Healthcare Information Technology’s Relativity Challenges: Distortions Created by Patients’ Physical Reality versus Clinicians’ Mental Models and Healthcare Electronic Records

Abstract

This paper examines the inconsistencies or distortions among three medical realities: patients’ physical reality (as reflected in clinical observations, lab reports, and other “objective” measures); clinicians’ mental models of patients’ conditions; and how that information is represented in the patient’s electronic chart—the electronic health record (EHR). We created a typology based on the semiotic triangle of “symbol,” “thought or reference,” and “referent.” Differing perspectives (or realities) are illustrated with examples from our observations in hospitals and medical facilities, interviews with clinicians, IT personnel and IT vendors, computer logs, and error reports. Scenarios/models enumerate how the differing perspectives can misalign to produce distortions in comprehension and treatment. These are categorized according to an emergent typology derived from the cases themselves and refined based on insights gained from the literature on interactive sociotechnical systems analysis, decision support science, and human-computer interaction. The scenarios reflect the misalignment between patients’ physical realities, clinicians’ mental models, and EHRs, identifying five types of misrepresentation: IT data too narrowly focused; IT data too broadly focused; EHRs miss critical reality; data multiplicities—perhaps contradictory or confusing; distortions from data reflected back and forth across users, sensors, and others. Conclusion: With humans, there is a physical reality and actors’ mental models of that reality. In healthcare, there is another player: the EHR/healthcare IT, which implicitly and explicitly reflects many mental models, facets of reality, and measures thereof that vary in reliability and consistency. EHRs are both microcosms and shapers of medical care.