Coordination of health services is one of the defining challenges of today’s healthcare system. The U.S. healthcare system has grown highly complex due to: a high pace of advances in science and technology; increasing expectations from patients who are more informed and better connected than ever; higher complexity of U.S. laws, regulations, and payment; and an increase in chronic illness.
A review of health informatics literature reveals that the introduction of information technology such as electronic health records (EHRs) has not fulfilled its promise of improving coordination. Research shows that the introduction of these systems is plagued with unintended consequences—many of which undermine communication and coordination. Studies have revealed that EHR systems misrepresent communication as information transfer, and misrepresent collective, interactive work as linear, predictable workflow. As a result of these problems, paper persists as a way of managing patient records.
Behavioral and mental health services for children are particularly lagging behind with regard to the adoption of EHRs. I was surprised to find that coordination for a child with special needs is driven by behavioral data recorded almost exclusively on paper. Paper data sheets constituted health records in this context. Behavioral data are complex and difficult to capture due to the invisibility and subjectivity of social behavior, but that was only a part of the story. I examined the persistence of paper, the use of health records for coordination, and the design of an EHR system to support coordination practices in a way that would meet the needs of this setting.
The contributions of this thesis are: a description of unstructured and informal workflow that drives long-term coordination in health services; the theoretical construct of collaborative reflection to inform the design of systems that improve coordination; a field deployment validation, demonstrating how designing for collaborative reflection improves coordination and avoids common unintended consequences of EHRs.
Anind Dey (Co-chair)
Sara Kiesler (Co-chair)
Madhu Reddy (Penn State)
Mary Czerwinski (Microsoft Research)