Information in Healthcare: An Ethnographic Analysis of a Hospital Ward.

Abstract

This dissertation uses psychosocial information as a lens to examine doctors’ and nurses’ information use and documentation practice. It draws on a 17-month ethnographic study, in-depth analysis of medical records, and semi-structured interviews to investigate clinicians’ documentation behaviors. This investigation produced several findings. First, adopting a Computerized Prescriber Order Entry (CPOE) system can cause loss of written psychosocial information as nurses reluctantly make certain data permanent. Second, CPOE adoption may create information gaps in nurses’ knowledge about patients. Third, while use of CPOE systems can successfully reduce medication errors, it removes discretion, nuance, temporality, and human interpretation from paper order practice to rigidly fit machine requirements. This can redistribute power and responsibility. Fourth, although doctors document psychosocial information in an electronic health records (EHR) system, they record it selectively and a medicalized viewpoint governs this selection process. As a result, missing patient representations affect work activities and patient care. This study has broad implications for medical informatics. It cautions against casual computerization. Many well-intentioned efforts to computerize paper records assume the transition only changes media, but this study shows how social agreement and institutional arrangement around documenting patient psychosocial information can be shattered by this transition. It also suggests that efforts should be made to respect local knowledge and practice in the computerization of medical information. The findings also suggest a need for a dual conceptualization of EHR as both a representation of medical work (process-oriented) and patients (patient-centered, as to consider information reuse from a long-term perspective). This study also seeks to extend theories of boundary objects. It reveals that the nature of a boundary object can change when that object and the practice surrounding its use are both automated. It proposes to conceptualize process-oriented systems, such as CPOE or EHR, as information assemblages, which embed multiple information objects, heterogeneous practices, work processes, and coordination mechanisms. Furthermore, the analysis of this study uses a stack of conceptual framings: boundary object, extended boundary object, assembled object, collection, and assemblage, and argues these framings together serve to understand computerized records in a medical setting far better than can any single concept.