Health Information Management: Integrating Information Technology ...

66 STARTING POINTS
not listened for a faint murmur that she might have heard if she were on a
diagnostic quest. Similarly, she has only auscultated the anterior side of the
chest, so to spare the inconvenience—for both patient and staff—of having to
turn over this patient to listen at his back. Given the severe constraints on residents’
time (they are responsible for the day-to-day care of all ICU patients, amongst
others), everyone considers it a sign of good practice to be brief where brevity is
wise, and to trust experienced nurses at those points where their skills and knowhow
surpasses the capacity of less experienced residents. To search meticulously
for faint murmurs in a patient such as this would be considered a wrong priority,
or, worse, a sign of not knowing how to distinguish what matters clinically from
what does not.
First, then, medical information is entangled with its context of production in
that the meaning, hardness and significance of a piece of information cannot be
detached from the specific purpose for which that information was gathered. A
second way in which medical information is contextual is closely linked to this
first phenomenon. An image of medical data as ‘atoms’, as isolated givens,
overlooks how medical data mutually elaborate each other. To conceptualize the
broad range of medical data on a patient as bits and pieces of an emerging story
is much more apt than to consider them as a heap of facts. The above case can
again illustrate what is meant here. The empty entries around the fields ‘rhythm’
and ‘murmurs’ transform the meaning of the entries in these fields much like a
new event in a story can bring a new meaning to its evolving plot. In this
situation, the empty entries indicate the routine nature of the event, and the nonproblematic,
stable cardiac status. Consider how the meaning of the data-item
‘murmurs: none’ would change if the entry after ‘remarks’ would read ‘now
three days after valvular surgery’. Not only would the significance and
poignancy of the data item change drastically, but we would then suddenly and
reasonably expect the ‘rhythm’ and ‘murmur’ information to be the result of a
meticulous investigation.
Examples from this same phenomenon abound. Take the following notes,
written by an experienced registrar, from a record of a young, female leukaemic
patient from the oncology ward of an academic hospital:
PE:
Nodes—
Spleen—
For an (already rather knowledgeable) outsider, the only information that seems
to be recorded is that in the physical examination, no enlarged lymph nodes or an
enlarged spleen were felt. An insider, however, would know this ward’s working
routines, would be familiar with the specific demands of this particular medical
situation, and would note that this is this registrar’s first own entry in the record.
Having this background information, this insider would read this as central
information on the core indicators in the staging for chemotherapeutic treatment:
both an enlarged spleen and enlarged nodes are important signs in