Towards Coherence for Electronic Health Records

Last week I spoke at the Theorising Digital Change workshop organised by Carlos Estrada Grajales and Stefanie Duguay from QUT’s Digital Media Research Centre and Urban Informatics Research Lab. This is an edited version of my talk.

Electronic Health Records are coming. The Australian Government has just re-branded the PCEHR to the My Health Record (though the government’s main information site still mixes the terms) and has begun the move from an opt-out model to an opt-in model with a trail at two sites in Queensland and the Northern Territory.

Like a train, electronic health records have a lot of inertia which is preventing them moving from a standstill. That inertia is often framed as resistance from the multiple stakeholders in the health system.

GWR_Super_Express_Train.jpg
By Hitachi Rail Europe (CC BY 3.0), via Wikimedia Commons

Last year my colleagues and I looked at the rollout of an electronic health records system (you’ll note that the date on that post is 2012. There’s a story there, too.). The electronic record we looked at was being implemented by a group of disability support organisations. It wasn’t PCEHR but it was intended to link to PCHER. When we started the research, the organisations were in the early stages of the rollout. Our main goal was to find out how the organisations understood the electronic record system. To do this, we invited ourselves to change management meetings and spoke individually with people who were tasked with the rollout in each organisation.

A theory that has been somewhat widely used to understand eHealth implementation is “normalisation process theory” by Mair, May et al. In NPT there are four “theoretical constructs”: coherence (or sense-making), cognitive participation, where people are enrolled into engaging with the new practice surrounding the EHR, collective action, which is the work that people do to enact the new practice, and reflexive monitoring which is a sort of reflective practice.

As we were investigating the early stages of the EHR implementation, we were looking for coherence work.

But we saw competing “modes” of coherence. NPT suggests that coherence or sense making is what happens when people figure out how, or if, a new technology is different to existing practices, how it will affect them personally and what the technology’s purpose actually is.

It’s what happens when people sort out one path from all the options available to them.

640px-SunsetTracks.jpg
By Arne Hückelheim (Own work) (CC BY-SA 3.0)

And we saw this happening. But we saw it happening differently, depending on how the people we spoke with understood their (organisation’s) role in providing support for people with disabilities.

What seemed to be going on was that there was more than one understanding of the electronic record depending on how the organisations, and people in them, saw themselves and their work. Lucy Suchman would call these various understandings “working relations” which are the “sociomaterial connections that sustain the visible and invisible work required to construct coherent technologies and put them into use” (source, p91 (pdf)).

Suchman suggests that a bridge is an example of “as an arrangement of more and less effectively stabilized” (source, p317) sociomaterial connections. A bridge has physical stability, obviously, but it also requires stability in the networks of social practice that are required for it to be constructed at all. For a bridge to be built at all, everyone involved needs to agree on very simple things, like how big a meter is, and very complex things, like what it means to build a suitable foundation.

By George Gastin (Own work) [CC BY-SA 3.0
By George Gastin (Own work) CC BY-SA 3.0
With the electronic record we looked at, because these organisations already worked, there were different existing sets of sociomaterial connections already in place. The new electronic record was going to have to integrate with these existing relations and it was going to have to be the same record across each different organisation.

The organisations couldn’t, at the time we were researching with them, get the record to achieve coherence because they hadn’t managed to stabilise it. They didn’t have a clear story on what work the record would do and without that, they couldn’t make the record line up in their existing networks of practice. That is, they lacked a stable set of sociomaterial connections between their existing work and the new work that the electronic record would require.

Without a stable set of sociomaterial connections, I don’t think you can start working towards coherence.


 

And now, I’m going to switch sides and ask if stabilisation is even desirable at all?

For people who work in disability support orgs, stabilisation of the electronic record is completely necessary for the record to become part of their work. But for people with a disability, is just one way of having and living with an electronic record useful? And is the way that an external organisation comes up with going to be the best for each person? A person with a physical disability may have different needs and uses for an electronic record than a person with a communication disability. And that person may have different needs to a person with an intellectual disability.

Stabilising electronic records within organisations may limit the agency of end users to decide how they can best use a electronic record to support their own health and wellbeing.

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