Doctors and Psychosocial Information: Records and Reuse in Inpatient Care

TitleDoctors and Psychosocial Information: Records and Reuse in Inpatient Care
Publication TypeConference Paper
Year of Publication2010
AuthorsZhou, X, Ackerman, MS, Zheng, K
Conference NameProceedings of the ACM Conference on Human Factors in Computing Systems (CHI’10)
KeywordsEHR, electronic patient records, health informaticshealth informatics, information access, information reuse, medical information, medical records, organizational memory, physician information needs, psychosocial information

We conducted a field-based study at a large teaching hospital to examine doctors’ use and documentation of patient care information, with a special focus on a patient’s psychosocial information. We were particularly interested in the gaps between the medical work and any representations of the patient. The paper describes how doctors record this information for immediate and long-term use. We found that doctors documented a considerable amount of psychosocial information in their electronic health records (EHR) system. Yet, we also observed that such information was recorded selectively, and a medicalized view-point is a key contributing factor. Our study shows how missing or problematic representations of a patient affect work activities and patient care. We accordingly suggest that EHR systems could be made more usable and useful in the long run, by supporting both representations of medical processes and of patients.