Health Information Management: Integrating Information Technology ...

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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.
60 STARTING POINTS Allowing such pragmatic interpretation of professional and legal requirements is not paramount to being ‘sloppy’ or ‘irresponsible’. Rather, a careful consideration of how medication systems may enhance the quality of work and patient safety may necessitate building in easy to use ‘work around’ routines for nurses that doctors may formally ‘sign’ after the fact. Unfortunately, many PCISs rely too heavily on abstract, rationalist models of medical work: a more empirically based perspective on medical work—as introduced in ‘<strong>Health</strong> care work’ (p. 48) and ‘The role of the record’ (p. 52)—is only recently gaining strength in debates on PCISs. It is still an all too common notion in the standard literature on PCISs that health care work ought to be structured like a rational scientific process with clearly delineated tasks and steps. Traces of this view abound in PCISs: tasks are divided into subtasks that can only be carried out in a pre-programmed sequence. The common result of this overly rationalist approach is that health care professionals have to put in a lot of extra work merely to compensate for misapprehensions in EPR design. How, then, can PCIS be made to interweave synergetically with health care work? How can the paradox of systems that have to ‘kill’ health care work in order to truly work be avoided? Before answering this question in Chapter 5, we will now turn to the nature of health care information in health care work and information systems. DISCUSSION QUESTIONS 1 Patient care information systems (PCIS) are seen by many to provide an answer to current problems of information handling and coordination in health care work. What kinds of problems would be amenable to amelioration through PCIS, and what problems would not? Think of an example of a well-founded and a poorly-founded PCIS project, and give arguments for your choice. 2 Does the depiction of health care work given in this chapter undermine or underwrite the need for more ‘Evidence Based Medicine’? Why? 3 Discuss examples of proper standardization of data, workprocesses and decision criteria in health care work, and of improper (or impossible) examples. NOTE 1 From now on, we will use the term PCIS to imply a computer-based information system, except when explicitly noted.
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Health Information Management In al
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Health Information Management Integ
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Contents List of illustrations vii
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Illustrations FIGURES 3.1 Medicatio
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Contributors Marc Berg is a physici
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Series preface In almost all Wester
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Acknowledgements I would like to th
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Chapter 1 Introduction In all Weste
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INTRODUCTION 3 touch upon the deplo
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INTRODUCTION 5 can draw upon to mai
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INTRODUCTION 7 Physician Order Entr
Page 24 and 25: Part I Starting points Understandin
Page 26 and 27: WAITING FOR GODOT 11 KEY TERMS ■
Page 28 and 29: WAITING FOR GODOT 13 Netherlands an
Page 30 and 31: WAITING FOR GODOT 15 facts to show
Page 32 and 33: WAITING FOR GODOT 17 (Lewinski-Corw
Page 34 and 35: WAITING FOR GODOT 19 In most cases,
Page 36 and 37: WAITING FOR GODOT 21 (Anonymous 191
Page 38 and 39: WAITING FOR GODOT 23 Because of the
Page 40 and 41: WAITING FOR GODOT 25 they simply sa
Page 42 and 43: WAITING FOR GODOT 27 expected. Stil
Page 44 and 45: WAITING FOR GODOT 29 organize their
Page 46 and 47: WAITING FOR GODOT 31 performance in
Page 48 and 49: WAITING FOR GODOT 33 different HIS
Page 50 and 51: WAITING FOR GODOT 35 CONCLUSION: TH
Page 52 and 53: WAITING FOR GODOT 37 assumption tha
Page 54 and 55: WAITING FOR GODOT 39 Anonymous (191
Page 56 and 57: WAITING FOR GODOT 41 Berg, M. (1997
Page 58 and 59: Chapter 3 Health care work and pati
Page 60 and 61: HEALTH CARE WORK AND INFORMATION SY
Page 78 and 79: THE CONTEXTUAL NATURE OF INFORMATIO
Page 94 and 95: Chapter 5 Meeting the challenge Int
Page 96 and 97: STARTING POINTS 81 ‘gender, race,
Page 98 and 99: STARTING POINTS 83 Now, imagine an
Page 100 and 101: STARTING POINTS 85 organization,
Page 102 and 103: STARTING POINTS 87 Figure 5.2 Incre
Page 104 and 105: STARTING POINTS 89 already overflow
Page 106 and 107: STARTING POINTS 91 responsibilities
Page 108 and 109: STARTING POINTS 93 answer the quest
Page 110 and 111: STARTING POINTS 95 Kohn, L.T., J.M.
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Page 114 and 115: DESIGNING INTERACTIONS 99 the way t
Page 116 and 117: DESIGNING INTERACTIONS 101 1 Identi
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DESIGNING INTERACTIONS 109 ■ Figu
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DESIGNING INTERACTIONS 111 measurem
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DESIGNING INTERACTIONS 113 Figure 6
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DESIGNING INTERACTIONS 115 Figure 6
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DESIGNING INTERACTIONS 117 Covell D
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Part II Information strategy, imple
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INFORMATION STRATEGY: AN INTRODUCTI
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Chapter 8 Developing the informatio
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STRATEGY, IMPLEMENTATION AND EVALUA
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Guidelines for information system d
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Chapter 9 Implementing information
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IMPLEMENTING INFORMATION SYSTEMS 16
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Chapter 10 Project management of in
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Index accumulation 53-4, 61, 73-4,
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INDEX 223 contingent and emergent c
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INDEX 225 satisfaction 176 patient
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INDEX 227 support 164 technology de
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