The professional and policy context for this work
My interest in the EPR began in 2001 when, as a recently appointed general practitioner (GP), I became 'information technology lead' for my practice. Like most local practices, our clinical system had been installed about ten years earlier, but the main medical record was paper-based, with computers used primarily for appointment scheduling and prescribing. In 2000, the UK government had removed the legal obligation for paper medical records, paving the way for practices to 'go paperless'. I led the practice team in this process, enthusiastic to harness this technology to improve patient care through clinical audit. I later delivered a successful local educational programme for primary care staff on the theme of 'going paperless'.
As time went on I started to become unsettled by the ways in which the EPR was changing my work. I felt it was placing additional unanticipated demands on me in my role as personal doctor to my patients. Technically it was cumbersome, slow and unresponsive at times, and it was not always easy to find what I was looking for. Sometimes it seemed to get in the way. Colleagues expressed concern about how to keep the screen out of view from third parties in the consulting room, now we could no longer hide notes discretely on our laps. But clinical audit - which I had seen as its great potential - was indeed much easier.
Some significant changes in national policy were afoot. I will not cover these in detail, but they included the UK government's ambitious and controversial National Programme for IT (NPfIT) with its commitment to developing a fully networked electronic health record accessible from all points of care (Connecting for Health 2005). In addition, a new national GP contract was introduced (Department of Health 2003). This included a shift of responsibility for funding IT systems to Primary Care Organisations who would own the technology (instead of GPs). Computer systems had to be accredited against UK-wide standards and would become essential if practices were to meet the requirements of another key component of the new contract - the Quality and Outcomes Framework (QOF) (General Practitioners Committee 2009). QOF is an incentive scheme which rewards practices financially for demonstrating nationally approved quality standards. Clinical audit was no longer an activity undertaken in-house to examine care practices, but an opportunity for surveillance by external parties and a key instrument of performance-related pay. Although my GP colleagues were delighted we were so well placed to achieve our 'quality points' in this new climate, I began to feel ambivalent about the bigger picture, concerned that this heralded more fundamental changes at the core of general practice. I started to take a more critical view of an innovation which I had previously embraced as wholly positive. Like many 'latecomers' to linguistic ethnography (Rampton 2007) it was out of this sense of professional disquiet that my interest in researching the EPR in its social context developed.
Although the NPfIT folded in 2010 (after the election of a new government) and a fully networked electronic health record remains elusive, QOF is alive and well. The quality standards have been revised several times and QOF now constitutes approximately 30% of practice remuneration. The political zeal for gathering data to build nationally standardised comparative data sets is strong, not least because recent legislation mandated that general practitioners join Clinical Commissioning Groups (CCGs) with responsibilities for overseeing NHS budgets and commissioning care. Good data quality is seen as critical to this process (Department of Health 2010; Department of Health 2012) and there is an explicit intention to establish 'a principle of recording data once and using it in many ways' (Department of Health 2010: 52). Although my research was conducted prior to the advent of CCGs, I mention it to draw attention to the ever-evolving wider 'macro' social structures within which the requirement for data collection at the point of care continues to gather momentum.