My research seeks to investigate the historic relationship between doctors and obstetric patients during the rise of Electronic Health Records (EHR) in the United States and Armenia, to more fully understand how technology affects relationships in the present day. The geographically, politically, and technologically contrasting contexts of the US and Armenia offer the opportunity for rich comparison and recognition of both the advantages and limitations of digital presence in the exam room. To better grasp these potential implications, this research will explore:

1. What has historically been the relationship of obstetric patient medicalization in both Armenia and the United States? 
2. In recent history, has the rise of EHR impacted these relationships and subsequent health outcomes, specifically, patient experience of birth, rates of cesarean sections, and maternal and infant mortality rates?
3. To what extent do these histories inform current demand for healthcare data, use of EHR or automation, and overall patient care? 

Armenia is an ideal point of contrast to the United States’s highly technological medical landscape. Armenia’s publicly-funded health system costs the state roughly 12% of GDP, much less than the 20% seen in the US. Moreover, the Armenian system has a low degree of digitization in its health care infrastructure (World Bank Health Expenditure, 2023). The value of Armenia as a case study is bolstered by its post-soviet identity. The 1990s, and the dissolution of the soviet block, triggered a major reformulation of its social and political infrastructure. The US, meanwhile, was undergoing a very different transformation, as the government invested millions of dollars into the digitisation of medical records.

Research Context, Questions, and Significance: 

Harvard Medical School professor Beth Lown likens the use of digital tablets and laptops during patient visits to the presence of an additional person, demonstrating that such technology introduces a new dynamic for doctors and patients, necessitating negotiation by each (Carr, 102). This rise in technologically-mediated interactions is just one result of data work, the time spent producing data through documentation (Hoeyer, Data Paradoxes, 92). Doctors have become significantly more dependent on technology because there has been an exponential increase in demand for healthcare data (Hoeyer, Health in Data Spaces, 1). One example is the proposed European Health Data Space (EHDS), a “technical infrastructure operating on a new legal mandate to make health data accessible for citizens, clinicians, governmental actors, and companies across the entire [European] Union” (Hoeyer, “Health in Data Spaces,” 2). Many countries operate under legislation or incentive programs that demand the collection and reporting of this data, and while there is certainly merit for security, research, and public health efforts, the use of technology required for data gathering may have negative implications for patient care. One example would be EHR’s prompting direct data entry during a patient visit.

Data entry that occurs during doctor-patient interactions throughout consultations can have a significant impact on patient care. Following questions that are prompted by EHR systems may distract from or interrupt patient dialogue. Lisa Sanders, physician and Associate Professor of Medicine at Yale, cites that during consultations, only two percent of patients are able to recount their story in full without being interrupted by their doctor and that this is an increasingly common occurrence. One study Sanders presents demonstrates that while 70% of patients will provide diagnostic tip-offs when able to recount their stories in-full, doctors frequently interrupt them, limiting their ability to give doctors with critical information. Further, during patient’s initial descriptions of symptoms, over 75% of the time doctors will interrupt patients after an average of just 16 seconds (Sanders, Every Patient Tells a Story, 7 and 56). Interrupting patients not only limits doctors’ ability to acquire critical information, it can also impact doctor-patient relationships, which have a direct and indirect impact on patient care, including trust, knowledge, regard, and loyalty (Chipidza, Wallwork, and Stern, 1). Within the broader context of the rapid emergence of AI, it is imperative to study possible implications of continued digital integrations.

The use of EHR systems competing for physician attention is further exacerbated by the biomedical model of health and disease. One key component  of the biomedical model is to treat the disease rather than the patient (Kaczmarek, 121; David Stuckler; Randall Packard; Aro Velmet; Foucault, The Birth of the Clinic, 55). Under this approach, doctors tend to prioritize the short-term resolution of symptoms over the development of deeper relationships. This commonly results in doctors failing to listen to patients describe their symptoms and jumping to conclusions by guessing diagnoses. Abundant literature demonstrates that connection and intimacy are among the most important aspects of effective medicine, especially when it comes to patient outcomes (Hellin, 450-4; Kaba and Sooriakumaran, 58; Chipidaz, Wallwork, and Stern, 1). Although technology can highlight the gaps in the biomedical model, it can also obscure those gaps. Rarely does it solve them.

Background and Credentials:

I am prepared to explore the contemporary development of medical technology in the US and Armenia as I have a professional, educational, and personal relationship to the research at hand. 

Professionally, I have worked in two different private medical practices, lending itself to a greater understanding of how technology is used practically in the US. Although I have worked in a variety of roles for these practices, one of the most pertinent examples is my current work on researching and selecting our new Electronic Health Record (EHR) System. The EHR dictates much of how the practice is run from project management to billing to clinical. One priority for developers, administrators, and clinicians is AI. Seeing the rapid development of these products, even in a relatively brief period, shows the need for further research into how these types of technology will impact doctor-patient interactions. 

Academically, I have had a long-standing interest in this intersection of technology and medicine. I completed similar research during my honors undergraduate thesis on algorithmic medical software, which sought to challenge the notion that more automation and technology in medicine leads to improvement in patient outcomes. I developed an interest in this topic while conducting research for a two-year grant project on algorithmic awareness. The grant project focused heavily on creating transparency in algorithms through both product design and interdisciplinary education, teaching people that algorithms are human constructs, instead of neutral, mathematical black boxes. My graduate studies in the History of Science, Medicine, and Technology at the University of Oxford provides further interdisciplinary grounding for the successful pursuit of this research. Over the course of my two year masters program, I honed my skills in contextualized analysis, understanding of global public health, historical methodologies, and critical thinking. Applying these to the exploration of contemporary issues in a variety of academic coursework, Oxford catalyzed the development of my independent research skills. For my master’s dissertation, I was researching the history of genetic engineering when I came across the large gender-biased sex selection that was happening in Armenian, only second to China per capita. 

I decided to become a Birthright participant where I could volunteer at the International Center for Human Development (ICHD) over the course of the four months I lived in Yerevan, a turning point in my life. The ICHD worked closely with the United Nations on the sex-biased gender selection and as I finished my Master’s Degree, I knew I wanted to incorporate Armenia into my PhD work. I began volunteering with the Michel Odent Mother (MOM) Center as a consultant. The MOM center is an organization that aims to provide holistic, evidence-based care for women in Armenia throughout pregnancy and postpartum. I led the development and publication of an official website, aided in research and educational content creation, and currently collaborate on drafting and editing grant proposals. Joining the MOM Center team only made me more certain of my decision to orient my professional life around Armenia. I aim to continue and expand this work as it relates to my PhD studies on technology within medical settings and the subsequent effect on obstetric patients. I believe this work will create positive changes for both Armenian and the US. I could not have imagined that going to Armenia for those four months would have not only altered my career, but my whole life. Not only did Birthright help me discover this professional interest, but personally, the Armenian community embraced me with open arms. I want to be fluent in Armenian, live in the country again, and give back as much as I can.

Research Methods, Project Plan, and Timetable: 

This project consists of two interrelated analyses: an investigation of the history and contemporary construction of US and Armenian healthcare systems and the types of intensive data sourcing they adhere to; along with the resulting experiences of obstetric patients and their doctors in the exam room. In both contexts, the project will focus on obstetric patients as a way to discern the doctor-patient relationship more longitudinally, over the prenatal, birthing, and postpartum period. 

The PhD will entail historical research and in-depth analysis of the rise of EHR in both the US and Armenia through government funding, policy requirements, and practice trends. In tandem, it will require an analysis of obstetric health outcomes in order to draw together qualitative tendencies, how patients anecdotally report the impact of technology in the exam room, and quantitative understanding, rates of cesarean sections, and maternal and infant mortality rates. This will provide the necessary context for informed comparison.

UCLA’s History Department is the ideal context for this project and the further development of my experience and training. In particular, I will be working with professors Elizabeth O’Brien and Soraya de Chadarevian faculty in the Department’s program in the History of Science, Technology, and Medicine. Both professors provide a range of content and methodologically-based feedback, especially as having to do with reproductive healthcare and modern bioscience. UCLA’s resources could not be a better fit for this project, as the university is home to the Promise Armenian Institute, the Armenian Language and Culture Program, and the DataX initiative for critical data studies. UCLA also boasts robust academic connections with the Cedars Sinai hospital and faculty. 

I propose a six year PhD with two years of coursework, one year of prospectus and exams, one year of research, and two years of writing up research results. These initial years of coursework to help ground and make adjustments to the proposal. The prospectus year will allow for focused examination of the history of EHR and other analog forms of data entry in the US and Armenia, forming a robust literature review and offering qualitative information which may inform subsequent research. This will advise the next part of the analysis which will be conducted during the research year. This investigation and analysis will cover both Armenian and US obstetric health outcomes. There are a variety of anonymized, open-source health data platforms available through the World Health Organization’s Maternal, Newborn, Child, and Adolescent Health and Aging data portal. These will inform the medicalization of obstetric patients. The formal writing and conclusions on the comparative work will take place during the final two years.

I am aware that Huys Foundation is granting the scholarship to me with the anticipation of my good faith pursuit and implementation of the projects and undertakings described in this letter, to which I hereby commit.