Opening up the ‘black box’ of the electronic patient record: a linguistic ethnographic study in general practice

“72 Swinglehurst et al. 62 provide a different example, in which an alert that the patient is registered with the United Kingdom’s government-initiated Quality and Outcomes Framework (QOF) for hypertension remained open throughout the consultation, indicating there are two QOF items that require attention.”

“45,46 In addition, physicians find it hard to divide their attention between the patient and the computer screen.”

“This research, including the use of ethnographic or sociolinguistic methodologies, has instead highlighted how technology can be seen as an agent within consultations (Swinglehurst et al., 2011); context as emergent through users interacting with technology (Suchman, 2007); and a view of the user as relational with bo…”

“31 What emerges is a conceptualisation of the electronic record as integral to the social processes of consultation, not simply a peripheral ‘ add-on ’ to the consultation.”

“Brief summary of the case We have described and analysed this case study in detail elsewhere.(58,92,93,95) Electronic local detailed records emerged within UK general practice decades before the government-led NPfIT began.”

“Similarly, studies examining the impact of physician's use of EHR suggest it may have the capacity to change interactions and communications, both positively and negatively (Booth et al., 2004; Greatbatch et al., 1993; Makoul et al., 2001; Margalit et al., 2006; McGrath et al., 2007; Newman et al., 2010; Swinglehurst…”

“…interaction and cause “ dilemmas of attention ”— for example, in cases where doctors receive alerts in their screen that may lead them to utter statements like “ Now my computer ’ s asked me whether you smoke ” to patients (Swinglehurst, 2014; see also Swinglehurst, Roberts, & Greenhalgh, 2011).”

“Administrators kept in the balance two different ‘versions’ of the patient, the patient as individual ‘person’, to whom they felt informally accountable, and the patient as one of a population of patients sharing some characteristic of institutional relevance (a manifestation of what we have termed a ‘dilemma of atten…”

“…record encounter” (EPRE) to denote medical interactions with a further interlocutor (i.e. the electronic medical record) other than the patient 5 and quantified that residents have approximately 10 EPREs daily, which last little more than half an hour each, for a total of 5 h in data entry…”

“Patients perceived this lack of ‘hearership’ (Swinglehurst et al. 2011) as ‘the doctor not listening’ but selective encoding by the patient (based on available time) contributed.”

“The methods have been described elsewhere (Swinglehurst et al., 2011) and are summarised here.”

“…electronic patient records have coined the term ‘triadic’ consultation to highlight the computer as an influential third party in the consultation.7–10 Swinglehurst et al11 12 go further, conceptualising the EPR as bringing a wide range of competing voices Strengths and limitations of this study ▪…”

“Analysis drew on recent research focussing on positive dimensions of safety, 26-28 the informal work required to achieve safety across different healthcare organisational routines and contexts, 1 2 29 and Hollnagel’s ETTO.”

“(47) conducted a linguistic ethnographic study on general practices and discovered that doctors often experience a “dilemma of attention” when balancing the immediate interpersonal interaction with the institutional requirements imposed by the electronic medical record (EMR) system.”

“…point out that “the voices which the EPR admits into the consulting room are forceful, pervasive, difficult to ignore, and they constitute particular ways of accounting for clinical practice, legitimizing particular ideals of what ‘good care’ consists of” (Swinglehurst et al., 2011, p. 25).”

“Qualitative data obtained from ethnographic studies can enhance our understanding of how to introduce a technological innovation into healthcare [61,62].”

“Furthermore, as stated by Swinglehurst et al [28], for HCPs, balancing the adoption of novel, digital health tools while also delivering compassionate care is a significant challenge.”

“The EPR can be viewed as a multivoiced third party: EPR documentation is shaped by discourses in place from different timescales – the voices of the participants and of others from the past and present – as well as by the anticipated presence of others (see also Linell 2009; Swinglehurst et al. 2011).”

“Exemplary is the study by Swinglehurst, Roberts, and Greenhalgh (2010) who observed health professionals using electronic templates to guide consultations with the explicit aim of opening “the black box” of formfilling (p. 3).”