Ethnotale: Up Close and Personal

It’s not our imagination—observing health care provider/patient interactions was simpler when Ethnographic Research, Inc. opened its doors in 2001. This was before HIPAA’s Privacy Rule, its Security Rule, and its HITECH Rule all went into effect, and although these are all important and necessary, the required processes and paperwork can be intimidating for our clients, for the HCPs we meet, and for us too.

This article will highlight some of the challenges involved in doing observational research in health care spaces and provide some insights into how we have adapted and continue to do work in these settings. Whether you’re a researcher or you are thinking about hiring ethnographers to observe health care in action, we hope these provide you with some food for thought.

1.    Getting your foot in the door is difficult.

HIPAA regulations can make recruiting an enormous challenge; the HCPs have to trust that we, complete strangers, will treat their patient data as sacredly as they do. Even without HIPAA, HCPs would likely be uncomfortable with the idea of folks showing up at their work with cameras. That’s true of any workplace, particularly customer-facing workplaces. By letting us in, they’re vouching for us and that’s a risk for them.

Compounding the challenge are gatekeepers, usually office managers, whose job it is to filter the calls that make it to the decision-makers, usually physicians. This is another uphill battle, a kind of modern-day gauntlet. Finally, these are busy places, and they simply don’t have time for us. We have to convince them that we’ll be as little of a bother as possible and that their practice can function almost as efficiently as it normally does.

What is the secret sauce to recruiting health care providers? Persistence and an indestructible will. Also, although it isn’t always practical, we have found that recruiting in-person can go a long way in showing sincerity and resolve. When dealing with a tight timeline, getting the help of a third party recruiter can also be a viable option.

2.    Incentives can be complicated.

HIPAA isn’t the only regulatory barrier we contend with doing healthcare research. There’s also the Sunshine Act, and although it sounds very pleasant, it can make incentives for participants a little tricky. The Physicians Payments Sunshine Act is anti-bribery legislation designed to keep pharmaceutical companies and others from incentivizing physicians to prescribe their products. It seems totally removed from ethnography, but we have to make sure that any incentives we pay health care providers don’t top fair market value.

As a result, our incentives are never so much that they will really drive HCPs’ participation. So, again, we need to make sure that participating in our research causes as little inconvenience as possible and that their time with us is, if not loads of fun, at least mildly interesting.

3.    Be careful what data you collect.

Once we’re in the door, keeping the data we collect safe and sound is always our top priority. It is essential for everyone involved: the patient, the practice we are observing, our client, and our company. The first step is to only collect patient data when necessary. This can be hard if we’re videotaping the research. Here, video’s greatest strength, that it records everything, becomes its biggest weakness, that it records everything. Like a vacuum cleaner inhales random coins, hairpins, and the occasional sock, the camera is going to record off-camera conversations, random patients walking in front of the camera, and computer screens displaying patient data. We minimize this by:

• Not recording in hallways and waiting rooms whenever possible (where other patients tend to roam).
• Being far enough away from computer screens that they aren’t legible on the recording.
• Only having the camera on and recording when necessary. 
• Being careful not to record patient data unnecessarily (e.g., if we don’t really need to record a patient’s face, we don’t record their faces).

Also, we get informed consent from anyone whose data we collect so they know what we’re collecting and how it is going to be used.

4.    Be careful how you store and transmit your collected data.

After we’re done with data collection, that data needs to stay safe. It is important to have solid security policies ahead of time—multiple layers of protection in place to prevent unauthorized access. It helps to enlist a professional with a background in information security to make sure that everything is airtight.

5.    You may need to take a few extra steps to protect your clients.

All of our clients have different needs when it comes to regulatory compliance, and it is best to discuss their needs from the start. Again, we make sure our planned incentive won’t cause our client any unnecessary hassle. We also see whether our client needs the study to be blinded or double-blinded. Like other industries, it is common for health care clients to want their identity withheld from participants. That might make recruiting more difficult, but it is fairly routine. If they need the research to be double-blinded, for whatever reason, we need to take a few additional steps. We will need to remove names and other information that may identify the practices in anything we give to the client, including initial sample spreadsheets and final reporting. We’ll also need to mask all of the video in the video deliverable. This includes participant faces, ID tags, and any paperwork with the practice’s name on it—it is always surprising how many identifiers need blurring. Understanding a client’s needs from the start is extremely helpful in preventing bumps down the road as the research unfolds.

So those are five things to be thinking about when undertaking in-context research in health care settings. It can be a challenge for sure, but there are ways you can navigate the challenges and get the job done. The insights possible from seeing health care providers in action are very much worth the effort.