1. ©2003 Sowerby Centre for Health Informatics at Newcastle Problems Encountered in Electronic Health Record Research K. Neil Jenkings Sowerby Centre for Health Informatics at the University of Newcastle, University of Newcastle-upon-Tyne, Tel: (0191) 243 6181 Fax: (0191) 243 6101 neil.jenkings@ncl.ac.uk

2. ©2003 Sowerby Centre for Health Informatics at Newcastle Aims Introduction The Problem of Fitness for Purpose The Problem of Modelling The Problem of Previous Research Strategies The Problem of Gatekeepers The Practical Problem of Data Representation Discussion.

3. ©2003 Sowerby Centre for Health Informatics at Newcastle Introduction This paper attempts to highlight what some of the problems for researchers, other than purely technological capabilities, are that can be encountered in electronic health records research. EHR Scope

4. ©2003 Sowerby Centre for Health Informatics at Newcastle EHR Scope large multi-disciplinary health and social care environment not under the management of a single authority differing bodies have both formal and informal structures and working patterns and communication structures legacy systems: not confined to communication hardware and software formal and informal work organization personnel organisational memory previous initiatives and experience of work collaboration and current pilot initiatives not sponsored by Electronic Health Record projects.

5. ©2003 Sowerby Centre for Health Informatics at Newcastle The Problem of Fitness for Purpose Ready-to-Hand Unready-to-Hand At such times, inspection and practical problem- solving occur, aimed at repairing or eliminating the disturbance in order to get going again. In such times of disturbance, our use of equipment becomes explicitly manifest as a goal-orientated activity, and we may then try to formulate procedures or rules. (Suchman 1987 p53) Requirement for detailed descriptions of work But we arrive with legacy systems in place and, more significantly, legacy rationalisations of why those systems do not operate in the desired fashion. The problem being their ability to set the agenda for EHR requirements and design

6. ©2003 Sowerby Centre for Health Informatics at Newcastle The Problem of Modelling Models that do not adequately reflect the everyday world Producing products where readiness-to-hand is absent. Risk of producing reality disjunctures on users The disjuncture between the ideal and reality may be so significant that it generates significant dissonance and conflict, leading to abuse, misuse and disuse of tools and systems May only produce adaptation and coping strategies In either case inadequate description can lead to unreadiness-to-hand products that are not fit-for- purpose

7. ©2003 Sowerby Centre for Health Informatics at Newcastle The Problem of Previous Research Strategies Imperative that we have detailed information as to what occurs at these sites – and why Actual activities official and unofficial the why question not being predetermined by official or formal accounts whose versions are designed to fit in with service provision protocols A whole industry has grown up providing quantitative services to, and within, the NHS. Design and implementation activities have relied upon non-existent or inadequate gloss descriptions of the actual activities of healthcare professionals they wish to support or transform. The problem being a preference for quantitative strategies has now become a legacy of previous strategies.

8. ©2003 Sowerby Centre for Health Informatics at Newcastle The problem of gatekeepers Users as Guardians of privacy Powerful professional bodies Hierarchical Organisation Gatekeepers determining access and hence methodology Respondents who speak on behalf of (but in effect, instead of) their employees, i.e. those who handle much of the inter-healthcare organisation and patient communication, and talk authoratively about work practices which they do not do and often have never done.

9. ©2003 Sowerby Centre for Health Informatics at Newcastle The practical problem of data representation process model approach almost a universal standard for NHS managers at all levels Consequently a major resource for the designers of EHRs technologies. Need to accommodate this preference Models need not be information poor Problem of prose representation Lengthy and inaccessible The challenge is not only to collect detailed information, but also to be able to represent it to an audience with a preference for process model representations of the world

10. ©2003 Sowerby Centre for Health Informatics at Newcastle Discussion Five interrelated problems The Problem of Fitness for Purpose The Problem of Modelling The Problem of Previous Research Strategies The Problem of Gatekeepers (methodology) The Practical Problem of Data Representation Ethnographic dimension of our work is not a substitute for the managerial or architectural perspectives but that these three perspectives have to be combined appropriately if the concept of EHR is to result in tools that are ready-to-hand and thus meet political and clinical needs