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THE CONTEXTUAL NATURE OF INFORMATION 71 ■ ■ It could more easily allow for changing the logics of the information handling (whereas in the paper-based record, the information is always presented per patient and by source, an electronic PCIS could facilitate searching the database by disease-category, by year of admission, by treating specialist and so forth). It could make real-time information handling possible (the PCIS could perform all the above mentioned operations in real-time: give immediate feedback upon the entry of a wrong medication, for example). In the previous paragraph, however, we have argued that medical information is fundamentally context-bound. What are the implications of this observation? Does this imply that data can only be used within that context? To start answering this question, let us look at the case studies above. The way the fluid balance actively calculates with and aggregates entered data is a basic but illuminating example of the way IT can enhance the accumulating role of medical records. The computer automatically transfers information from other locations in the record to the fluid balance and it adds columns and totals. This more active role affords a more precise measurement of the fluid balance. Before the coming of this EPR, the fluid balance was calculated only once a day; now there is a continuous, up to date fluid balance available. This function also saves time: the daily calculations had to be done manually, and took about 15 minutes per patient. Yet to afford this active accumulating function, the nurses have to be more meticulous in their routines: they have to follow a similar action sequence every two hours (check urine, enter values, validate values), and they have to ensure that all values are entered correctly, precisely and error-free. If they fail to do so, the computer’s totals will be unable to calculate totals, or it will produce erroneous figures. A critical investigation of Figure 4.2 could lead one to the conclusion that these totals are wrong anyway. The total fluid balance of this patient is more than 28 litres positive—a fatal condition. The reason for this phenomenon was simple. Notwithstanding all the precise procedures that contributed to the calculating of the fluid balance, the loss of fluid through respiration and transpiration were not taken into account: the instruments that would be needed to measure these values were too cumbersome and expensive for daily, routine use. Since an ‘average’ patient loses about 1–1.5 litres of fluid through respiration and transpiration, however, this implies that patients that are about 1–1.5 litres positive per day are ‘in fact’ rightly balanced. The judgement whether ‘0.75 litre positive’ constitutes a negative fluid balance depends on a judgement of the psychological condition of a patient, his physical condition and the temperature of his surroundings. In the case of a tense patient that has spent his day lying in the sun, for example, ‘0. 75 litre positive’ might count as a negative fluid balance. Although this is a very significant ‘fudge factor’ (the total fluid that goes in and out per day is only a few litres!), the fluid balance is adequate for the purposes of this ward’s needs: the uncertain transpiration and respiration values hardly ever constitute a problem.
72 STARTING POINTS The values are indicative and useful, and clinical knowledge and experience to interpret them is always available. A more precise fluid balance is not worth the investments that would have to be made. In a similar way, the built-in warnings and the influenza module of the general physicians’ PCIS supported the work of the doctors and their assistants. The automatic generation of warnings or reminders may reduce the chance of error, while the automatic selection of risk patients, as well as the automatic processing of letters to those in this category, enables a vaccination campaign of a much larger scale than would have been possible without this particular module. Yet, here too it is true that the PCIS can only fulfil these functions effectively if physicians code their patients’ complaints and diagnoses according to the rules and if assistants carefully monitor any changes in the ‘IS’, ‘IM’, and ‘IV+’ codes. Moreover, physicians have to check the module-generated list patient by patient and the meaning of each warning has to be assessed individually. This, however, does in no way lower the usefulness of the influenza module: it is simply less work to check the list manually than to keep the data files updated and flawless so that any manual checking would become superfluous. Here as well, then, we see that data are bound to the context of their production. The fluid balance functions adequately as long as it is used and interpreted by experienced users, who can relate the always positive figures to their clinical experience and other information at hand. Outside of this context, these figures would be absurd: read at face value, we would have to conclude that this was an ICU where medical miracles (or lethally inadequate care) were the order of the day. The fluid balance, Agnes’ data, the empty fields and the ‘IM’ codes are data that are richly and adequately meaningful within the context of their use—yet they are meaningless, faulty or even patently absurd outside this context. For this reason, attempts at aggregating primary medical information—for secondary utilization, or for advanced functions within the care process—are problematic. As one commentator put it: ‘we may aggregate nonsense as effortlessly as we aggregate fact’ (Levitt 1994). This insight has been translated into a First Law of Medical Informatics: ‘Data shall be used only for the purpose for which they were collected. If no purpose was defined prior to the collection of the data, then the data should not be used’ (van der Lei 1991). If data are nevertheless transported outside the context of their immediate use, things indeed often go wrong. In one health care practice, for example, medical specialists wanted to process electronic bills by automatically linking them to the health care activities recorded in the PCIS. Previously, doctor’s assistants used to keep track of all the medical interventions on separate lists. The PCIS designers, quite logically, expected that the PCIS could process such a list automatically. However, after the introduction of the PCIS it turned out that not all interventions were entered into the computer. Activities that were part of standard routines, for example, were often not separately entered. The effect was
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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
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Part I Starting points Understandin
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WAITING FOR GODOT 11 KEY TERMS ■
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WAITING FOR GODOT 13 Netherlands an
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WAITING FOR GODOT 15 facts to show
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WAITING FOR GODOT 17 (Lewinski-Corw
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WAITING FOR GODOT 19 In most cases,
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Page 38 and 39: WAITING FOR GODOT 23 Because of the
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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.
Page 112 and 113: Chapter 6 Designing interactions En
Page 114 and 115: DESIGNING INTERACTIONS 99 the way t
Page 116 and 117: DESIGNING INTERACTIONS 101 1 Identi
Page 118 and 119: DESIGNING INTERACTIONS 103 the deve
Page 120 and 121: DESIGNING INTERACTIONS 105 communic
Page 122 and 123: DESIGNING INTERACTIONS 107 Figure 6
Page 124 and 125: DESIGNING INTERACTIONS 109 ■ Figu
Page 126 and 127: DESIGNING INTERACTIONS 111 measurem
Page 132 and 133: DESIGNING INTERACTIONS 117 Covell D
Page 134 and 135: 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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