Health Information Management: Integrating Information Technology ...

74 STARTING POINTS
the ones who profit most: they gain more time than they invest, and they now
have a more precise fluid balance at their disposal. Likewise, general
practitioners who use their PCISs to code data for their own research purposes,
or to facilitate screening activities and the generation of automatic reminders
invest a bit of work from which they themselves benefit. In hospitals, separate
‘record administrators’ often do the coding of DRGs or ICD codes for
administrative purposes, and research assistants do the translations between
patient record and clinical trial form. They disentangle the data from different
contexts, fill in gaps, interpret unexpected phrasings and outliers, and translate
all this into a single ‘code’ that has all the characteristics of a commodity. In this
case, the work of those who manage the patient’s trajectory is not affected: the
work to ‘commodify’ information for use by administrators is delegated to an
additional group of people, specially assigned to this task.
Yet just as the skill and tacit knowledge that comes to play in the work of
these coders is often overlooked, the task to produce data for secondary
utilization by others than the primary care givers is often unthinkingly delegated
to those primary care givers. Too often, current PCIS designs implicitly or
explicitly make them responsible for the production of standardized,
‘transportable’ data. They have to fill in long, coded forms, to write elaborate
explications, and to be—from their viewpoint—overly complete.
One way in which this friction plays up is in the discussion on ‘free text’. Some
information specialists see the multiple use of free text in patient records—in the
progress reports of physicians, in the observations of nurses, in radiology
reports, in reports on ultra-sound scans—as a shortcoming of health care
practices. After all, quantifiable information is the apex of scientific
accomplishment. Everything that can only be captured in vague phrases is
therefore less scientific and hence subject to perfection: ‘The kinds of
information that are currently stored as free text have not generally evolved to as
mature a state of evolution as that which is currently stored as structured
formats’ (McDonald 1992).
This assumption, however, rests on a misconception. The coding and
quantification of information are methods for taking information out of the
context in which it is used. Yet this does not imply that ‘coding’ and
‘quantification’ render this work itself more scientific. This is by no means
necessarily the case. The use of free text and local dialects are actually highly
functional for an optimal and flexible performance of common tasks by a joint
team of professionals: more ‘standardized’ information generally is less
informative in such circumstances. Coded data often can hamper the ongoing
work because the nuances and details—which are so crucial in the management
of patients’ trajectories—tend to disappear behind the ‘generic’ codes. Likewise,
health care professionals run the risk of losing their general overview of the
situation as soon as they are exposed to an overdose of isolated ‘items’ or to too
much standardized prose. For primary users of a patient record, a summary of
three lines in the ‘conclusion’ section of an observation form is much richer in