The Preclusive and Productive Power of Information Systems: Psychiatric Clinicians, Electronic Health Records, and the Making of Health Information

At the heart of this project is a question about how our interactions with information systems shape our actions, and the products of those actions. To explore this question, I look at clinical work, a field that has been transformed over the past few decades by the widespread adoption of a particular kind of information system, the electronic health record (EHR). EHRs, designed not only for clinical record keeping, but also to facilitate information sharing and reduce medical errors, promise to reduce clinical labor and improve patient care. However, as these systems attempt to meet the needs of a broad set of actors, and as they shape the production of clinical information by structuring what information can be collected and by acting upon information recorded by clinicians, EHRs reorganize clinical work and the information produced through that work in ways that have not been fully explored. Drawing from institutional ethnography, infrastructure studies, and sociomaterial approaches in this project I use in-depth interviews with psychiatric clinicians, interviews with health information technology professionals, observations at two industry conferences and close readings of three EHRs used by psychiatrists to better understand how these information systems have impacted the work of psychiatrists and the health information produced through that work. I find that in attempting to meet the needs of a many different groups that utilize healthcare information, these systems can encroach on clinical autonomy, facilitate the redistribution of billing labor, and direct clinical notes in ways that are not physician-focused, but rather are geared towards government requirements, billing issues, and risk management. The new electronic form of these systems can also create challenges for patient privacy and it can intrude on clinical spaces, pulling attention away from patients and disrupting clinicians\u27 visual exams. My research shows how common functions built into EHRs, like templates, checklists, and \u27copy, paste, forward\u27 functionality can both homogenize and decontextualize clinical information as well as create an overabundance of information, resulting in less clinically intelligible notes. And this project identifies ways in which EHRs both orient the collection of health information, encouraging and prioritizing the recording of some information while making it difficult to record other kinds of information, and also act upon the health information recorded by clinicians, at times changing that information in ways that are not fully understood by the clinicians using these systems. This project contributes to the fields of sociology and science and technology studies by exploring some of the ways that management orientations, built into EHRs, ultimately direct clinical work as clinicians change their record keeping processes to match those of the EHR, take on the additional work required to make sense of information in these new clinical notes, and/or develop workarounds to document care in ways that they find more clinically useful. It also attends to techno-social relations at play in the production of clinical information through the EHR by identifying EHRs as a co-producer of patient health information, in conjunction with clinicians, as these systems both shape how clinicians record information and act upon that information once it has been entered. It does this with the hope that by more fully understanding the sociomaterial assemblage that produces health information we can better understand when, why and how the work of clinicians fails to produce information that is clinically intelligible or clinically relevant, and what interventions could help resolve these issues