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Home Page > 5 Case- Narrative Analysis of MiVIA



Design Lesson Plan: Angela Chen

Introduction: 

The economics pressure of increasing healthcare costs and great healthcare outcome are driving the search of new approaches to health management.  Currently, public policy is attaching importance to the role of consumers in managing their own health while partnership with healthcare providers.  Personal Health Records systems are one of the tools to improve health care through consumer empowerment.  There are quite a few Personal Health Records or health data exchange systems implemented in several cities or counties.  My case analysis will focus on the electronic Personal Health Records on the vulnerable and underserved population-the migrant and seasonal winery worker in Sonoma, California.  The Health Resources Service Administration defines medically underserved populations as those with “economic barriers, or cultural and/or linguistic access barriers to primary medical care services.”  The Advisory Commission on Consumer Protection and Quality in the Health Care Industry consider the vulnerable population are individual who are vulnerable to health care quality problems for one or more underlying reasons including financial circumstances, place of residence, health, age, functional status developmental status, ability to communicate effectively race, ethnicity, and gender (Chang et al, 2004).  The migrant workers often find it difficult to access health care, and even when they are successful, the care they receive is sporadic and fragmented as they move form job to job and community to community.  Due to this nature, migrant workers fall into the categories of vulnerable and underserved group; in addition, they are facing digital divide- has typically been used to describe decreased access to information technologies, particularly the Internet, for racial and ethnic minorities, persons with disabilities, rural populations, and those with low socioeconomic status. Governmental agencies and cooperative partnership are taking steps to close the gap of access to health care information and communication.  National, regional, state and medical center partnerships are evaluating the effects of information technology use on health and health care outcomes.  In order to minimize the barriers that underserved populations continues to face in accessing or using of health information, the Informatics has been identified a critical role in designing a health system that produces care that is safe, effective, patient centered, timely, efficient, and equitable, as well as a strategy for reducing health disparities in underserved populations.         

Background:

MiVIA, which means “my way” in Spanish, is an electronic Personal Health Record created by Community Health Resource & Development Center and is specially designed for the migrant and seasonal workers in Sonoma, California.  Migrant and seasonal farmworkers suffer disproportionately from undiagnosed and/or unattended chronic medical conditions, poor health outcomes, and increased health costs (duplication of services or tests) for their transient lifestyles.  As they move around the medical records, test results and care plans are usually left behind; thus created increased costs for an already overburdened healthcare system.  MiVIA offers a solution while the purpose of it is to store and download health information and make that information available to multiple doctors and clinics.  In sum, the goal of MiVIA is to prevent unneeded testing and repeat immunizations that delay treatment, crowd waiting rooms and waste taxpayers dollars.   In detail, a PHR makes it possible to store critical health information, such as diagnoses, medications, allergies, chronic conditions, treatment plans and test results- in an extremely compact, portable device that workers can easily take with them as they relocate.  The information MiVIA typically stores includes the patient’s medical history, name of doctors and other care providers, and a record of immunizations, hospital visits and any serious conditions.  MiVIA also provides the Service Wheel, which is an Internet portal that leads users to social services.  At security side, MiVIA seeks the balance access and security considerations.  Users, including patients, any health care providers, or advocates can download their information at any time, providing audit trails, secure messaging and provider entry portals.  Each PHR is password protected, using 128 bit encryption, and his HIPAA compliant besides the audit trails and secure messaging.  The MiVIA record is owned by the user or user’s legal representative while allowing user or user’s representative to authorize others to download their information at any time or to have the information downloaded by a healthcare provider.  No one, including the government, can have access to the information without user’s authorization.  Therefore, the fear that the information could be used to deport workers is unfounded.  Plus, federal laws prevent immigration officials from looking at medical health records or identification information.      

      There were 1, 092 MiVIA users since January 2005, with the word is spreading through the farmworker community that the service is safe, the number hit impressively to 41,773 at June 2005.  The program proved popular as MiVIA service is getting serious interest from groups in the Napa Valley, the Central Valley, the Pacific Northwest and Texas.      

Learning Objective:

Our learning object is to understand how the narratives can be used to assess online health service.  With an increasing focus on developing a theoretical understanding of everyday life information behaviors, researchers need to consider the appropriateness of the methods and techniques utilized in empirical research in this area.  The narrative and episodic interviewing techniques are qualitative research methods that sustain a person-centered paradigm of human information behavior and that provide a particularly useful methodological framework for studies of everyday life information-seeking behavior.  According to Bates, narrative and episodic interviews are best suited to qualitative research and in-depth studies involving a relatively small number of study participants when interviews can be conducted in the interviewees own natural (everyday) environment and where the purpose of the study is to understand the research topic from the perspective of the study participants.  Besides Bates’s study, there are similar studies predominantly emphasize the need to understand everyday information behavior from a person-centered perspective and also reflect a shift towards and increased use of qualitative research methods (Bates, 2003.)   Since using MiVIA is considered as an everyday life information-seeking behavior, narrative approach would be one of the effective tools to assess MiVIA- an online health service. First, according to Jovchelovitch and Bauer, narrative interview is described as a qualitative research method used to stimulate interviewees or study participants to express their experiences and view of the topic being studied through telling stories or narratives.  It is believed that the perspective of the interviewee is best revealed in stories where the informant is using his or her own spontaneous language in the narration of events (Jovchelovitch and Bauer, 2000.)  A narrative interview takes the form of a conversation and participants related their experiences, bringing in whatever they consider to be relevant.  The technique of narrative interviewing stimulates storytelling and encourages interviewees to describe an event as they saw it, in their own language, using their own terms of reference, and emphasizing actions or participant which they regard as being significant.  In addition, how study participants report and narrate episodes from their everyday life reflects the factors which influence their behavior.  Because the interviewees will not be restrained by a specific form of answers but an open-end stories he/her wants to talk about, it is believed that the use of a narrative approach in social inquiry can overcome barriers that can arise when collecting data from people from relatively disadvantaged backgrounds who may lack educational experience and language or literacy competencies (Bates, 2003.)  Particularly, it is assumed that narrations preserve perspectives of the interviewees in a more genuine form.  As a non-native English speaker, I totally agree with the notion that narrative interview would create a more relax-typed of conversation so that the interviewees who lack language or literacy competencies tend to open up and disclose more details of his/her perspectives.  Furthermore, storytelling provides researcher with an insight into how the study participants make sense of their everyday lives in relation to the overall research topic. The following are some sample questions that could be asked to interviewees to (1) remember particular episodes and recount these to the interviewer, and (2) encourage them to describe particularly meaningful or relevant experiences.

·         Has there been an occasion where you found out something particularly helpful from a friend or family member?  Can you think of a particularly relevant experience where you needed some kind of health information? (1);

·         Could you please tell me about that situation?  Could you please tell me about a situation where you found that you were particularly helped by some information? (2).

       While reading the techniques of narrative interview, the following three notions are distinguished to me.  First, the closing stage of the interview involves evaluation and small talk and facilitates feedback from the interviewee.  It can be helpful to the overall depth of the interview to round-up with some small-talk as this more informal atmosphere can lead the participant to further reveal or substantiate previous comments.  The second one is that the detailed transcription should include any distinguishing features of the conversation (e.g., long pauses or laughter) and features of speech such as emphasis, pitch, and any other means used to indicate the relative importance of speech as these reveal the emotion of the narrator and how they perceive particular events or experiences.  The last one is that the closing phase of the interview that allows the interviewee to evaluate the interview should give room for the study participant and interviewer to discuss the interviewer’s interpretation of the interview which the interviewee can then confirm, correct or reject (Bates, 2003.)  

      There are three ways to analyze the data collected through narrative interviews (Bates, 2003.):

·         The sequential and temporal structure of narratives (to understand the linear sequencing of actions which comprise the story);

·         The focus, or perspective (orientation) of the narrative (to understand the views and perceptions of the interviewee and how they evaluated the situation); and

·         How the interviewee tells or reports the narratives or episodes, which includes their use of language, tone, etc. 

        The six common elements, according to Labov’s structural approach, which any fully formed narrative should contain, are as follows (Bates, 2003.)  :

·         An abstract (a summary of what the narrative is concerned with);

·         Orientation (context-time, place, situation, participants);

·         Complication action (sequence of events);

·         Evaluation (perspective on the event/actions, attitude, significance of the even for narrator);

·         Resolution (outcome);

·         And code (related the narrative even back to the present).

Analysis:

  What to do to achieve my learning objective?  What kind of the method I will be using?  To accomplish this learning object we will be…….How narratives would help to understand the effectiveness of MiVIA/ electronic personal health record used by migrant workers. 

 In order to learn if the narratives can be used to assess online health service, a semi-structured interview consisted of 10-15 participants will be conducted in terms of evaluating MiVIA including the aspects of usability, access, motivation, and health outcomes.    

Evaluation and Extension: 

How one would know if we achieve that learning objective.  In order to ensureThe learning objective will be achieved by ……How would I test u to see if u achieve the LO. What u gonna ask them if they learn after they read ur paper.For example, what is Narrative inquiry, narrative participation.  What would u expect the to learn.

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