How Linguistic Ethnography May Enhance Our Understanding of Electronic Patient Records in Health Care Settings

Deborah Swinglehurst

Introduction

The electronic patient record (EPR) is now widely integrated in many primary healthcare settings. Like its predecessor - the paper medical record - the EPR is a place where patients' medical notes are recorded. But it is much more. In the EPR, diagnoses, procedures and results are coded and made searchable for audit purposes; electronic templates (or forms) are completed in the chronic disease clinic; reminders and prompts urge clinicians to take specific action at specific times. Computers in the consulting room have been much studied by technology experts (in disciplines such as health informatics and systems design) and - to a lesser extent - by scholars of interpersonal communication. In the latter tradition, research efforts have tended to focus on the impact of the computer in what has become conceptualised as the 'triadic' consultation (clinician-patient-computer) (Booth, Kohannejad, & Robinson 2002; Margalit, Roter, Dunevant, Larson, & Reis 2006; Pearce 2007; Scott and Purves 1996; Ventres, Kooienga, & Marlin 2006).

In this chapter I describe a different approach, one which focuses on how the EPR contributes to shaping practices, both in the consultation and more widely. This socio-technical perspective assumes a dynamic interaction of people and technologies - and considers how this is enabled and constrained by local social and technical contingencies (Swinglehurst, Greenhalgh, Myall, & Russell 2010). Against this background I will describe how I used linguistic ethnography to explore the dynamic 'EPR-in-use'.

My data set arose from eight months of ethnographic observation in two UK general practices and included video-recording 54 consultations (19 clinicians) with simultaneous screen capture, recording the computer screen as the EPR was used in real time. Merging these two video streams opened the EPR to more detailed analysis than has previously been possible. Combining ethnographic observation as a way of exploring the institutional context with a micro-analysis of interaction enabled me to understand not only how the EPR contributes to constituting the interaction on a moment-by-moment basis, but also how it contributes to constituting the wider 'macro' organisational concerns of the clinic, and how these are interrelated. The EPR is a contemporary example of a 'phenomenon' which spans both time and space - that is, its meaning and influence may include past, present and future and is not constrained by its physical location.

I will begin this chapter by describing my own professional context as a GP-ethnographer and introducing the UK NHS policy context at the time of data collection. This sets out my own motivations for the research, and points to its timeliness in a climate of rapid technological change. I will then explain why I felt linguistic ethnography was a suitable research approach. After this groundwork I will introduce some short extracts of empirical data (ethnographic observations and transcripts from clinical consultations) with a view to achieving two broad aims. My first aim is methodological. I hope to paint a picture of the complexity of the EPR as a focus for research, highlighting the analytic challenges it presents and suggesting linguistic ethnography as a sophisticated approach which can handle this complexity. My second aim is to show how the EPR has become absolutely central to the accomplishment of particular concerns in the clinic. These include its role in redefining practices of chronic disease management and in meeting externally defined quality standards (Swinglehurst, Greenhalgh, & Roberts 2012). This redefinition of practice can be observed both in the 'micro' analysis of the unfolding interaction and through observation of organisational routines. The EPR can be seen to constitute the regimentation of practice, bringing new opportunities but also creating new demands and tensions.

 
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