Health Information Management: Integrating Information Technology ...

HEALTH CARE WORK AND INFORMATION SYSTEMS 59
have to adjust themselves more to the demands of the EPR: their work becomes
more standardized. Such adjustment is not problematic in itself: every
introduction of new medical technology brings along a transformation of
medical practices (cf. Chapters 2 and 4). In addition, to produce the standard
data, decision criteria and work processes required is a highly active task of the
health care professional (see also the next two chapters).
Yet the core question that was raised at the beginning of this chapter was
whether the professional work of doctors and nurses can be standardized without
hampering the very quality of that work. After all, as we argued earlier (p. 51),
health care work has a thoroughly contingent and emergent character. Bluntly
standardizing data, decision criteria and work processes would undo health care
professionals’ capacity to adequately adjust their skills to individual patient cases
—or so many would argue. We saw, however, that paper-based PCISs also
already require much standardization of data, work processes and decision
criteria —and that such tools have fulfilled rather powerful functions in health care
practices over the last century. So, some standardization is not antagonistic to
health care work, at the very least. But where does the ‘cut off point’ lie? At
what point does the added standardization pressure become so heavy that the
PCIS can no longer function?
There are many examples of PCISs that failed because their function required
a level of standardization of work tasks that was impossible to produce. Clinical
pathways, for example, often structure and sequence the work of nurses and
doctors in such detail that the central importance of articulating such general
pathways to individual trajectories is denied. The latter becomes noise upsetting
the smooth flow of the preset categories of trajectories rather than the core
activity typifying health care work. It is then up to the professionals to constantly
‘repair’ the cracks and fissures that this causes in the flow of their activities. This
generates the working failures of so many IT applications: the technology creates
difficulties in ‘“good working practices”…because it is insensitive to the
contextual reasons for the existence of those practices’ (Button and Harper
1993).
As another example, many medication systems run into problems because
they require the physician to issue and enter a medication order before nurses can
follow up on it, and hand out the medication. Yet, as is already suggested by the
case study on p. 58–9, in reality the boundaries between these tasks are rarely
strictly demarcated. In fact, frequently the experienced nurses are the ones who
take the initiative to change a patient’s medication. Similarly, it is no exception
that in emergency situations medication has already been administered before it
is entered into the patient record. The Kardex system allows for such deviations
from the protocol: experienced nurses may already fill out a form and have it
signed, or a form may be filled out and processed afterward (after administering
the medication). A medication system that would make it impossible to
administer medication that is not yet officially entered into the system would
seriously obstruct the proper course of medical work, rather than facilitate it.