Health Information Management: Integrating Information Technology ...

HEALTH CARE WORK AND INFORMATION SYSTEMS 51
provide a mirror of medical work: they are tools used in doing the work. Patient
records fulfil two, closely intertwined functions. First of all, they accumulate the
data gathered during the course of a patient trajectory, resulting in the powerful
‘external memory’ that a paper file provides. The progress notes, written down in
chronological order by the professionals while they circulate through the shifts,
afford the experienced reader a fast and efficient overview of the central key
developments, actions and problems. Likewise, blood test results are
accumulated in tables (generated by laboratory computers, or filled in by the
ward secretary) that allow the reader to overview the patterns of increase and
decrease in values through time, and to compare these fluctuations with the
fluctuations apparent in other (blood) test results.
The record’s accumulation function consists of two elements. First of all, it is
obvious that the record is the place where data are gathered (where the data
elements ‘accumulate’). Doctors, ward secretaries and nurses constantly write in
the record, or paste notes or computer prints in it. Second, and less immediately
obvious, the way the record organizes these data elements is important. The table
with its built-in ease of comparison, and the progress form with its built-in
chronology and standard headings add structure to the data entered: the data are
put in a specific historical sequence, or in a specific context with other relevant
blood test results. By collecting the data in this way, by providing for this
specific sequence and context, the record’s form enhances the information
content of these data: the blood test result becomes part and parcel of a whole
array of data whose overall evolution is vastly more informative than each
individual measurement. In pre-structured intake forms, for example, the pre-set
headings of the intake form— ‘complaints’, ‘history’, ‘objective findings’,
‘conclusion’ and ‘policy’ —suggest the classic reasoning process with which a
doctor moves from ‘patient problem’ to ‘action plan’. Yet the order in which
professionals enter bits and pieces of information on the form generally does not
follow the temporal sequence suggested by the form. Part of the professional’s
skill is to translate the patient’s stories and his actions into this neatly structured
reasoning process, leading from ‘complaints’ through ‘objective findings’ to
‘policy’. When such a form is re-read later, this implied and familiar reasoning
process structures and speeds up the reading process, and the isolated data entries
are interpreted in this framework. Even the paper forms in use in most current
health care practices, then, can be said to process data. By structuring data entry,
and by placing data elements in specific contexts and sequences, tables, progress
forms and intake sheets make an important step in the transformation of the ‘raw
data’ that is entered into ‘information’.
In addition, through structuring and sequencing the work of professionals,
PCISs coordinate activities and events at various locations and times. Standard
headings on the progress notes structure the questions that physicians ask and the
examinations that they perform, and make the notes of doctor A comparable to
any other doctor using this form. Likewise, structured forms that are used by
several people, at different moments (such as order-forms, checklists and so