Creating the Electronic Health Record, Re-inventing Medical Records a

761 Pages·2001·1.3 MB·English

UNIVERSITY OF CALIFORNIA, SAN DIEGO

Sorcerer's Apprentice:
Creating the Electronic Health Record,
Re-inventing Medical Records and Patient Care

A dissertation submitted in partial satisfaction of the

requirements for the degree Doctor of Philosophy in

Communication

by

Judith Gregory

Committee in charge:

Philip E. Agre, Chair
Michael Bernstein
Geoffrey Bowker
Professor Yrjö Engeström, Co-Chair
Professor Harley Shaiken
Susan Leigh Star
Lucy A. Suchman

2000
Copyright
Judith Gregory, 2000
All rights reserved
Signature page
To Dorothy and Chon Gregory for their love
and for the independence and curiosity
they instilled in me.
iv
TABLE OF CONTENTS

Signature Page ………………………………………………………………... iii
Dedication …………………………………………………………………….. iv
Table of Contents …………………………………………………………..… v
List of Figures ………………………………………………………………… viii
List of Tables ………………………………………………………………….. ix
Acknowledgements ………………………………………………………….. x
Vita, Publications …………………………………………………………….. xii
Abstract ……………………………………………………………………….. xiv

I. Introduction …………………………………………………………. 1
A. The Sorcerer’s Apprentice...................................…………… 17
B. The case study .............................................…..…………….. 24
C. Research approach, research sites, methods, data
and sources .................................................…………………. 35
C.1. Research sites ............................................………….. 38
C.2. Research methods .......................................………… 44
C.3. Access limits and constraints on research methods 59
C.4. My involvement in the EHR Prototype Project ..…. 65
C.5. Additional exposure to domains .......................…... 79
D. Locating the dissertation project intellectually ...............… 85
E. Chapter outline and synopses of chapters ..................…… 93

II. Theoretical Framework……………………………………………… 106

A. Activity theory core concepts, building blocks .............…. 115
A.1. Teleological objects of activity .........................……. 122
A.2. Object-hypotheses and mediator objects ................. 124
A.3. The “problem of the ideal” in dialectical materialism
125
A.4. History, transformation, and change ...................… 129
A.5. Gaps, problems, directions ..............................……. 133
B. Resources of imagination .........................................………. 146
v
B.1. Internalization oriented towards externalization 152
B.2. Argument, dilemmas, and heterogeneity .........…. 157
B.3. Conflict in design .........................................……… 164
B.4. Imaginaries, metaphors, and stories .................…. 165
C. Activity theory approach to field research ...................… 170

III Incomplete Utopian Projects ..............................................……… 180

A. The concept of incomplete utopian projects .................… 182
A.1. Influences and inspirations for the concept .....…. 192
B. Abbreviated history of the HMO ..............................…… 199
B.1. Historicizing the HMO ...................................…… 208
C. Dimensions and actors: clinical, technical, managerial ... 232
C.1. Clinical utopian projects .................................…… 241
C.1.1. Clinical logic(s) ...............................…….. 242
C.1.2. An error-ridden activity .....................….. 249
C.1.3. Evidence-based medicine to evidence-based
practice ........................................……….. 264
C.2. Technical design projects ................................…… 271
C.2.1. Medical informatics ..........................…… 273
C.2.1.1. Structured content design strategy 273
C.2.1.2. Standardized clinical
terminologies ………………… 283
C.2.1.3. Protocols and templates .......... 293
C.2.2. The object world ...............................…… 309
C.2.3. Clinical information infrastructure building 314
C.3. Managerial and regulatory projects ...................... 316
C.3.1. Measurement mandates ........................... 319
C.3.2. Continuous electronic audits ................... 329
C.3.3. Risk and risk management ....................... 332
C.3.4. A culture of alignment .........................…. 335
C.3.5. Managerial agendas in health care .......... 338
C.3.6. Taylorist trajectories ..........................….... 345
D. The incomplete utopian project of electronic health record
invention ..............................................................…………. 349
IV Changing Patient Care ......................................................……….. 354

A. Imagined future scenarios with EHR use ……............….. 358
A.1. Changes in metaphors for EHR/CPR design ..….. 367
A.1.1. Hospital to clinic: open doors to closure .... 377
A.2. Integration of patient records and data ................. 381
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A.3. The primary care team participating in EHR
prototyping ...................................................………. 382
A.4. Methods and rationale .......................................…... 386
B. Exemplar #1: Pediatric immunization visit ....................… 397
B.1. Discussion of Exemplar #1: a trouble scenario ..…. 419
B.2. Exemplar #1: imagined future scenario ................... 427
C. Complex patient visits, multiple problem patients ........... 434
C.1. Exemplar #2: complex patient, complex encounter 436
C.2. Exemplar #2: imagined future scenario .................. 456
C.3. Exemplar #3: 6 months review ............................…. 475
C.4. Exemplar #3: imagined future scenario .................. 491
E. Discussion of exemplars #1, #2, #3 ........................... 499
D.1. Problems in practice, practice dilemmas ................ 501
D.2. Changes in clinical work practices .......................... 517
D.3. Difficulties in early EHR use ..............................…. 528
D.4. Incomplete utopian projects, deepening
contradictions .................................................…….. 540
D.5. Contributions to EHR design ..............................… 550
E. Summary discussion ..................................................…….. 554

V. Conclusions .....................................................................…………. 559

A. Theorizing innovation, technology and work practices 562
B. Health informatics ....................................................…….. 568
C. Changes in patient care .............................................……. 574
D. Critique of theoretical framework and research approach 580

Appendix A: Reflections on Methods .....................................… 588

A. Concepts and terms ..................................................……. 592
B. Ethnographic approach ..............................................…... 606
B.1. Naturally occurring activity ................................. 614
B.2. Volunteering .................................................…….. 620
B.3. Pre-study .....................................................……… 625
B.4. Intermediate settings .......................................….. 628
C. Working in parallel: project work, dissertation work … 632
C.1. Types of studies and reporting ............................. 634
C.2. Techniques adapting research methods and
principles ....................................................………. 636
C.3. Audio-visual documentation and video exemplars 644
C.4. Resources for design .......................................…… 653
D. Ethnographic dilemmas ............................................……. 655

Bibliography ...................................................................…………. 661