Motifs in EHR Research

Technology has changed every major industry.  Whenever the benefits of technology have become obvious, and comparatively easier to realize, resistance to adoption has quickly dissipated.   Healthcare will be no different.  Current EHR systems still have a long way to go before they become easy to implement and use.   In fact, many of today’s systems were designed more than 10 years ago and retain aspects of user interfaces from the 1990s.  However, it is only a matter of time until newer development methods, tools, and technologies result in systems that clinicians will readily adopt—no one avoids change when it makes his or her life better.

Many of the challenges related to implementation difficulties—workflow glitches, training times, and usability annoyances—are rooted in fundamental design shortcomings.   The problem for EHR designers is accurately determining the requirements for an optimal system.  Having led a team that built an EHR, this subject continues to hold my interest.  Actually, it haunts me…

For the last month or so, I have been gathering literature on EHR architecture, design, workflow, and usability in an attempt to get a handle on the state of EHR-related research.  My goal is to understand how EHR design influences adoption by clinicians.    I came across an interesting paper that is worth sharing.

Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method, by Greenhalgh et al., is a highly philosophical paper that offers an impressive analysis of the state of EHR research.   The authors do a superb job of identifying the various motifs present in electronic health record research.   They identify seven “tensions” in the research literature that capture the diversity of opinions on what EHRs are and how they affect individuals and society.

Key tensions in the literature centered on

(1) the EPR (“container” or “itinerary”);

(2) the EPR user (“information-processer” or “member of socio-technical network”);

(3) organizational context (“the setting within which the EPR is implemented” or “the EPR-in-use”);

(4) clinical work (“decision making” or “situated practice”);

(5) the process of change (“the logic of determinism” or “the logic of opposition”);

(6) implementation success (“objectively defined” or “socially negotiated”); and

(7) complexity and scale (“the bigger the better” or “small is beautiful”).

These tensions accurately capture the range of issues that arise from the introduction of EHRs into health care organizations—even the smallest practices.   In addition, they have proven to be quite useful as I sort through my pile of papers and try to make sense of what I have found.

Given the philosophical nature of the paper, I was surprised by the concrete nature of the recommendations offered as a guide for future research.   While all of the recommendations are worth pursuing,  two in particular are personally compelling: 1) developing  a theory to guide research and 2) investigating the apparent difference in success between commercial and in-house developed systems.

As electronic health records have become tied to national health care policies for many nations, discussions of EHRs are found in an increasingly wider array of scholarly publications. This paper offers an insightful analysis of the scope, content, and assumptions of EHR research.   At more than 66 pages (15 pages of references), this is not light reading. However, for those who wish to understand the growth and development of this field, this is a great place to start.

(According to the paper’s taxonomy of philosophical positions, it appears I am a positivist–possibly with latent interpretivist tendencies). I’m not sure if this is okay or if I need to form a support group.)



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