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

Abstract

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

Institutional logics of the EMR and the problem of 'perfect' but inaccurate accounts

“…Further, similar to Bossen [9], we find that this coupling effectively inverts these functions, such that the work of making a perfect account directs and disrupts attempts to actually coordinate work. However, unlike past February 15-19, 2014, Baltimore, MD, USA studies, our findings highlight the fact that although the account that is created in the course of changing the IV is "perfect," it is also inaccurate.…”

“…A handful of CSCW oriented studies on health ICT build on this insight. These scholars have begun to focus attention on the accountability function of EMR, suggesting that the accountability function might impinge on the coordinating function [7,8,9]. We contribute to this burgeoning stream of research and argue that the relationship between coordination and accountability needs to be further untangled through an examination of institutional logics.…”

“…A handful of studies suggest that the accounting functions of EMR can interfere with situated coordination of work, thus leading to unintended negative consequences [7,8,9]. A recent meta-analysis goes so far as to assert that healthcare organizations are not actually re-shaping work practices around EMR systems in beneficial ways as had been previously hoped [19].…”

“…Sabrina is unable to violate the logics of the EMR when creating the account, because, as noted by Bossen [9], there is a "flip over effect" where the EMR is not a model of practice, but a model for practice. Thus, although the IV has been hung, Sabrina must follow the logics of the EMR.…”

Collective capabilities

“…[12]. Tools and practices like data collection [16], common goals and language, standards [2], procedural guidelines and plans [24] can all be ways of…”