Appl Clin Inform 2011; 02(04): 406-419
DOI: 10.4338/ACI-2011-06-RA-0035
Research Article
Schattauer GmbH

Sociotechnical Challenges of Developing an Interoperable Personal Health Record

Lessons Learned
G.L. Gaskin
1   Program in Science, Technology and Society, School of Humanities and Sciences, Stanford University, Stanford, CA
,
C.A. Longhurst
2   Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
3   Department of Clinical Informatics, Lucile Packard Children‘s Hospital, Stanford, CA
,
R. Slayton
4   Program in Science, Technology and Society, School of Humanities and Sciences, Stanford University, Stanford, CA
,
A.K. Das
5   Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA
› Author Affiliations
Further Information

Correspondence to:

Gregory Gaskin
MSOB X-215
251 Campus Drive
Stanford, CA 94305
Phone: (530) 314–9330   
Fax: (650) 725–7944   

Publication History

received: 01 June 2011

accepted: 21 August 2011

Publication Date:
16 December 2017 (online)

 

Summary

Objectives: To analyze sociotechnical issues involved in the process of developing an interoperable commercial Personal Health Record (PHR) in a hospital setting, and to create guidelines for future PHR implementations.

Methods: This qualitative study utilized observational research and semi-structured interviews with 8 members of the hospital team, as gathered over a 28 week period of developing and adapting a vendor-based PHR at Lucile Packard Children’s Hospital at Stanford University. A grounded theory approach was utilized to code and analyze over 100 pages of typewritten field notes and interview transcripts. This grounded analysis allowed themes to surface during the data collection process which were subsequently explored in greater detail in the observations and interviews.

Results: Four major themes emerged: (1) Multidisciplinary teamwork helped team members identify crucial features of the PHR; (2) Divergent goals for the PHR existed even within the hospital team; (3) Differing organizational conceptions of the end-user between the hospital and software company differentially shaped expectations for the final product; (4) Difficulties with coordination and accountability between the hospital and software company caused major delays and expenses and strained the relationship between hospital and software vendor.

Conclusions: Though commercial interoperable PHRs have great potential to improve healthcare, the process of designing and developing such systems is an inherently sociotechnical process with many complex issues and barriers. This paper offers recommendations based on the lessons learned to guide future development of such PHRs.


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Conflict of Interest Statement

None of the authors have any conflict of interest, financial or otherwise, relevant to the conduct or reporting of this study.

  • References

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  • 2 U.S. Department of Health and Human Services. American Recovery and Reinvestment Act Implementation Plans [Internet]. Washington D.C.: U. S. Department of Health and Human Services; 2010 June [cited 2010 August 30]. Available from: http://www.recovery.gov/Transparency/agency/Recovery%20Plans/HHS%20Recovery%20Act%20Plan%20-%20June%202010.pdf.
  • 3 Blumenthal D, Tavenner M. The ,,Meaningful use“ regulation for electronic health records. N Engl J Med 2010; 363: 501-504.
  • 4 Halamka JD, Mandl KD, Tang PC. Early experiences with personal health records. J Am Med Inform Assoc 2008; 15 (01) 1-7.
  • 5 Britto MT, Wimberg J. Pediatric personal health records: current trends and key challenges. Pediatrics 2009; 123 (02) S97-S99.
  • 6 Ahern D, Kreslake J, Phalen J. What is eHealth (6): Perspectives on the evolution of eHealth research. Journal of Medical Internet Research 2006; 8 (01) e4.
  • 7 Council on Clinical Information Technology.. Policy statement –using personal health records to improve the quality of health care for children. Pediatrics 2009; 124 (01) 403-409.
  • 8 Horan TA, Botts NE, Burkhard RJ. A multidimensional view of personal health systems for underserved populations. J Med Internet Res 2010; 12 (03) e32.
  • 9 Health 2.0 LLC: Blue Button Challenge [Internet]. San Francisco: Health 2.0 LLC; 2010 [cited 2010 August 30]. Available from: http://health2challenge.org/blog/blue-button-challenge.
  • 10 Robert Wood Johnson Foundation: Project HealthDesign [Internet].. Madison (WI): Robert Wood Johnson Foundation; 2010 [cited 2010 August 30]. Available from: http://www.projecthealthdesign.org.
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  • 12 Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. J Am Med Inform Assoc 2006; 13: 121-126.
  • 13 Kaelber DC, Jha AK, Johnston D, Middleton B, Bates DW. A research agenda for personal health records (PHRs). J Am Med Inform Assoc 2008; 15 (06) 729-736.
  • 14 Steinbrook R. Personally controlled online health data –the next big thing in medical care?. NEJM 2008; 358 (16) 1653-1656.
  • 15 Reti SR, Feldman HJ, Ross SE, Safran C. Improving personal health records for patient-centered care. J Am Med Inform Assoc 2010; 17: 192-195.
  • 16 Nazi KM. Veterans’ voices: use of the American Customer Satisfaction Index (ACSI) Survey to identify My HealtheVet personal health record users’ characteristics, needs, and preferences. J Am Med Inform Assoc 2010; 17: 203-211.
  • 17 Nazi KM, Hogan TP, Wagner TH, McInnes DK, Smith BM, Haggstrom D. et al. Embracing a health services research perspective on personal health records: Lessons learned from the VA My HealtheVet system. Journal of General Internal Medicine 2010; 25 (01) S62-S67.
  • 18 Kim MI, Johnson KB. Personal health records: evaluation of functionality and utility. J Am Med Inform Assoc 2002; 9: 171-180.
  • 19 Lee M, Delaney C, Moorhead S. Building a personal health record from a nursing perspective. Int J Med Inform 2007; 76 (02) S308-S316.
  • 20 Maloney FL, Wright A. USB-based personal health records: next term an analysis of features and functionality. Int J Med Inform 2010; 79 (02) 97-111.
  • 21 Do NV, Barnhill R, Heermann-Do KA, Salzman KL, Gimbel RW. The military health system’s personal health record pilot with Microsoft HealthVault and Google Health. J Am Med Inform Assoc 2011; 18 (02) 118-124.
  • 22 Madon T, Hofman KJ, Kupfer L, Glass RI. “Implementation science.” Science. 2007 318 1728-1728.
  • 23 Goldstein MK. Using health information technology to improve hypertension management. Current hypertension reports 2008; 10 (03) 201-207.
  • 24 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11 (02) 104-112.
  • 25 Wears RL, Berg M. Computer technology and clinical work: still waiting for Godot. J Am Med Assoc 2005; 293 (10) 1261-1263.
  • 26 Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Lessons from unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2006; 118 (02) 797-801.
  • 27 Ash JS, Sittig DF, Dykstra RH, Guappone K, Carpenter JD, Seshadri V. Categorizing the unintended socio-technical consequences of computerized provider order entry. Int J Med Inform 2007; 76 (01) 21-27.
  • 28 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care –an interactive sociotechnical analysis. J Am Med Inform Assoc 2007; 14 (05) 542-549.
  • 29 Shen B. Bio-socio-technical underpinnings of participatory medicine. J Participat Med 2009; 1 (01) e7.
  • 30 Goldstein MK, Coleman RW, Tu SW, Shankar RD, O’Connor MJ, Musen MA. Translating research into practice: organizational issues in implementing automated decision support for hypertension in three medical centers. J Am Med Inform Assoc 2004; 11 (05) 368-376.
  • 31 Pinch T, Bijker W. The social construction of facts and artefacts: or how the sociology of science and the sociology of technology might benefit each other. Social Studies of Science 1984; 14 (03) 399-441.
  • 32 Jasanoff S. editor. States of knowledge: The co-production of science and social order. Routledge and Kegan Paul; London: 2004
  • 33 Taylor P. Building on construction: an exploration of heterogeneous constructionism using an analogy from psychology and a sketch from socioeconomic modeling. Perspectives on Science 1995; 3: 66-98.
  • 34 Orlikowski WJ, Gash DC. Technological frames: making sense of information technology in organizations. ACM Transactions on Information Systems 1994; 12 (02) 174-207.
  • 35 Hevner A, March S, Park J, Ram S. “Design science in information systems research,”. MIS Quarterly 2004; 28 (01) 75-105.
  • 36 Bernstein JA, Imler DL, Sharek P, Longhurst CA. Improved physician work flow after integrating sign-out notes into the electronic medical record. Jt Comm J Qual Patient Saf 2010; 36 (02) 72-78.
  • 37 Longhurst CA, Parast L, Sandborg CI, Widen E, Sullivan J, Hahn JS. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics 2010; 126 (01) 14-21.
  • 38 Tang PC, Black W, Buchanan J, Young CY, Hooper D, Lane SR. et al. PAMFOnline: integrating EHealth with an electronic medical record system. AMIA Annu Symp Proc 2003: 644-648.
  • 39 Tang PC, Lansky D. The missing link: bridging the patient-provider health information gap. Health Aff (Millwood) 2005; 24 (05) 1290-1295.
  • 40 Tang PC, Lee TH. Your doctor’s office or the Internet? Two paths to personal health records. N Engl J Med 2009; 360 (13) 1276-1278.
  • 41 Strauss AL. Qualitative analysis for social scientists. Cambridge, MA: Cambridge University Press,; 1987
  • 42 Ash J, Berg M. Report of conference track 4: socio-technical issues of HIS. Methods Inf Med 2003; 69: 305-306.
  • 43 Forsythe DE. “It’s just a matter of common sense“: ethnography as invisible work. Computer Supported Cooperative Work 1999; 8: 127-145.
  • 44 Emerson R. et. al. Writing ethnographic fieldnotes. Chicago: University of Chicago Press,; 1995
  • 45 Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. New York: Al-dine De Gruyter,; 1967
  • 46 Strauss AL. Corbin J. Basics of grounded theory methods. Beverly Hills, CA.: Sage,; 1990
  • 47 Corbin J, Strauss AL. Grounded theory research: Procedures, canons and evaluative criteria. Qualitative Sociology 1990; 13: 3-21.
  • 48 Weiss Robert S. Learning from strangers. New York, New York: The Free Press,; 1995
  • 49 Spector A. Update from the Google Health Team. 2010 March 1 [cited 2010 August 30]. In: The Official Google Blog [Internet]. Mountain View (CA), Google, Inc. Available from: http://googleblog.blogspot. com/2010/03/update-from-google-health-team.html.
  • 50 Giustini D. How Google is changing medicine. BMJ 2005; 331: 1487-1488.
  • 51 Berg M. “Implementing information systems in health care organizations: myths and challenges.”. Int J Med Inf 2001; 64: 143-143.
  • 52 Lorenzi Nancy M, Riley, Robert T. Organizational issues = change. Int J Med Inf 2003; 69 (2–3) 197-203.
  • 53 Lorenzi N M, Riley R T. Managing change: an overview. J Am Med Inform Assoc 2000; 7 (02) 116-124.
  • 54 Thursky KA, Mahemoff M. ,,User-centered design techniques for a computerised antibiotic decision support system in an intensive care unit.“. International journal of medical informatics 2007; 76 (10) 760-768.
  • 55 Ash JS, Fournier L, Stavri PZ, Dykstra R. Principles for a successful computerized physician order entry implementation. AMIA Annu Symp Proc 2003: 36-40.
  • 56 Finkel SE, Guterbock TM, Borg MJ. Race-of-interviewer effects in a pre-election poll: Virginia 1989. Public Opinion Quarterly 1991; 55: 313-330.
  • 57 Forsythe DE, Buchanan BG, Osheroff JA, Miller RA. Expanding the concept of medical information: An observational study of physicians’ information needs. Computers and biomedical research, an international journal 1992; 25 (02) 181-200.
  • 58 Forsythe DE. Using ethnography to investigate life scientists’ information needs. Bull Med Libr Assoc 1998; 86 (03) 402-409.
  • 59 Brown A, Weihl B. An update on Google Health and Google PowerMeter. 2011 Jun 24 [cited 2011 Jun 24]. In: The Official Google Blog [Internet]. Mountain View, CA: Google Inc. c2011. Available from: http://goog leblog.blogspot.com/2011/06/update-on-google-health-and-google.html.

Correspondence to:

Gregory Gaskin
MSOB X-215
251 Campus Drive
Stanford, CA 94305
Phone: (530) 314–9330   
Fax: (650) 725–7944   

  • References

  • 1 White House: The White House Homepage [Internet]. Washington D.C.: The White House [updated 2010 August 30]; Health Care. [updated 2010 August 30; cited 2010 August 30]. Available from: http://www. whitehouse.gov/issues/health-care.
  • 2 U.S. Department of Health and Human Services. American Recovery and Reinvestment Act Implementation Plans [Internet]. Washington D.C.: U. S. Department of Health and Human Services; 2010 June [cited 2010 August 30]. Available from: http://www.recovery.gov/Transparency/agency/Recovery%20Plans/HHS%20Recovery%20Act%20Plan%20-%20June%202010.pdf.
  • 3 Blumenthal D, Tavenner M. The ,,Meaningful use“ regulation for electronic health records. N Engl J Med 2010; 363: 501-504.
  • 4 Halamka JD, Mandl KD, Tang PC. Early experiences with personal health records. J Am Med Inform Assoc 2008; 15 (01) 1-7.
  • 5 Britto MT, Wimberg J. Pediatric personal health records: current trends and key challenges. Pediatrics 2009; 123 (02) S97-S99.
  • 6 Ahern D, Kreslake J, Phalen J. What is eHealth (6): Perspectives on the evolution of eHealth research. Journal of Medical Internet Research 2006; 8 (01) e4.
  • 7 Council on Clinical Information Technology.. Policy statement –using personal health records to improve the quality of health care for children. Pediatrics 2009; 124 (01) 403-409.
  • 8 Horan TA, Botts NE, Burkhard RJ. A multidimensional view of personal health systems for underserved populations. J Med Internet Res 2010; 12 (03) e32.
  • 9 Health 2.0 LLC: Blue Button Challenge [Internet]. San Francisco: Health 2.0 LLC; 2010 [cited 2010 August 30]. Available from: http://health2challenge.org/blog/blue-button-challenge.
  • 10 Robert Wood Johnson Foundation: Project HealthDesign [Internet].. Madison (WI): Robert Wood Johnson Foundation; 2010 [cited 2010 August 30]. Available from: http://www.projecthealthdesign.org.
  • 11 Detmer D, Bloomrosen M, Raymond B, Tang PC. Integrated personal health records: transformative tools for consumer-centric care. BMC Med Inform Decis Mak 2008; 8: 45.
  • 12 Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. J Am Med Inform Assoc 2006; 13: 121-126.
  • 13 Kaelber DC, Jha AK, Johnston D, Middleton B, Bates DW. A research agenda for personal health records (PHRs). J Am Med Inform Assoc 2008; 15 (06) 729-736.
  • 14 Steinbrook R. Personally controlled online health data –the next big thing in medical care?. NEJM 2008; 358 (16) 1653-1656.
  • 15 Reti SR, Feldman HJ, Ross SE, Safran C. Improving personal health records for patient-centered care. J Am Med Inform Assoc 2010; 17: 192-195.
  • 16 Nazi KM. Veterans’ voices: use of the American Customer Satisfaction Index (ACSI) Survey to identify My HealtheVet personal health record users’ characteristics, needs, and preferences. J Am Med Inform Assoc 2010; 17: 203-211.
  • 17 Nazi KM, Hogan TP, Wagner TH, McInnes DK, Smith BM, Haggstrom D. et al. Embracing a health services research perspective on personal health records: Lessons learned from the VA My HealtheVet system. Journal of General Internal Medicine 2010; 25 (01) S62-S67.
  • 18 Kim MI, Johnson KB. Personal health records: evaluation of functionality and utility. J Am Med Inform Assoc 2002; 9: 171-180.
  • 19 Lee M, Delaney C, Moorhead S. Building a personal health record from a nursing perspective. Int J Med Inform 2007; 76 (02) S308-S316.
  • 20 Maloney FL, Wright A. USB-based personal health records: next term an analysis of features and functionality. Int J Med Inform 2010; 79 (02) 97-111.
  • 21 Do NV, Barnhill R, Heermann-Do KA, Salzman KL, Gimbel RW. The military health system’s personal health record pilot with Microsoft HealthVault and Google Health. J Am Med Inform Assoc 2011; 18 (02) 118-124.
  • 22 Madon T, Hofman KJ, Kupfer L, Glass RI. “Implementation science.” Science. 2007 318 1728-1728.
  • 23 Goldstein MK. Using health information technology to improve hypertension management. Current hypertension reports 2008; 10 (03) 201-207.
  • 24 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11 (02) 104-112.
  • 25 Wears RL, Berg M. Computer technology and clinical work: still waiting for Godot. J Am Med Assoc 2005; 293 (10) 1261-1263.
  • 26 Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Lessons from unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2006; 118 (02) 797-801.
  • 27 Ash JS, Sittig DF, Dykstra RH, Guappone K, Carpenter JD, Seshadri V. Categorizing the unintended socio-technical consequences of computerized provider order entry. Int J Med Inform 2007; 76 (01) 21-27.
  • 28 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care –an interactive sociotechnical analysis. J Am Med Inform Assoc 2007; 14 (05) 542-549.
  • 29 Shen B. Bio-socio-technical underpinnings of participatory medicine. J Participat Med 2009; 1 (01) e7.
  • 30 Goldstein MK, Coleman RW, Tu SW, Shankar RD, O’Connor MJ, Musen MA. Translating research into practice: organizational issues in implementing automated decision support for hypertension in three medical centers. J Am Med Inform Assoc 2004; 11 (05) 368-376.
  • 31 Pinch T, Bijker W. The social construction of facts and artefacts: or how the sociology of science and the sociology of technology might benefit each other. Social Studies of Science 1984; 14 (03) 399-441.
  • 32 Jasanoff S. editor. States of knowledge: The co-production of science and social order. Routledge and Kegan Paul; London: 2004
  • 33 Taylor P. Building on construction: an exploration of heterogeneous constructionism using an analogy from psychology and a sketch from socioeconomic modeling. Perspectives on Science 1995; 3: 66-98.
  • 34 Orlikowski WJ, Gash DC. Technological frames: making sense of information technology in organizations. ACM Transactions on Information Systems 1994; 12 (02) 174-207.
  • 35 Hevner A, March S, Park J, Ram S. “Design science in information systems research,”. MIS Quarterly 2004; 28 (01) 75-105.
  • 36 Bernstein JA, Imler DL, Sharek P, Longhurst CA. Improved physician work flow after integrating sign-out notes into the electronic medical record. Jt Comm J Qual Patient Saf 2010; 36 (02) 72-78.
  • 37 Longhurst CA, Parast L, Sandborg CI, Widen E, Sullivan J, Hahn JS. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics 2010; 126 (01) 14-21.
  • 38 Tang PC, Black W, Buchanan J, Young CY, Hooper D, Lane SR. et al. PAMFOnline: integrating EHealth with an electronic medical record system. AMIA Annu Symp Proc 2003: 644-648.
  • 39 Tang PC, Lansky D. The missing link: bridging the patient-provider health information gap. Health Aff (Millwood) 2005; 24 (05) 1290-1295.
  • 40 Tang PC, Lee TH. Your doctor’s office or the Internet? Two paths to personal health records. N Engl J Med 2009; 360 (13) 1276-1278.
  • 41 Strauss AL. Qualitative analysis for social scientists. Cambridge, MA: Cambridge University Press,; 1987
  • 42 Ash J, Berg M. Report of conference track 4: socio-technical issues of HIS. Methods Inf Med 2003; 69: 305-306.
  • 43 Forsythe DE. “It’s just a matter of common sense“: ethnography as invisible work. Computer Supported Cooperative Work 1999; 8: 127-145.
  • 44 Emerson R. et. al. Writing ethnographic fieldnotes. Chicago: University of Chicago Press,; 1995
  • 45 Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. New York: Al-dine De Gruyter,; 1967
  • 46 Strauss AL. Corbin J. Basics of grounded theory methods. Beverly Hills, CA.: Sage,; 1990
  • 47 Corbin J, Strauss AL. Grounded theory research: Procedures, canons and evaluative criteria. Qualitative Sociology 1990; 13: 3-21.
  • 48 Weiss Robert S. Learning from strangers. New York, New York: The Free Press,; 1995
  • 49 Spector A. Update from the Google Health Team. 2010 March 1 [cited 2010 August 30]. In: The Official Google Blog [Internet]. Mountain View (CA), Google, Inc. Available from: http://googleblog.blogspot. com/2010/03/update-from-google-health-team.html.
  • 50 Giustini D. How Google is changing medicine. BMJ 2005; 331: 1487-1488.
  • 51 Berg M. “Implementing information systems in health care organizations: myths and challenges.”. Int J Med Inf 2001; 64: 143-143.
  • 52 Lorenzi Nancy M, Riley, Robert T. Organizational issues = change. Int J Med Inf 2003; 69 (2–3) 197-203.
  • 53 Lorenzi N M, Riley R T. Managing change: an overview. J Am Med Inform Assoc 2000; 7 (02) 116-124.
  • 54 Thursky KA, Mahemoff M. ,,User-centered design techniques for a computerised antibiotic decision support system in an intensive care unit.“. International journal of medical informatics 2007; 76 (10) 760-768.
  • 55 Ash JS, Fournier L, Stavri PZ, Dykstra R. Principles for a successful computerized physician order entry implementation. AMIA Annu Symp Proc 2003: 36-40.
  • 56 Finkel SE, Guterbock TM, Borg MJ. Race-of-interviewer effects in a pre-election poll: Virginia 1989. Public Opinion Quarterly 1991; 55: 313-330.
  • 57 Forsythe DE, Buchanan BG, Osheroff JA, Miller RA. Expanding the concept of medical information: An observational study of physicians’ information needs. Computers and biomedical research, an international journal 1992; 25 (02) 181-200.
  • 58 Forsythe DE. Using ethnography to investigate life scientists’ information needs. Bull Med Libr Assoc 1998; 86 (03) 402-409.
  • 59 Brown A, Weihl B. An update on Google Health and Google PowerMeter. 2011 Jun 24 [cited 2011 Jun 24]. In: The Official Google Blog [Internet]. Mountain View, CA: Google Inc. c2011. Available from: http://goog leblog.blogspot.com/2011/06/update-on-google-health-and-google.html.