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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

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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
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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
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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
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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
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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,
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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
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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
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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
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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.
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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
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