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

Abstract

Electronic Medical Records promise to simultaneously enhance coordination and provide transparency and accountability in work process. As such, EMR are purported to benefit both hospitals and patients. In this paper we use grounded empirical data to explore how this promise plays out in the everyday tasks of healthcare providers. Building on the small body of CSCW literature that suggests that the accounting functions of EMR are impinging on the ability of medical personnel to coordinate work, we draw on the theoretical lens of new institutionalism to outline how certain institutional logics around safety and accountability are shaping the experience of EMR systems in situ. We suggest that the institutional logics that currently characterize U.S. healthcare are embedded in the EMR design itself, structuring how institutional values such as "safety" are achieved and evaluated. Using over one year of ethnographic research in an obstetrical unit, we find that the institutional logics of "safety" embedded in the EMR create negative organizational outcomes, effectively undermining coordination and necessitating inaccurate accounts of work. We provide design implications to address these issues in the current institutional environment and envision how systems might be designed to promote alternate logics of safety that are social, dynamic, and cast humans as expert agents in the system.

Design Challenges in Converting a Paper Checklist to Digital Format for Dynamic Medical Settings

“…They commented, however, that they quickly familiarized with the new placement of vitals. Even so, further investigation is needed to identify a better solution for supporting periodic monitoring activities and adaptation to the actual work practices (“work as is”) as opposed to imposing “logical” solutions that disregard those practices (“work as imagined”) [15]. …”

The Politics of Measurement and Action

“…Our first case is drawn from Pine's ongoing ethnographic work on information practices in maternal and child healthcare [47,48,49], and specifically current development of a measurement of severe maternal morbidity. The severe maternal morbidity measure is directly linked to efforts from medicine, public health, and social justice groups to impact the high incidence of maternal mortality in the U.S., the number of women dying directly of pregnancy or childbirth related causes.…”

How the presentation of patient information and decision-support advisories influences opioid prescribing behavior: A simulation study

“…However, there has been an extensive body of literature suggesting that alerts delivered through modal dialogs are frequently overridden, 22,45 much like in our study, in which participants overrode 96% of modal dialogs. Further, modal dialogs are a significant contributing factor to clinician frustration, 46 burnout, 47 and potentially unsafe prescribing practices. 27…”