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Gary David highlights that when considering designs, we need to take into account the entire experience ecosystem and how its elements align and intersect. By approaching design through a systems perspective, we can create better solutions that better fit the needs of system stakeholders.

Image courtesy of interviewee. March 26, 2024

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This video discusses the importance of viewing healthcare as a complex ecosystem rather than focusing solely on the patient. It emphasizes that various stakeholders—including caregivers, clinicians, family members, and administrative staff—play crucial roles in delivering healthcare. If any part of this system breaks down, patient care is compromised.

The speaker, a sociologist, advocates for a systems-based approach that examines interactions at macro, meso, and micro levels to improve the healthcare experience. They introduce the concept of "boundary objects," like medical records, which must serve multiple stakeholders—patients, doctors, insurers, and researchers—each with different needs.

The speaker highlights the essential work of medical transcriptionists, who transform doctors' dictations into usable records, emphasizing their overlooked contribution to the healthcare system. Furthermore, they explain that medical records are pivotal not only for clinical use but also for reimbursement processes.

Ultimately, the speaker calls for a balanced design of electronic health record systems, which accommodates the various requirements of all stakeholders to enhance the overall healthcare experience. Prioritizing one aspect over others could render the system less effective for its intended purposes.

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When we only look at one part of the ecosystem,

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we're only treating one part of the complex environment.

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That is, for instance, healthcare.

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If we're only looking at the patient,

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we're leaving out things like the caregiver, the clinician,

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the family member, the administrative staff.

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And if there's a breakdown in any one of those parts,

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we're gonna have a breakdown in

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how well the system performs for the patient.

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Patient, which, you know,

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obviously is the most important part of the process.

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But these other parts are important too.

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And if we don't pay attention to those,

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we're not gonna do best for the patient by training.

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I'm a sociologist and a sociologist is trained

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to look at systems, both what we would call macro systems,

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the big level meso systems, the middle level

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and microsystems, the smaller level

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or the interactions that people have.

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And being a systems based thinker, I always like

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to think about those different levels.

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How we can go from what happens in the exam room,

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for instance, at the micro to

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what might happen in the hospital at a mezo,

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and then what happens overall in a national healthcare

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system at the macro.

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So just by nature, I'm primed, you could say,

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to look at these things at various levels.

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And by paying attention to those levels,

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we can deliver a better comprehensive experience

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for everyone involved.

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A boundary object you could think about as a thing

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that spans different kinds of spaces

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or what we in the business might call institutional domains.

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So if you think about a medical record, for instance,

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a medical record is primarily for the patient, right?

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But it's also for the doctor, it's for the clinician,

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but it's also for, at least in the United States,

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the insurance company, it might also be for, researchers

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who are doing epidemiological research.

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So this one thing, the medical record needs

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to cut across all of these different spaces

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and be useful to all these different stakeholders

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in their own way.

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And so this becomes really difficult if you can think about

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it as how do we make a useful thing to everybody

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that has different purposes

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and different needs for this object?

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And so that's what we mean when

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we're talking about a boundary object.

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It's a thing that spans spaces and institutional domains

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and needs to service a lot of different needs

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for a lot of different audiences.

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When I first started this research on medical records,

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I was primarily interested in the work

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of a profession called medical transcription,

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medical transcriptionist.

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And these are primarily women whose task it was to turn

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what a doctor dictated or said into a usable medical record.

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And so it wasn't just saying what a typing,

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what a doctor said.

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If they did that, you'd have a pretty unusable record.

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If you ever listen to a doctor dictate, you really need

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to make it usable, not just for the clinician,

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for the doctor, for the whoever is using the record

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for clinical care, but also potentially for the patient

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and also for the reimbursement agents, the coders,

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especially in the United States, how we mod, you know,

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how we run our medical system based off

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of coding different kinds

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of treatments in the medical record. And so I became

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Very fascinated with the work

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of this really underrepresented, under acknowledged group

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of women whose job it was, was

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to make this thing upon which the entitled the entire

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healthcare system,

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was set upon resided, independent upon.

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It's interesting because when I first started doing this

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research with some colleagues,

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I was told all the medical transcriptionists did was type

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what doctors said.

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And it became pretty clear pretty early on

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that they did much more than that.

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That you had a, this workforce that was essential,

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but really under acknowledge and underappreciated.

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So part of the job of, of me as a workplace ethnographer was

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to understand their world, understand their their work,

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understand their identity, their professional sense of self

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as an important part of the healthcare process.

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And so that became the primary element was

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to really appreciate the expertise, the knowledge,

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the workmanship

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that was involved in making this medical record usable so

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that healthcare could work.

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You know, the customer, the user, and the patient.

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All might be completely different people.

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So for instance, let's say you have an elderly parent,

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as many of us getting to the the age that I am,

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have elderly parents.

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The parent might be the patient when they go

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to a doctor's office, correct?

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They might not be the customer

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because the customer in a sense might be the insurance

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company, might be at least the United States Medicare,

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or it might be whoever is on, whoever has the insurance

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that the person who's the patient's using to receive care.

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The user might be the child who has to go online,

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find the information of the medical record,

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or find what is needed for helping with the pa,

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with the parent's care, and use the technological domain

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of the electronic health record

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or just use the paper record.

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So the user might be the child,

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the patient might be the parent,

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and the customer might be the federal government

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or whoever has the health insurance.

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So each of those areas can have a very different stakeholder

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that's involved in the process.

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Oh, absolutely. I mean, without the medical

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record, nothing happens.

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There's a saying in medical transcription

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and in healthcare, at least in the United States,

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if it isn't written down, it didn't happen.

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And we can say, we can extend that to say,

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if it isn't written down, you can't get reimbursed for,

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it's not what a doctor does in the United States

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that they get paid for.

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It's what's written down on the medical record.

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And so the medical record is not just a clinical document,

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it's a reimbursement document.

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It's something that is necessary in order for reimbursement

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and payment to happen, as well as continuity of care.

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And so the medical record becomes the linchpin, the thing

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that ties it all together.

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Crucial things in systems design is looking at the use

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of the different stakeholders

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and really mapping out what I would call

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that experience ecosystem.

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We really understand who is all

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Involved in this ecosystem

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and what their particular needs are, and we have to study

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and look at how they're using the object,

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the boundary object, the medical record in this instance,

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how they're using that so that we can design systems

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that better support that use.

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We run into a lot of trouble when we prioritize one area

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of use over another area of use.

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So if we're creating an electronic health record system

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that's primarily about reimbursement,

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then we might lose its usefulness as a clinical tool

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or we might use Lose its usefulness as a patient care tool

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or creating health literacy for the patient.

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We might create it unusable for the user,

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whoever that user might be.

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So it becomes a tricky balancing act around trying

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to create one system that can really tap into all

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of the needs of the different stakeholders

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and make something that supports this complex environment

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that we call healthcare.

Understanding Healthcare's Complex Ecosystem

00:00:00 - When we only look at one part of the ecosystem, we're only treating one part of the complex environment. That is, for instance, healthcare. If we're only looking at the patient, we're leaving out things like the caregiver, the clinician, the family member, the administrative staff. And if there's a breakdown in any one of those parts, we're gonna have a breakdown in how well the system performs for the patient. Patient, which, you know, obviously is the most important part of the process. But these other parts are important too. And if we don't pay attention to those,
00:00:34 - I'm a sociologist and a sociologist is trained to look at systems, both what we would call macro systems, the big level meso systems, the middle level and microsystems, the smaller level or the interactions that people have. And being a systems based thinker, I always like to think about those different levels. How we can go from what happens in the exam room, for instance, at the micro to what might happen in the hospital at a mezo, and then what happens overall in a national healthcare
00:01:03 - So just by nature, I'm primed, you could say, to look at these things at various levels. And by paying attention to those levels, we can deliver a better comprehensive experience for everyone involved. A boundary object you could think about as a thing that spans different kinds of spaces or what we in the business might call institutional domains. So if you think about a medical record, for instance, a medical record is primarily for the patient, right? But it's also for the doctor, it's for the clinician,
00:01:35 - the insurance company, it might also be for, researchers who are doing epidemiological research. So this one thing, the medical record needs to cut across all of these different spaces and be useful to all these different stakeholders in their own way. And so this becomes really difficult if you can think about it as how do we make a useful thing to everybody that has different purposes and different needs for this object? And so that's what we mean when
00:02:04 - It's a thing that spans spaces and institutional domains and needs to service a lot of different needs for a lot of different audiences. When I first started this research on medical records, I was primarily interested in the work of a profession called medical transcription, medical transcriptionist. And these are primarily women whose task it was to turn what a doctor dictated or said into a usable medical record. And so it wasn't just saying what a typing, what a doctor said. If they did that, you'd have a pretty unusable record.
00:02:37 - to make it usable, not just for the clinician, for the doctor, for the whoever is using the record for clinical care, but also potentially for the patient and also for the reimbursement agents, the coders, especially in the United States, how we mod, you know, how we run our medical system based off of coding different kinds of treatments in the medical record. And so I became Very fascinated with the work of this really underrepresented, under acknowledged group of women whose job it was, was

Understanding the Role of Medical Transcriptionists

00:03:09 - healthcare system, was set upon resided, independent upon. It's interesting because when I first started doing this research with some colleagues, I was told all the medical transcriptionists did was type what doctors said. And it became pretty clear pretty early on that they did much more than that. That you had a, this workforce that was essential, but really under acknowledge and underappreciated. So part of the job of, of me as a workplace ethnographer was
00:03:40 - understand their identity, their professional sense of self as an important part of the healthcare process. And so that became the primary element was to really appreciate the expertise, the knowledge, the workmanship that was involved in making this medical record usable so that healthcare could work. You know, the customer, the user, and the patient. All might be completely different people. So for instance, let's say you have an elderly parent,
00:04:10 - have elderly parents. The parent might be the patient when they go to a doctor's office, correct? They might not be the customer because the customer in a sense might be the insurance company, might be at least the United States Medicare, or it might be whoever is on, whoever has the insurance that the person who's the patient's using to receive care. The user might be the child who has to go online, find the information of the medical record,
00:04:43 - with the parent's care, and use the technological domain of the electronic health record or just use the paper record. So the user might be the child, the patient might be the parent, and the customer might be the federal government or whoever has the health insurance. So each of those areas can have a very different stakeholder that's involved in the process. absolutely. I mean, without the medical record, nothing happens. There's a saying in medical transcription
00:05:14 - if it isn't written down, it didn't happen. And we can say, we can extend that to say, if it isn't written down, you can't get reimbursed for, it's not what a doctor does in the United States that they get paid for. It's what's written down on the medical record. And so the medical record is not just a clinical document, it's a reimbursement document. It's something that is necessary in order for reimbursement and payment to happen, as well as continuity of care.
00:05:46 - that ties it all together. Crucial things in systems design is looking at the use of the different stakeholders and really mapping out what I would call that experience ecosystem. We really understand who is all Involved in this ecosystem and what their particular needs are, and we have to study and look at how they're using the object, the boundary object, the medical record in this instance, how they're using that so that we can design systems that better support that use. We run into a lot of trouble when we prioritize one area

Balancing Electronic Health Record System Usability

00:06:17 - So if we're creating an electronic health record system that's primarily about reimbursement, then we might lose its usefulness as a clinical tool or we might use Lose its usefulness as a patient care tool or creating health literacy for the patient. We might create it unusable for the user, whoever that user might be. So it becomes a tricky balancing act around trying to create one system that can really tap into all
00:06:52 - and make something that supports this complex environment that we call healthcare.

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