Health Information Management: Integrating Information Technology ...

48 STARTING POINTS
trajectory (Strauss et al. 1985). A core feature of this work is that it is a social,
collective process. Only rarely do individual health care professionals determine
the management of a specific patient trajectory on their own: ‘how to intervene’
is decided in formal meetings, at random encounters in the hallway, and in the
continuous flow of phone conversations. Even in the case of an individually
operating general physician, a home care nurse or a medical specialist, the
intervention is decided in interaction with the patient and—through the patient
record, letters or immediate contacts—with colleagues and other care
professionals. Seldomly, a patient’s trajectory is decided on the basis of
individual contacts or consultations alone. In particular in the case of chronic or
complicated medical complaints, the course of the trajectory may constantly be
changed or adjusted from various sides. The final minutes of the terminal patient
described above take shape in part in the interaction between various nurses, the
ward physician, and the patient’s relatives.
The interactions continually cross professional boundaries. Also, not one of the
individuals involved has full control of how exactly one event is followed by the
next, or how, in other words, the trajectory unfolds. This is equally true of the
way the decision process is shaped in the first case study. The brief dialogue
between John, the nurse, and Agnes, the supervising physician, is characteristic
of the way in which health care professionals function in hospital departments.
John proposes to check the basics only, to which Agnes readily agrees, and she
takes his suggestion one step further by deciding to also cancel the ECG and the
x-ray. Frequently, decisions are the outcome of formal meetings, written
communications or brief verbal exchanges. As such, ‘decisions are collective
acts, not individual acts’ (Anspach 1993).
In these interactions, a broad range of considerations can play a role. The
management of patient trajectories is not only moulded by medical concerns:
trajectories and decisions ‘are shaped by the social context in which they are
made’ (ibid.). This seems evident in terminal cases; typically, in such situations
social considerations are given priority over medical ones. In order to make it
possible for the patient to die in a dignified manner, for instance, no new
infusions or other interventions were ordered. Yet it is important to underline
that concerns about the preferences or desires of the patient or the opinions of
relevant colleagues constitute an important component of health care work in
general, as is true of economic considerations or issues related to workload or
organizational priorities. Such considerations are not ‘secondary to’ or a ‘bias in’
the interventions of physicians and nurses: they are part and parcel of the work
of health care professionals. They are, then, constitutive of the patient trajectory,
as much as the medical/ nursing information and the professional decision
criteria. The suggestion of John, which resulted in a departure from the standard
admission protocol, can only be understood in terms of the need to save costs, a
concern for avoiding unnecessary work, or the consideration not to burden the
patient with inessential interventions. And the actions of Agnes and John can
only be explained in light of the fact that both are seen as experienced