Doctors and Psychosocial Information: Records and Reuse in Inpatient Care Xiaomu Zhou 1 , Mark S. Ackerman 1,2 , and Kai Zheng 1,3 1 School of Information, 2 Department of EECS, 3 School of Public Health University of Michigan, Ann Arbor {xmzhou, ackerm, kzheng}@umich.edu ABSTRACT 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. Author Keywords Medical records, electronic patient records, organizational memory, physician information needs, EHR, psychosocial information, CSCW, health informatics. ACM Classification Keywords H.0 [information systems]; K.4.3 [organizational impacts]: Computer-supported cooperative work. INTRODUCTION The strategic role that health information technology (HIT) plays in enabling the healthcare reform in the U.S., combined with the ongoing national debate on how HIT should be used ‘meaningfully’ to achieve the desirable transformative change, has created a critical need for research studies that contribute to a better understanding of how to utilize electronically available data for constructive, cooperative use and reuse. While electronic health records (EHR) systems provide tremendous promise for improving quality of care and controlling soaring costs, a large body of literature has noted the cumbersome usability of these systems, including numerous unintended adverse work- related and care-related consequences (e.g. [10]). Further, increasingly, doctors have to cope with patients’ chronic illnesses, which affect a patient personally and socially overtime beyond the disease-specific medical symptoms and treatments [11]. For example, there has been an increasing number of patients who demonstrate various kinds of pain issues, many of which are caused by, or contribute to, serious psychosocial problems they bear in life. This trend requires doctors to acquire a complete view of a patient’s history in order to make informed treatment decisions. Unfortunately, it has been shown that a patient’s history can be poorly documented in an EHR system [10]. Through this field-based study, we aimed to explore how information is used and documented to support medical work, how it is reused across a patient’s multiple care episodes, and how an improved understanding of doctors’ information practices could inform more accommodating and usable EHR designs. The findings of this study contribute to HCI/CSCW by explicating the dichotomized purpose of medical records –as both a representation of medical work to facilitate real-time activities (i.e. practice-centered) and a representation of the patient to support long-term information reuse (i.e. patient-centered). In addition, this study contributes to health informatics research and practice by highlighting several key functionalities that have been missing from the current designs of healthcare information systems. Our field data were collected at a large teaching hospital by shadowing the routine patient care practice of over 24 physicians and residents. An in-house developed EHR system, eCare, has been deployed and used in the hospital for over a decade. Approximately 14,000 users in the hospital system use eCare to generate or retrieve patient records on a daily basis. In this paper, we examine how doctors acquire, document, and use information across multiple episodes of patient care with special attention paid to how they cope with a patient’s psychosocial experience. In this study, we define psychosocial information as a patient’s psychological and social issues in her illness experience. With this focus, we explored (1) under what circumstances doctors choose to document psychosocial information and what kinds of psychosocial information they choose to document and (2) how this information, or its absence, affects a patient’s Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee. 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