a journey into the hidden lives of electronic medical records (emrs)

307 Pages·2010·3.75 MB·English

A JOURNEY INTO THE HIDDEN LIVES OF ELECTRONIC
MEDICAL RECORDS (EMRS): ACTION RESEARCH IN THE
MAKING

by

Nina Boulus
B.Sc., Norwegian University of Technology and Science, 2001
M.Sc, University of Oslo, 2004

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF

DOCTOR OF PHILOSOPHY

In the
School of Communication

© Nina Boulus, 2010

SIMON FRASER UNIVERSITY

Spring 2010

All rights reserved. However, in accordance with the Copyright Act
of Canada, this work may not be reproduced, without authorization, under
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APPROVAL
Name: Nina Boulus
Degre: PhD
Title of Thesis: A Journey into the Hidden Lives of Electronic Medical
Records (EMRs): Action Research in the Making
Examining Committee:
Chair: Bary Truax

_
Dr. Ellen Balka
Senior Supervisor
Professor, School of Communication

_
Dr. Gary McCarron
Supervisor
Associate Professor, School of Communication

_
Dr. Richard Smith
Supervisor
Professor, School of Communication

_
Dr. Sandra Jarvis-Selinger
External Examiner
Assistant Professor, Faculty of Medicine
University of British Columbia

_
Dr. Olga Volkoff
Internal Examiner
Assistant Professor, Business, SFU
Date Defended/Approved: March 1, 2010
ii
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Last revision: Spring 09
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ETHICS APPROVAL
The author, whose name appears on the title page of this work, has
obtained, for the research described in this work, either:
(a) Human research ethics approval from the Simon Fraser University
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Last update: Spring 2010
ABSTRACT
Drawing upon a three and a half year long research project, this dissertation
examines the adaptation process of an electronic medical record (EMR) in a primary
healthcare setting, with emphasis on methodological reflections on doing action research
with a community partner. This dissertation thus comprises two components: the first
focuses on the implementations of EMRs, and the second focuses on action research as a
method used for studying the EMRs, thus giving a glimpse of the research process.
Drawing upon concepts from the fields of Computer-Supported Cooperative
Work (CSCW) and Information Systems (IS), I analyze how health care practitioners
adapt technology to their situated work practices. Investigating the factors promoting the
adaptation process showed that reflective activities were essential for constructing
emergent work practices. I therefore provide a conceptualization of the essential aspects
of these reflective activities. I analyze how the technology transforms the medical
practice, and identify two types of sociotechnical changes and their implications.
Introducing insights from Actor-Network Theory (ANT), I argue that the EMR is more
than just a tool that simply enables/constrains the medical practice. Rather, it is an active
actor that has come to play an increasingly central role in the delivery and organization of
care, and it is gradually transforming the medical profession.
Following a self-reflective and critical epistemological stance, I shed light on
methodological complexities faced when conducting action research. I investigate the
norms that are enacted within IS action research, and I argue that these are built upon a
rigid and standardized platform, similar to the one that traditional action research was
originally opposed to. I also argue that these norms fail to critically address ways of
discussing and managing empirical uncertainties and dilemmas. Drawing upon reflexive
research methodologies, first-person action research and confessionals, I illustrate how
empirical uncertainties can be transformed into fruitful practical interventions and
utilized as knowledge providers. Finally, I propose conceptualizing action research as an
actor-network with different sociomaterial connections which configure and produce
particular roles in diverse settings. A network model enables us to see how future roles
and interventions can be interpreted through past connections.
Keywords: Electronic medical record; hospital information systems; medical
informatics; computer-supported cooperative work; science and technology studies;
technology-in-use practices; reflection-on-practice; technology adaptation;
sociotechnical; actor-network theory; reflexive research methodologies; action research;
confessionals
iii
DEDICATION
In memory of my father,
who always wanted his children to achieve
the education he did not get for himself
iv
ACKNOWLEDGEMENTS
It goes without saying that this dissertation was made possible with the help of
people who provided me with an intellectually nourishing environment and to whom I
must remain forever indebted.
I am deeply grateful to my supervisory committee for supporting me during my
doctoral education. I wish to thank Ellen Balka, for leaving me with memorable
experiences. A special thanks to Gary McCarron, for his endless support, both as a
committee member but also as a graduate chair. You served as a true mentor, showing
continued interest in my work, providing me with comprehensive, critical and insightful
comments that had impact on my thinking. A special thanks to Richard Smith, for his
endless generosity, enthusiasm, perseverance and good humor. You have been a
wonderful mentor, someone who would always go the extra mile for his students.
This dissertation would have not been possible without the invaluable assistance I
received from a range of colleagues who also became dear friends. I had the good fortune
to work with Pernille Bjørn Rasmussen. The endless conversations, fruitful collaborations
and strong friendship that have developed throughout these years are invaluable. I could
have never written this thesis without your continued interest and enthusiasm, as well as
your committed and careful reading of earlier drafts of the entire dissertation. I am deeply
grateful for Kjetil Rødje, who has provided me with intellectual stimulation and critical
comments throughout my entire doctoral studies. Your insights were indispensable in
pushing the action research component of the dissertation beyond its conceptual infancy
and onto a theoretical analytical level. Special thanks goes to Miria Grisot, for much
appreciated support, encouragement and guidance during her brief, yet rewarding, stay at
SFU. Without her critical and sharp insights, I fear the action research component of the
dissertation would have never materialized.
Thanks to Guenther Krueger, for the many interesting debates about qualitative
research, for being always available for reading and commenting earlier papers, and for
the endless personal support you have given me throughout my entire doctoral studies. I
am also indebted to Casper Bruun Jensen, for the many intense and enjoyable discussions
we had during the first year of my doctoral studies. Your critical work will always remain
a great source of inspiration. Thank you also for pushing me into writing about fieldwork
troubles; a topic I came to develop great passion towards. I also wish to thank Marianne
Tolar for her careful reading and help with parts of the dissertation during the final period
v
of writing, as well as Tracy Lee, whose resilience, kindness, encouragement and feedback
have been invaluable.
I am grateful to Nicki Kahnamoi, with whom I had the great pleasure to work at
the start of the project, and Lindsay Lynch for being my thesis buddy and for helping me
with editing. Thanks also to the staff and faculty of the School of Communication; in
particular, Denise Vanderwolf, Lucie Menkveld, Monique Cloutier and Amy Soo, for
making the bureaucratic aspects of academic work manageable. Special thanks go to Jan
Marontate for helping smooth out the path as I went through the final stages of my PhD.
I had the pleasure to meet a range of people whose outstanding work have
motivated and inspired me throughout my research endeavor. This includes Sisse Finken
and Ingunn Moser, as well as Els Goorman and Sally Wyatt who kindly read early drafts
of papers I have written.
I am indebted to my mentors from the University of Oslo, Margunn Aanestad and
Judith Gregory. Their continuous trust and belief in me are part of the reasons for the fact
that I have thus far chosen an academic career.
My appreciation belongs to the staff of the community partner’s clinic whose
generosity and openness made the fieldwork possible. I am also grateful to the Social
Sciences and Humanities Research Council of Canada, for their support of the ACTION
for Health Research Program, Grant #512-2003-1017, funded through the Initiative for a
New Economy Collaborative Research Initiative.
I am also indebted to friends and family for their never ending support. This
includes Servane Mason, for the beers and the many good laughs we had. Kjetil Rødje
deserves special thanks for being so supportive and patient with me, and for keeping
things in perspective. You remain the true engine that kept me going and sustained my
efforts throughout my entire doctoral work. Special thanks goes to my mother, May
Boulus, my brother and sister, Toofik and Georgina Boulus, for their love and support,
for always believing in me and encouraging me to follow my interests. You are my true
heroes.

Vancouver, March 2010

vi
TABLE OF CONTENTS
Approval .............................................................................................................................ii
Abstract ............................................................................................................................ iii
Dedication......................................................................................................................... iv
Acknowledgements ........................................................................................................... v
Table of Contents ............................................................................................................vii
List of Figures................................................................................................................... xi
List of Tables ...................................................................................................................xii
Glossary of Acronyms.................................................................................................... xiii
Chapter 1: Introduction......................................................................................................1
1.1 Setting the Stage ...............................................................................................4
1.1.1 Field Site.......................................................................................................5
1.1.2 EMRs: Media and Policy Discourse ..............................................................5
1.1.3 The Turn to Action: A Contemporary Research Trend ...............................13
1.2 Motivation for the Study.................................................................................16
1.3 Research Questions ........................................................................................18
1.4 Relevance of the Study and Expected Contributions.......................................20
1.4.1 Healthcare IT and EMRs ............................................................................20
1.4.2 Methodological Reflections on Action Research .........................................23
1.5 An Overview of the Dissertation Structure .....................................................26
Chapter 2: Literature and Related Research ..................................................................28
2.1 Introduction ...................................................................................................28
2.2 Theoretical Orientation...................................................................................28
2.3 Healthcare IT and Medical Practice ................................................................29
2.3.1 Brief History of EMRs................................................................................30
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2.3.2 EMR Literature...........................................................................................31
2.4 Action Research..............................................................................................39
2.4.1 Traditional Action Research........................................................................40
2.4.2 IS Action Research .....................................................................................51
2.4.3 STS Action-Oriented Research ...................................................................56
2.5 Summary ........................................................................................................61
Chapter 3: Ontological, Epistemological and Methodological Assumptions .............64
3.1 Theoretical Platform...................................................................................64
3.2 Constructivist Paradigm..................................................................................64
3.2.1 Constructivist Ontology and Epistemology.................................................67
3.2.2 Constructivist Methodologies .....................................................................69
3.3 Science and Technology Studies......................................................................71
3.3.1 Actor-Network Theory: Core Analytical Concepts and Insights..................73
3.4 Empirical Case and Methods for Studying the EMR.......................................84
3.4.1 Research Project and Field Setting ..............................................................85
3.4.2 Research Methodology and Design .............................................................88
3.4.3 Data Collection Techniques and Fieldwork.................................................90
3.4.4 Coding and Data Analysis ...........................................................................98
3.5 Studying Action Research- The Reflexive Turn.............................................102
3.5.1 Second-Order Inquiry and Action Research ‘in the Making’......................102
3.5.2 Reflexivity and First-Person Action Research............................................103
3.5.3 Reflective Thinking- Reflexive Methodology.............................................104
3.5.4 Confessionals: Reflexive Voice and Writing Style......................................107
3.6 Summary ......................................................................................................108
Chapter 4: Electronic Medical Records........................................................................110
4.1 Introduction .................................................................................................110
4.2 Setting the Stage ...........................................................................................112
4.2.1 Unpacking EMRs: Visions and Technologies............................................112
4.2.2 ‘The Jewel in our Crown:’ Pre-EMR Implementation ...............................116
4.3 The Birth of the EMR ..................................................................................120
4.3.1 Beyond Technical Infrastructure ...............................................................121
4.3.2 Identifying and Analysing Technology Practices .......................................124
4.3.3 Summary and Implications for EMR Adaptation ......................................129
4.4 Factors Supporting the Adaptation Process ..................................................132
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