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IMPLEMENTING INFORMATION SYSTEMS 175 results, medication and so forth. The IS professionals and specialists had designed this record to facilitate their research: in this way, the structured information they required for their clinical investigations could be drawn directly from the databases of the patient record. For this purpose, the system functioned well: in this sense, the system was successful. In the everyday processes of outpatient care, however, the system appeared to be less functional. Many physicians complained that the system was too ‘rigid’ to capture the essence of a patient’s visit. The list of coded complaints, pressures, examination results and so forth was very useful to track some overall parameters—yet it could not capture that the core reason of the patient’s visit was his increased anxiety about his hypertension, for example, triggered by the recent death of his father. To overcome this limitation, many physicians started to use the one small free text section that the system had (‘conclusion’) as a field to enter such information. This resulted in a some what awkward use of the system, with physicians maximally using the limited amount of text they could put in this small field, and having this lower right corner of one of the screens function as the central focus during patient visits. From the perspective of the original aims of the system described in this case vignette, generating ‘good research data’, the developments described could be seen as a problem. The one field that generated unstructured data that were almost impossible to aggregate was heavily used—often at the expense of the more structured fields. When framed as such, an appropriate response might be to try to eliminate this unstructured usage, and to attempt to structure this field as well, or restrict its utilization. A more creative response to this unplanned use, one that would be sensitive to the multiple and changing viewpoints that characterize any implementation, would be to make this field more readily accessible and enlarge it. The structured items could be regrouped around this field so that the required back-and-forthing between the fields would be designed to facilitate the evolved usage as much as possible. In this way, a compromise between different demands would be optimized, and a synergy between the computer’s aggregating and ordering powers and the physician’s recording routines would be carefully crafted. The transformation of success criteria, the resetting of what it is the system aims to do during the very process of implementing the system, characterizes larger scale examples just as much—or even more—than this small scale example. This is what happened in the order-entry system implementation project described by Massaro: once it was realized that cost-savings were not going to be immediate, the overall goals of the project slowly changed. One can introduce a PCIS to reduce administrative costs, and find that the increase in administrative efficiency is paralleled by an increase in the amount of information required by external parties. System requirements evolve in and through the process of learning from unexpected workarounds and unforeseen usage of the IS
176 STRATEGY, IMPLEMENTATION AND EVALUATION (Hartswood et al. 2000). The following two case vignettes illustrate this phenomenon. CASE VIGNETTE A PCIS is a double edged sword for health care professionals: it may facilitate and support their work, but it often does so through importing novel constraints to their work, and facilitating the scrutiny of their work for outsiders. In the case of four US order-entry using hospitals, the use of carepaths gave nurses both more autonomy and less. They received less orders that were difficult to decipher or interpret, and could create their own order sets, yet they regretted the loss of subtle influence that they used to have in helping doctors formulate orders. In such situations, one often does not know how care professionals will react: for young interns, the possession of ‘individual’ order sets gave an unexpected sense of ‘control and even pride’. Such reactions cannot be predicted, yet are key: when carefully nurtured and acted upon, they can help further the creation of truly powerful PCIS (Ash et al. 2003). CASE VIGNETTE In an increasing number of hospitals in the Netherlands, clinical workstations are being placed where the physician can gain access to all the patient information present in the Hospital <strong>Information</strong> System. The systems do not support data entry, but the data retrieval is well designed, using a Windowsbased graphical user-interface, with many visual clues indicating what information is present and all this information just a few mouse-clicks away. One may criticize this system for its lack of data entry capacities, but that would overlook the phenomenon that it is in fact the very presence of this read-only system that generates a new ‘need’. Whereas in most of these hospitals, ‘computers’ were low on these physicians’ priority list, the coming of these workstations has sparked their interest. It is the very confrontation with its potential capacities that have turned the physicians into fervent supporters of a more aggressive PCIS strategy. Radical redesign is doomed to fail, to destroy much tacit knowledge, and to produce massive organizational upheaval and chaos. A much wiser approach is to learn from the embedded wisdom and already present synergies between work and (often paper-based) tools in existing working practices, and to work from there. This does not mean that one can or should not envision radical changes in work practices—this is not a plea against ambition! It does mean, however, that starting from scratch may be a useful thought experiment, but it is not a wise implementation strategy. It means, also, that we should carefully reconsider what paper-based information technologies do do well—their simplicity and robustness, for example, or their unsurpassed efficacy in small-group
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Health Information Management In al
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Health Information Management Integ
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Contents List of illustrations vii
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Illustrations FIGURES 3.1 Medicatio
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Contributors Marc Berg is a physici
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Series preface In almost all Wester
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Acknowledgements I would like to th
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Chapter 1 Introduction In all Weste
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INTRODUCTION 3 touch upon the deplo
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INTRODUCTION 5 can draw upon to mai
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INTRODUCTION 7 Physician Order Entr
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Part I Starting points Understandin
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WAITING FOR GODOT 11 KEY TERMS ■
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WAITING FOR GODOT 13 Netherlands an
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WAITING FOR GODOT 15 facts to show
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WAITING FOR GODOT 17 (Lewinski-Corw
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WAITING FOR GODOT 19 In most cases,
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WAITING FOR GODOT 21 (Anonymous 191
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WAITING FOR GODOT 23 Because of the
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WAITING FOR GODOT 25 they simply sa
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WAITING FOR GODOT 27 expected. Stil
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WAITING FOR GODOT 29 organize their
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WAITING FOR GODOT 31 performance in
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WAITING FOR GODOT 33 different HIS
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WAITING FOR GODOT 35 CONCLUSION: TH
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WAITING FOR GODOT 37 assumption tha
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WAITING FOR GODOT 39 Anonymous (191
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WAITING FOR GODOT 41 Berg, M. (1997
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Chapter 3 Health care work and pati
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HEALTH CARE WORK AND INFORMATION SY
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THE CONTEXTUAL NATURE OF INFORMATIO
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Chapter 5 Meeting the challenge Int
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STARTING POINTS 81 ‘gender, race,
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STARTING POINTS 83 Now, imagine an
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STARTING POINTS 85 organization,
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STARTING POINTS 87 Figure 5.2 Incre
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STARTING POINTS 89 already overflow
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STARTING POINTS 91 responsibilities
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STARTING POINTS 93 answer the quest
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STARTING POINTS 95 Kohn, L.T., J.M.
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Chapter 6 Designing interactions En
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DESIGNING INTERACTIONS 99 the way t
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DESIGNING INTERACTIONS 101 1 Identi
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DESIGNING INTERACTIONS 103 the deve
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DESIGNING INTERACTIONS 105 communic
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DESIGNING INTERACTIONS 107 Figure 6
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DESIGNING INTERACTIONS 109 ■ Figu
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DESIGNING INTERACTIONS 111 measurem
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DESIGNING INTERACTIONS 117 Covell D
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Part II Information strategy, imple
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INFORMATION STRATEGY: AN INTRODUCTI
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INFORMATION STRATEGY: AN INTRODUCTI
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INDEX 225 satisfaction 176 patient
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INDEX 227 support 164 technology de
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