This post is authored by Priyanka Ivatury, who is a final semester student of the MSc. in Digital Society program at IIIT Bangalore.
I conducted a study a few months ago, to understand the implications of an electronic health record (EHR) system for doctors and I will discuss some of the challenges that I faced during the course of this research. An EHR is an electronic version of a patient’s medical history which is maintained by the health care provider. It consists of all the key administrative and clinical data relevant to a patient’s care under a provider. This includes demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (Medicare, Baltimore, & Usa, 2012). Private hospitals have their own Hospital Information System (HIS) which contains patient health records at different levels of digitization. The HIS is usually local to the hospital it is being deployed in and this data is not shared with other hospitals.
EHR can be considered an internet mediated interaction (IMI) as patient data is entered onto a cloud based system. This data needs to be updated real time on the system and is connected across branches of the hospital. The hospital that I was observing had an intra hospital network, where different branches as well as departments were connected over this platform. This also locked in patients to their network to an extent as all patient data was on their system.
Through some initial interviews with people working on deploying EHR systems within hospitals, I understood that the main bottleneck of implementing such a system was collecting the data from the out-patient departments (OPD) at the hospital. To better understand why doctors were reluctant to shift to such a system, I shadowed a doctor at a private hospital in Bangalore and this also required me to observe doctor patient interactions. EHR was implemented at the registration desk, the lab and the in-patient department. The next step was getting doctors to update their data during their OPD hours. In addition to observing the current implementations, the primary purpose of the study was to understand why doctors were unwilling to make the switch.
There were three primary stakeholders of the system: the patients, the hospital and the third party who was deploying the system which made the question of access difficult as I didn’t know who to contact at first. My primary point of contact was the hospital. I gained access to the hospital through personal contacts at the administration and was permitted to sit in on consultations for participant observation to collect data. The doctor at the clinic then provided me with more contacts whom I could interview for my study. However, in addition to shadowing the doctor, I also wanted to understand the EHR system at the hospital which proved to be challenging. Patient data was spread across registration, in-patient details, radiology and pathology reports. To understand some of the workflows across the EHR system, I was required to get access to the system itself. However, since there were different departments of the hospital talking to each other, the question of access itself proved to be difficult. Patients were expected to get their prescriptions scanned at the end of the consult. The doctors told me that only half the patients got it scanned. It was difficult to verify whether each of them went through with this process was not possible as I couldn’t follow them out of the OPD. EHR contains all patient records and to understand the system, I couldn’t ask multiple patients for access to their data. While doing a study on a system like this, how do you seek consent from multiple patients?
Being in the health domain, the ethical concerns with my study were high which was closely related to the issues I faced with access as the data I required access to was sensitive. Initially I faced resistance as doctors themselves were unwilling to allow me to shadow them. Once I gained access to the doctor’s office, my role was to take my place quietly in the corner of the room with a notebook and a pen and wasn’t allowed to talk during the consultancy. One primary concern that I had was justifying my presence to some of the patients that entered the office. Understanding how certain processes worked also included gaining access to some of the patient data which the hospitals didn’t allow as a part of their policy. There also came the question of what I’d do if I came across a misdiagnosis if I had access to the system. This was a primary concern of most doctors which was why they were unwilling to make the shift. There was a fear of litigation that remained consistent across multiple doctor interviews.
While my setting was offline as I was in the hospital, interacting with doctors and different staff members, the study also required an understanding of the electronic health record system. The physical interactions between the doctors and patients was easier to observe as it required following the doctor and sitting in a corner at the clinic. His interaction with the computer was more difficult. Most of his usage was limited to the hospital’s scheduling software which allowed doctors to keep track of their OPD patients for the day. However, he only explained this system to me and I wasn’t allowed to sit at the screen and see how it worked. This system also connected the registration department, the radiology department and the labs. The radiology department refused to allow me to view how their module worked which was when I decided to talk to the registration desk. The staff at the registration desk were also unwilling to let me see how the software worked and the sensitivity of data prevented the other departments from letting me in as well. Data like the patient’s name and contact details were also sensitive information as I couldn’t get access to it. They told me to personally go and ask patients for data but they were unwilling to show me how their system worked even if the patient complied.
The primary difference between the offline and the online was the understanding of the work flows. The online system proved to be a black box and understanding these processes were difficult. However, the offline work flow was easier to understand as the doctor as well as different hospital staff explained their tasks to me in detail. Gaining access to the patient records was not influenced by the online or offline as this was sensitive data either way. While the conversation about EHR has been continuously talking about its implications for the patients and doctors, what does it mean for researchers and designers who are trying to understand the system which is a black box to any outsider?
Medicare, C. for, Baltimore, M. S. 7500 S. B., & Usa, M. (2012, March 26). Overview. Retrieved February 25, 2017, from https://www.cms.gov/Medicare/E-health/EHealthRecords/index.html
Disclaimer: The views expressed in this post are those of the author and do not necessarily reflect the views of CITAPP and IIIT Bangalore.