EXAMINING ELECTRONIC MEDICAL RECORDS SYSTEM ADOPTION AND IMPLICATIONS FOR ...

443 Pages·2015·21.98 MB·English

EXAMINING ELECTRONIC MEDICAL RECORDS SYSTEM ADOPTION
AND IMPLICATIONS FOR EMERGENCY MEDICINE PRACTICE
AND PROVIDERS
A Dissertation
Submitted to the Graduate Faculty of the
Louisiana State University and
Agricultural and Mechanical College
in partial fulfillment of the
requirements for the degree of
Doctor of Philosophy
in
The Department of Communication Studies
by
Barbara Cook Overton
B.A., University of Charleston, 1995
M.F.A., University of New Orleans, 1999
August 2015
This dissertation was inspired by and is dedicated to my husband, the love of my
life. Obtaining my doctorate would not have been possible without his love, support,
patience, and encouragement. I am forever grateful to him.
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ACKNOWLEDGEMENTS
This dissertation was made possible because of the emergency medicine
physicians, midlevel providers, nurses, and technicians at Hospital H who welcomed me
into their emergency room and shared their insights and opinions. I am grateful for their
support and honesty. I hope that this dissertation makes them proud, and that the
challenges of their work and intricacies of emergency medicine practice are appreciated
more fully by those who read this document.
I am indebted to the emergency medicine physicians who consented to interviews
with me at medical conferences. Dr. Ken Milne and Dr. Peter Viccellio shared their
insights with me when I am certain their time may have been spent more richly not
discussing electronic medical records systems. I thank them for humoring a doctoral
student’s inquiries.
Dr. Richard Bukata, an awe-inspiring emergency medicine physician and scholar,
has lectured and written about electronic medical records systems for years. His keen
insights and intellect shaped significantly my view of the topic. I am grateful for his
scholarship.
I am appreciative of Dr. Anne Nicotera’s guidance. She shared her work on
structurational divergence theory with me and helped me to see my research site, study
participants, and data in a new light. With her prodding, I discovered important
connections and made theoretical linkages that, otherwise, I may have missed.
My dear friend and mother-in-law, Charlotte, supported and nourished me
throughout this journey. Without her love and home-cooked meals, I would not have
endured. I am thankful for her friendship, and happy that she entrusted me with her son.
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Jack, Béni, Chanceux, Veinard, and Élu provided companionship through what,
oftentimes, was a lonely pursuit. Their presence was much valued.
My family and friends, neglected regularly, were patient and kind as I navigated
this dissertation. I appreciate immensely their understanding and support. I hope that my
nieces and nephews will be inspired by “Aunt B’s” accomplishment and that they, too,
will follow their dreams, no matter how daunting the pursuit may seem. If I can do this,
they can do anything.
I appreciate the guidance given by my dissertation committee members, Dr.
Graham Bodie and Dr. Renee Edwards. They, thankfully, whittled an overly ambitious
prospectus into a manageable dissertation project.
Dr. Lawrence Frey, a dear friend and brilliant scholar, volunteered to serve on my
committee, and I am forever in his debt. He painstakingly reviewed and edited multiple
drafts of this very long dissertation. Dr. Frey’s insights have made me a better scholar
and a better writer.
Dr. Loretta Pecchioni was my advisor, but, more important, she is my friend. As I
wallowed in seemingly endless details, she reminded me to look at the big picture. Dr.
Pecchioni’s encouragement and commitment helped me to earn this doctorate. I am
proud to know her and pleased to have worked with her.
A Louisiana State University Dissertation Year Fellowship funded my research. I
am appreciative that the faculty of the Department of Communication Studies nominated
my work for consideration and that fellowship committee members selected it as 1 of 10
winning proposals. I am grateful for the financial assistance.

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I am thankful to have had the support and encouragement of so many people. I
am deeply grateful for all of you. I am especially grateful for Dr. C. Thank you for
everything.
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS iii
LIST OF TABLES viii
LIST OF FIGURES ix
ABSTRACT x
CHAPTER ONE: INTRODUCTION 1
CHAPTER TWO: REVIEW OF LITERATURE 12
Communication Research in Healthcare Contexts 12
Communication and Health Information Technologies 29
Communication Research in Emergency Room Settings 42
Emergency Medicine and Electronic Medical Records Systems 56
Consequences of Using Electronic Medical Records Systems 84
Conclusion 95
CHAPTER THREE: PRELIMINARY RESEARCH, THEORETICAL
FRAMEWORKS, AND RESEARCH QUESTIONS 97
Preliminary Research 97
Theoretical Frameworks Used to Analyze Effects of Electronic
Medical Records Systems in Emergency Rooms 114
Research Questions 134
CHAPTER FOUR: METHODOLOGY 135
Methodological Issues in Observational Emergency Room Studies 135
Ethnographic Methods 137
Research Sites 140
Participants 148
Data Collection 151
Validity of Findings 162
Researcher Subjectivity 163
Ethical Concerns 169
Data Analysis 172
CHAPTER FIVE: FINDINGS 177
Electronic Medical Records System Training for Providers 177
Appropriation Moves 192
Structurational Divergence 234
Providers’ Strategies for Coping with Electronic Medical
Records Systems 273
How the Electronic Medical Records System Affected
Communication Patterns among Providers 283
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How the Electronic Medical Records System Affected
Provider–Patient Interactions and Patients’ Satisfaction 291
Unintended and Perverse Consequences of Electronic Medical
Records Systems 298
Conclusion 314
CHAPTER SIX: DISCUSSION 319
Research Goals 319
Summary of Major Findings that Addressed the Research Questions
and Contributed to the Scholarly Literature 322
Conceptual/Theoretical, Methodological, and Practical Implications
of the Findings 330
Limitations of the Study and Directions for Future Research 359
Conclusion 363
REFERENCES 365
APPENDIX
A. INTERNAL REVIEW BOARD EXEMPTION 389
B. HIPAA AGREEMENT 393
C. QUESTIONNAIRE ADMINISTERED DURING
PRELIMINARY RESEARCH 394
D. PHYSICIANS’ TSHEET 413
E. PHYSICIANS’ ORDER SET 415
F. NURSES’ NOTE 417
G. AFFILIATION AGREEMENT 423
H. QUESTIONNAIRE 427
I. MODIFIED INTERNAL REVIEW BOARD EXEMPTION 432
VITA 433
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LIST OF TABLES
4.1 Themes and Subthemes for Identifying Structural Changes
Amid an Electronic Medical Records System Adoption 175
5.1 Microanlysis of Providers’ Talk: The 12 Words and Phrases
Used Most Frequently to Describe the Electronic Medical
Records System 194
5.2 Responses to the Questionnaire Item, “Overall, how satisfied
are you with the EMR that your emergency room uses?” 232
5.3 Responses to the Questionnaire Item, “I feel burned out from
my work.” 247
5.4 Responses to the Questionnaire Item, “I have become more
callous toward people since I took this job.” 248
5.5 Individual Burnout Scores 249
5.6 Individual Structurational Divergence Scores 272
5.7 Responses to the Questionnaire Item, “How has the EMR system
impacted communication between you and your coworkers?” 284
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LIST OF FIGURES
5.1 Word Cloud Illustrating the Words and Phrases Used Most by
Providers to Describe the Electronic Medical Record System 195
5.2 Physician Workflow When Using Paper TSheets 213
5.3 The Interpenetration of Contradictory Structures and the Resulting
Negative Spiral 242
5.4 Computer on Wheels 293
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ABSTRACT
This ethnographic research study documented the use and effects of an electronic
medical records system (EMR) by healthcare providers working in a community hospital-
based emergency room. Using data collected from participant observation, in-depth
interviews, questionnaires, and hospital documents, the research findings suggest EMRs
impinge providers’ agency, alter emergency room systems, affect communication
patterns among providers, and exacerbate structurational divergence (SD) conditions.
Findings suggest that providers’ attempts to regain lost agency tips the SD-nexus into an
SD-cycle, characterized by negative communication spirals between providers. The
discussion chapter examines the impact of EMRs on emergency room structures, system
reproduction, providers’ workflow and communication patterns, patients’ experiences,
and unintended consequences, and it expounds implications of the study with regard to
what lessons learned from this analysis suggests might be best practices for hospitals and
emergency rooms adopting EMRs.
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