Computer templates in chronic disease management: ethnographic case study in general practice
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OBJECTIVE: To investigate how electronic templates shape, enable and constrain consultations about chronic diseases. DESIGN: Ethnographic case study, combining field notes, video-recording, screen capture with a microanalysis of talk, body language and data entry-an approach called linguistic ethnography. SETTING: Two general practices in England. PARTICIPANTS AND METHODS: Ethnographic observation of administrative areas and 36 nurse-led consultations was done. Twenty-four consultations were directly observed and 12 consultations were video-recorded alongside computer screen capture. Consultations were transcribed using conversation analysis conventions, with notes on body language and the electronic record. The analysis involved repeated rounds of viewing video, annotating field notes, transcription and microanalysis to identify themes. The data was interpreted using discourse analysis, with attention to the sociotechnical theory. RESULTS: Consultations centred explicitly or implicitly on evidence-based protocols inscribed in templates. Templates did not simply identify tasks for completion, but contributed to defining what chronic diseases were, how care was being delivered and what it meant to be a patient or professional in this context. Patients' stories morphed into data bytes; the particular became generalised; the complex was made discrete, simple and manageable; and uncertainty became categorised and contained. Many consultations resembled bureaucratic encounters, primarily oriented to completing data fields. We identified a tension, sharpened by the template, between different framings of the patient-as 'individual' or as 'one of a population'. Some clinicians overcame this tension, responding creatively to prompts within a dialogue constructed around the patient's narrative. CONCLUSIONS: Despite their widespread implementation, little previous research has examined how templates are actually used in practice. Templates do not simply document the tasks of chronic disease management but profoundly change the nature of this work. Designed to assure standards of 'quality' care they contribute to bureaucratisation of care and may marginalise aspects of quality care which lie beyond their focus. Creative work is required to avoid privileging 'institution-centred' care over patient-centred care.
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The goals and characteristics of the sociotechnical network in which Choose and Book was introduced and implemented are typical of expert systems, and the same is true for chronic disease management templates in general practice, though it applies less to the SCR.
“The goals and characteristics of the sociotechnical network in which Choose and Book was introduced and implemented, for example, are typical of such systems, 125 and the same is true for chronic disease management templates in general practice, 93 though it applies less to our third case of the SCR.”
93 consultations for chronic disease surveillance invariably centred on the evidence-based protocols inscribed in the QOF templates.
“As we have illustrated in detail elsewhere, 93 consultations for chronic disease surveillance invariably centred on the 'evidence-based' protocols inscribed in the QOF templates.”
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- Authors
- Swinglehurst, D., Greenhalgh, T., & Roberts, C.
- Affiliations
- Queen Mary University of London (GB)
- King's College London (GB)
- Corresponding author
- Swinglehurst, Deborah
- Venue
- BMJ Open
- Publisher
- BMJ
- Published
- 2012
- Volume
- 2
- Issue
- 6
- Pages
- e001754
- ISSN
- 2044-6055 (ISSN-L)
- PMC
- PMC3533031
- OpenAlex
- W2048341830
- Cited by
- 79
- References
- 64
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 6 · 2023: 1 · 2022: 6 · 2021: 4 · 2020: 6 · 2019: 5 · 2018: 9 · 2017: 5 · 2016: 9 · 2015: 9 · 2014: 9 · 2013: 6 · 2012: 1
- FWCI
- 13.00
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by-nc
- Locations
- BMJ Open (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Queen Mary Research Online (Queen Mary University of London) (submittedVersion, cc-by)
- Funders
- National Institute for Health and Care Research (RDA/03/07/07, RDA/03/07/076, 10/1011/01)
- Rural Development Administration
- Medical Research Council
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Keywords
- chronic disease management, nurse-led consultations, general practice, bureaucratic encounters, patient-centered care, clinical documentation, socio-technical systems theory, patient narratives, clinical decision support
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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