Health Information Management: Integrating Information Technology ...

WAITING FOR GODOT 21
(Anonymous 1916)
Just like the College of Surgeons, the Dutch medical professional organization
was confronted with vast differences in reporting methods in Dutch hospitals. In
contrast to its American counterpart, however, it argued that the liberty of
hospitals and physicians should not be encroached upon. Consequently, it merely
issued a request to those involved to comply with minimal standards.
This episode from the early history of the paper record during the 1910s and
1920s illustrates that the construction and implementation of a technology
implies a transformation of the practice in which it is functioning. The patientoriented
record system made it necessary to hire new clerical personnel,
rearrange hospitals, and set up a new division of roles between physicians and
nursing staff. What at first seemed to be just a minor organizational effort at
improving medical reporting turned out to involve a far-reaching process that led
to large-scale organizational transformations, including changes in the tasks of
established professionals and even the invention of new professions. This
process, however, works its way in two directions: during the implementation
process, the technology is transformed as well. The juridical role that the patient
record acquired in the process caused a further institutionalization of record
keeping procedures; yet it also created a new mental reality among those
involved: the constant awareness that each note in the record might one day end
up on the desk of a lawyer or judge. Moreover, differences between the health
care systems of the United States and those of European countries caused the
reporting of medical data to develop along different lines. In the Netherlands, for
example, the position of the major medical professional organization contributed
to a situation in which, for the time being, the responsibility for record keeping
was left in the hands of individual physicians and individual organizations.
The history of the patient record can be characterized as a process of
negotiations, in which both the technology and the practices involved are
changed and become intertwined. In addition, the particular episode discussed
elucidates that the development of the patient record was not simply in the hands
of one actor. There were multiple driving forces at work that represented a
variety of interests. The actual shape of a technology’s developmental trajectory
is rarely predictable or linear. The American College of Surgeons was actively
engaged in the realization of patient-oriented records for two main reasons. First,
it could thus strengthen its hold on hospitals and second, it wanted to establish
accreditation standards so as to be able to distinguish ‘fellow surgeons’ from
insufficiently qualified physicians. However, the Hospital Standardization
Movement it initiated soon found other allies as well. The new medical record
professionals, hospital boards, scientists—each had its own stake in further
stimulating this standardization process. As a result, the technological
development gained momentum as well as acquired a specific character—one
that was different from the one envisioned by the College of Surgeons. For
instance, the Record Department’s ‘custodians’ began to check on the activities