Health Information Management: Integrating Information Technology ...

52 STARTING POINTS
forth), help to link their activities without the need for ‘face-to-face’ or real-time
interaction.
These forms link their worktasks by making clear who is responsible for what
and when, and by indicating when one actor has done something and when
another’s action is requested. Rather than having to arrange by him/herself that a
series of examinations (blood tests, x-rays) is performed on a patient, a doctor
can simply write these requests on examination-request forms. More often than
not, these forms not only play a vital role in getting the right request to the right
department (and getting the result back to the right patient!): by providing
automatic copies (already carrying the appropriate codes) for the financial
departments, the doctors’ work is automatically coordinated with billing
activities as well. Through devices as simple as check lists and structured forms,
then, doctors’ activities are coordinated with each other, with other health care
professionals and with supporting services without the need for any explicit
coordination work by any of these actors.
The patient record is a ‘reiterative, cumulative manuscript’ (Hunter 1991):
medical professionals constantly produce new summaries of their progression
reports, in which they condense the details of the previous trajectory in a few,
brief sentences. These sentences follow the standard narrative patterns as well.
From the perspective of the current situation, they represent the relevant
elements of the pre-history in a logical sequence. A series of blood pressure
measurements is summarized as ‘stable blood pressure’, the complex situation of
Mrs. Meijer is concluded by prescribing Seresta and more Seroxat, and the brief
conversation between John and Agnes on their handling of the protocol will
never end up explicitly in the patient record at all. Later on, such summaries,
conclusions and silences are condensed once more in new letters and notes,
whereby the recorded patient trajectory is rearranged on the basis of the new
situation.
These observations seem to underscore Bleich’s harsh criticism of the status
of patient records: medical professionals leave out details, rewrite events, and
rearrange linear chronologies. This criticism, however, starts from the
assumption that patient records must be carbon copies of patient trajectories. Yet
when the production of medical notes and data is understood as part of the
management of a patient trajectory, rather than as the reporting of this work, it
becomes clear that it is very useful to describe patient trajectories in terms of
established narrative patterns. The reductions, summaries, simplifications and
standardizations found in the accounts of individual patient trajectories are
‘needed to produce an account ordered enough to enable action or to
communicate what is going on’ (Gooding 1992). In such accounts, all that
appears to have little or no importance for colleagues is discarded, highlighting
only those details that are believed to be relevant.
This reconsideration of the role of the patient record leads us to a revaluation
of the merits of the paper patient record. Advocates of EPRs, as we have seen,
are generally depreciative of paper records, yet in the eyes of experienced