Electronic Patient Records (EPRs) are in widespread use in UK general practice. Although often taken-for-granted by clinicians, managers, administrators and patients, there is limited understanding of how EPRs shape care processes and healthcare interactions in this setting. The EPR is ubiquitous in practice, but its social impact remains under-researched. In this thesis I present a novel approach to examining the role of the EPR, which draws on ethnography and discourse analysis. My work is based on eight months of ethnographic observation in clinical and administrative areas of two general practices. This included observation of clinical consultations, with videorecording of the interpersonal interaction and contemporaneous screen capture of the EPR. This opens up the ‘EPR-in-use’ to detailed scrutiny. In my analysis, which draws particularly on the theoretical work of Goffman and Bakhtin, I pay close attention to the detail of local action and interaction, whilst maintaining sensitivity to the wider context of the general practice organisation. This makes an original contribution to the emerging field of linguistic ethnography. My analysis shows that the EPR contributes to shaping and regimenting interactions and care practices in profound ways, both within the consultation and more widely in general practice organisations. It creates new opportunities, but also creates new demands and tensions. In particular, it sharpens the tension between different ways of framing the patient – the patient as ‘individual’ and the patient as ‘one of a population’ – the latter a more institutional version of the patient. This creates what I have called a ‘dilemma of attention’ for clinicians engaged in patient care. I show ways in which the EPR contributes to the bureaucratisation of care, the construction and circulation of authority within and beyond the consultation, and the production of new notions of patienthood and professional habitus in contemporary general practice.

L’état de santé de la population Française est parmi l’un des meilleurs au monde. Cependant, les inégalités caractérisent notre système de santé. Les dernières modifications du système de santé peuvent les accentuer. Ainsi, la T2A, nouveau mode de tarification, doit être associé à un système de régulation. Pour cela, le modèle RAWP apporte une grille d’analyse pertinente. Tout d’abord, au niveau local, une expérience d’analyse des besoins, de l’utilisation et de l’offre de soins d’une population d’un territoire permet de montrer que l’on peut détecter des problèmes d’accès aux soins et réorganiser l’offre. L’expérience de 2006 à 2011 de la Région Nord-Pas-de-Calais propose une première approche de définition de cibles d’activité en fonction des besoins, mais les volumes de soins augmentent. Ensuite, l’appui à la conception d’une méthode nationale de la régulation des volumes des régions de France basée sur une analyse comparative des consommations de soins redressées par âge par sexe et corrigées de la mortalité est un des résultats de cette thèse. Cela a permis de concevoir un modèle systémique de régulation des soins national, régional et local. Enfin, pour ouvrir la réflexion à l’échelle des territoires de santé, une typologie des territoires de santé de France a été réalisée à partir des principaux facteurs du modèle (état de santé, utilisation et offre de soins) et des facteurs socioéconomiques liés à la population, et ceux liées au parcours de soins. L’analyse montre qu’il y a trois grands types de territoires de santé et qu’il faut donc adapter la stratégie de régulation: « Attractifs-surproducteurs », « tout curatifs » et « dépendants sous-consommateurs ». / The health of the French population is among the best in the world. However, inequalities characterize our health system. The latest amendments to the health care system may increase. Thus, DGRs, new pricing method should be associated with a control system. For this, the RAWP model provides useful analytic grid. First, at the local level, an experiment needs analysis, use and provision of care for a population of a territory allows us to show that we can detect problems of access care and reorganize supply. Experience from 2006 to 2011 the Nord-Pas-de-Calais region offers a first approach to target setting activities as needed, but the volume of care increases. Second, support for the development of a national approach to the volume control regions of France based on a comparative analysis of healthcare consumption adjusted by age and sex-adjusted mortality is one of the results of this thesis. This helped to develop a systemic model of regulation of national, regional and local care.Finally, to open the discussion to the level of health territories, a typology of health territories of France was carried from the main factors in the model (health status, use and provision of care) and socioeconomic factors the population, and those related to the care pathway. The analysis shows that there are three types of areas of health and therefore to adapt the control strategy: "Attractive-overproducing", "all healing" and "sub-dependent consumers."

No description available.

No description available.

No description available.

No description available.

No description available.

No description available.

No description available.

No description available.