal forms of media. I looked at the types of media incorporated into the electronic system. In charting, many things such as EKG’s are printed and notes are written on paper before being interpreted or filtered and added to the chart. EKG’s and scans, tests results, etcetera are also uploaded into the patient record, but they aren’t necessarily tied to the patient visit. One way in which GTH’s system erases the remediation can be seen in the free text notes the physician types about such scans. Free text notes in the record are often derived from scrap notes and working memory of conversations with the patient, nurses, and others involved. So information about a radiological scan is transferred by image, through conversation, then handwritten language and memory, and then typed as if it is coming directly from observation, erasing the remediation of the information. Insight for system design Through the lens of remediation, it is clear that information takes many forms before it is documented in the patient record. Rather than remediating this information into something that appears to be transparent (such as the physician’s free text narrative) and concealing or erasing the media used to form that information, a system could incorporate other media directly, which would reduce time in repurposing and retyping and also make the information less susceptible to being altered in an inappropriate way. For instance, speech-to-text functionality would be a more direct appropriation of information that is being remediated in various forms. Additionally, directly linking radiology scans with written notes, arrows, and markings overlaying the scan 8
  9. 9. would provide a more direct form of remediation than the current roundabout way of adding notes. MULTITASKING The final perspective of multitasking is particularly relevant to the design of systems and organization of work in the HIT. In their study of multitasking, Gonzalez and Mark looked at the way work is information fragmented by both internal and external interruptions. [12] Others have looked at the interruptions that specifically occur in the ED, such as as Brixey et al.’s study of physicians and nurses as initiators and recipients of interruptions in workflow. [8] Further study of multitasking in the ED could help investigate the interrupted nature of the workflow and show how EMR systems can aid in non-linear work that bridges multiple working spheres. Overview of approach and data In order to better understand interruptions and multitasking in the ED, I timed two hours of a morning shift. Using a stopwatch function, I timed and noted lap segments for each task that occurred outside of patient rooms. Since the work in the ED is related to the patient cases currently open, these were the working spheres which the physicians switched between. Due to the chaotic nature of the ED and my lack of understanding of medical terms, I was not always able to connect a task to the appropriate patient case. Additionally, I was unable to note whether each task switch was an internal or external interruption. Since the data is incomplete it does not merit a detailed analysis. However, a brief look at task times indicates that only a handful of the 74 tasks went beyond 1.5 minutes, and more than half were under 1 minute 10 seconds. The longer tasks were mostly phone calls, which skewed the average, as phone calls were typically 3 minutes or longer. To add to the complexity, working spheres were also always changing as new patients came in and other patients were discharged. The range of length of patient visits can completely vary too. In an interview, one physician said he typically starts a shift with a maximum of 5 patients in a cycle and visits each patient from a minimum of twice to upwards of 10-15 times for more complicated cases. Patient visit times noted on the tracking board ranged from approximately 1.5 hours (including triage time) to over 6 hours. Most patients are moved to inpatient care for anything longer. Thus, involvement in some working spheres is much longer than others, and it is constantly changing. Insight for system design From the lens of multitasking in working spheres, it is clear the current system focuses on very linear charting on a per-patient basis, but this is not the workflow used in the ED. System redesign should look for ways to enable a non- linear workflow and integration of information within the interface. The current desktop organization requires specific paths of actions to reach appropriate windows. Additionally, redesign could incorporate other ways of handling interruptions. Currently, after each interruption, the physician must reenter from a login screen if the interruption lasts more than one minute and locate the place he last left off in the interaction process. Shortcuts to return to specific patient charts would be helpful. Further empirical study could help illuminate the issues at hand and try to strike a balance between security needs and facilitating a smoother workflow. CONCLUSION This paper has shown that EMR system design and ED work can be viewed through many different lenses. The observational and interview data confirm that each framework provides a different way to view the processes, artifacts, and contexts of work in the ED. This paper has also identified ways system design can benefit from each of these socio-technical approaches. It follows that through studying ED work through a multiplicity of frameworks and theories, the resulting mosaic provides a richer understanding of the needs for EMR systems in practice. A chart available in the appendix attempts to summarize what can be gleaned from the lenses used in this study and what the potential implications are for system design. Systems developers everywhere are vying for large contracts with hospitals and their affiliates. Hopes are high at GTH that the new system will be an answer to solving complex problems in the ED and throughout the hospital. However, in the implementation meetings that are already occurring, it is clear that the focus remains on the technical, as little has been done to understand the social aspects of the work and the complex 9
  10. 10. social and organizational contexts in which the technology will be used. It is my contention that in-depth ethnographic study using a variety of socio-technical frameworks would help inform the design of the EMR system in a way that creates a richer, better system that more fully supports the complex work of the ED. REFERENCES 1. Aarts, J., Callen, J., Coiera, E., and Westbrook, J. Information technology in health care: socio-technical approaches. International Journal of Medical Informatics 79, 6 (2010), 389-90. 2. Ackerman, M.S. and Halverson, C. Considering an Organization’s Memory. Proceedings of the 1998 ACM conference on Computer supported cooperative work, ACM (1998), 39–48. 3. Bardram, J.E. Plans as situated action: An activity theory approach to workflow systems. Proceedings of the fifth conference on European Conference on Computer-Supported Cooperative Work, Kluwer Academic Publishers (1997), 17-32. 4. Bardram, J.E. Activity-based computing for medical work in hospitals. ACM Transactions on Computer- Human Interaction 16, 2 (2009), 1-36. 5. Barley, S.R. Technology as an Occasion for Structuring: Evidence from Observations of CT Scanners and the Social Order of Radiology Departments. Administrative science quarterly 31, 1 (1986), 78–108. 6. Bhattacherjee, A., Davis, C.J., Hikmet, N., and Kayhan, V. User Reactions to Information Technology: Evidence from the Healthcare Sector. Proceedings of the 29th International Conference on Information Systems (ICIS) Paper, (2008). 7. Bolter, J.D. Remediation and the Desire for Immediacy. Convergence: The International Journal of Research into New Media Technologies 6, 1 (2000), 62-71. 8. Brixey, J.J., Robinson, D.J., Turley, J.P., and Zhang, J. The roles of MDs and RNs as initiators and recipients of interruptions in workflow. International journal of medical informatics 79, 6 (2008), 109-115. 9. Engestrom, I. Learning by Expanding: An Activity Theoretical Approach to Developmental Research, Orienta-Konsultit, Helsinki, Finland, (1987). 10. Fields, B. and Duncker, E. Articulating Resources : The Impact of Electronic Health Records on Cross- Professional Healthcare Work. Technical Report, Interaction Design Centre (2003). 11. Gerson, E.M. and Star, S.L. Analyzing due process in the workplace. Proceedings of the third ACM-SIGOIS conference on Office automation systems - 4, 3 (1986), 70-78. 12. González, V. and Mark, G. “Constant, Constant, Multi- tasking Craziness”: Managing Multiple Working Spheres. Proceedings of the SIGCHI conference, (2004), 113-120. 13. Hollan, J., Hutchins, E., and Kirsh, D. Distributed cognition: toward a new foundation for human- computer interaction research. ACM Transactions on Computer-Human Interaction 7, 2 (2000), 174-196. 14. Kaptelinin, V. and Nardi, B. Activity Theory in a Nutshell. In Acting with Technology: Activity Theory and Interaction. The MIT Press, 2006. 15. Kristensen, M., Kyng, M., and Palen, L. Participatory design in emergency medical service: designing for future practice. Proceedings of the SIGCHI Conference, (2006), 161-171. 16. Nemeth, C. How cognitive artifacts support distributed cognition in acute care. Human Factors and Ergonomics Society Annual Meeting Proceedings, Human Factors and Ergonomics Society (2003), 381–385. 17. Orlikowski, W.J. and Yates, J.A. Genre repertoire: The structuring of communicative practices in organizations. Administrative Science Quarterly 39, 4 (1994), 541– 574. 18. Orlikowski, W. The Duality of Technology: Rethinking the Concept of Technology in Organizations. Organization science 3, 3 (1992), 398-427. 19. Patel, V.L., Arocha, J.F., and Kaufman, D.R. A Primer on Aspects of Cognition for Medical Informatics A Primer on Aspects of Cognition for Medical Informatics. Journal of the American Medical Informatics Association, (2001), 324-343. 20. Star, S. This is Not a Boundary Object: Reflections on the Origin of a Concept. Science, Technology & Human Values 35, 5 (2010), 601-617. 21. Star, S. and Griesemer, J. Institutional Ecology, ‘Translations’ and Boundary Objects: Amateurs and Professionals in Berkely’s Museum of Vertebrate Zoology, 1907-39. Social studies of science 19, (1989), 387-420. 22. Suchman, L. Office procedure as practical action: models of work and system design. ACM Transactions on Information Systems 1, 4 (1983), 320-328. 23. Xiao, Y., Schenkel, S., Faraj, S., Mackenzie, C.F., and Moss, J. What whiteboards in a trauma center operating suite can teach us about emergency department communication. Annals of Emergency Medicine 50, 4 (2007), 387-95. 24. Yeow, Y.K.A. The Work Network Model: Understanding the Interplay of Actor, Artifact and Action in Technology-Based Change. Dissertation, McGill University (2008). 10
  11. 11. APPENDIX: PERSPECTIVE CHART Framework/ Theory View of system (or part of system) Data Observed/Collected Potential Implications Activity Theory a mediating tool in the collaborative process of caring for patients looked at activities, actions, operations, and goals in the ER and how the system plays role in this system could be improved to mediate multiple activities for multiple goals and simplify hierarchy of processes, minimizing operations DCog an organizational product that helps create organizational memory and part of the larger cognitive system as well took a high-level look at gathering and synchronization of information for the patient chart and de- and re- contextualization system could better integrate cognitive components into system, particularly through feature/term/pattern matching to generate differential diagnosis Situated Action a tool used in improvising that plays a different role in each unique situation looked at the context of system at a low-level, the moment-to-moment activities and emergent goals system could be more flexible to accommodate uniqueness of situations and support changing goals; less enforced procedure and protocol for specific symptoms/complaints Structuration Theory a technology that has impacted org structure and interactions, particularly those related to power interviewed physicians to learn more about power dynamics related to system and way they use and shape the technology system could invoke less hierarchy by allowing for input from multiple users; org structure could also be modified Boundary Objects records in system are boundary objects to translate and negotiate between social worlds the narrative the physician creates through the chart and social worlds it is used in system could enable more thorough input for narrative in chart (more free text, addition of ancillary input, etc) Articulation Work a structure that cannot anticipate all conflicts and contexts, so tacit knowledge and articulation work must be used looked at the various conflicts, errors, and workarounds for completing the record and caring for patient system could account for multiple viewpoints; new system design could engage variety of groups in participatory design Genre Repertoire record is a communicative form built through the use of other genres tried to look at all the methods of communication (outside of patient rooms) system could incorporate more informal communications directly into record and allow for collaborative creation of chart Remediation a hypermedia combo of analogue predecessors and other digital media looked at the types of media incorporated into the electronic system system could incorporate other media more directly in the record through scans, voice recording, speech-to-text, etc. Multitasking a structure for workflow comprised of multiple working spheres (pt cases) timed two hours of a visit, doing segments for each task; tried to connect tasks to working spheres (patient cases) system could enable a multi-task workflow and better shortcuts 11

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