Health Information Management: Integrating Information Technology ...

HEALTH CARE WORK AND INFORMATION SYSTEMS 49
professionals who have the authority and credibility to depart from the standard
protocol without prior consultation.
An important aspect of health care work is the contingent and emergent
character of the evolution of patient trajectories. In the case of the neurological
ICU patient, the actual policy (few blood tests, no ECG, no x-ray) was directly
produced by the conversation between John and Agnes—it is unlikely that either
one of them had planned this particular approach in advance. Agnes responded to
John’s remark and the specific content of their exchange led to their
reinterpretation of the protocol. If Agnes had not run into John by accident, she
probably would just have routinely asked for the standard list of tests. This
phenomenon is typical of health care work: the management of patient
trajectories is not a matter of making detailed plans for action for individual
cases. The complexity of patient trajectories makes this impossible. The wide
range of considerations that may come up at any point and the great number of
parties involved in the interactions imply that each patient trajectory is best
understood as ‘an in-course accomplishment’ (Lynch 1985). It cannot be
anticipated how long a terminal patient is going to live, what the exact reaction
of the relatives will be like, or what the arrival of another emergency admission
will do to the workload. Especially in cases of long-term chronic disease, the
actual patient trajectory takes shape through the many ad hoc decisions and
improvised interventions of the patient and his or her caregivers.
Our description of health care work could be read as a critique: after all, it
appears to suggest that the work of health care professionals is not primarily
guided by a scientific logic. Our emphasis on the provisional and pragmatic
dimension of health care work could be interpreted as yet another sign of the
limited rational and scientific character of that kind of work. This, however,
would be a mistaken conclusion. The decision not to adhere as strictly as
possible to the ICU admission protocol in our case study above is not a sign of
irrational intervention. A protocol is just one tool that may contribute to a proper
coordination of patient trajectories. Expertise, protocols and intervention
strategies are but a few of the considerations that play a role simultaneously.
Amidst ringing phones, emergency admissions and daily meetings, physicians,
nurses and other health care professionals seek to manage patient trajectories by
assigning tasks to others, by making short-term decisions and by questioning
whether organizational routines and protocols should be followed or not. The
contingencies that shape patient trajectories and the ad hoc responses to such
situations are what health care work is all about. Concluding that its pragmatic
character and its intertwining of ‘social’ with ‘medical’ considerations would
stand in the way of the rational essence of that work is ‘very much like
complaining that if the walls of a building were only gotten out of the way one
could see better what was keeping the roof up’ (Garfinkel 1967). What is at stake
here is a fundamental feature of work in a vast array of contexts, ranging from
basic factory labour to sophisticated academic work.