Health Information Management: Integrating Information Technology ...

76 STARTING POINTS
idea, for instance, that the level of completeness or the clarity of the record is a
direct measure of the quality of the medical care is a misguided one. As the
sociologist Garfinkel already claimed in 1967, there might be ‘good organizational
reasons for “bad” records’. For outsiders, most notes and remarks in patient
records are indeed hopelessly incomplete and incomprehensible. For those
directly involved, however, they are generally adequate. Health care
professionals tend to include in their records only what is strictly necessary at
that moment and in a given situation. They generally legitimately presume that
insiders will recognize the particular situation and that on the basis of their local
knowledge of such situations they will fill in the missing context and implicit
details. A patient record is only comprehensible for those ‘who know both the
code and the cultural expectations that inhere in the situation it delineates’
(Hunter 1991). Or, as Garfinkel put it: ‘The folder contents much less than
revealing an order of interaction, presuppose an understanding of that order for a
correct reading’ (1967).
An adequate interpretation of the meaning of medical data implies, in other
words, that the specific clinical context in which that data is generated can be
interpreted adequately. The patient record does not so much represent what has
happened; it is a potentially very useful tool in that work. It presupposes that the
reader will know what normally happens in comparable situations, and hence it
supplies only a few data needed to establish the specificity of a particular
situation. The conciseness and the seeming incompleteness ‘works’ because
insiders, just like the participants in any conversation, understand the context in
which medical professionals produce notes. They know what their tasks are, what
will cause them worries regarding a patient, and what they will be looking for. In
the busy context of medical work, succinctness is a form of saving time, both for
the one who enters the information in the patient record and for the one who
quickly tries to trace it. During their training and socialization process, interns
and residents learn that brevity is a virtue—and with good reason. Lengthy and
exhaustive narratives are even distrusted because they betray the author’s
inexperience.
Yet however much we can learn from the powers of paper records, it is
obvious that the PCIS has the potential to enhance the accumulation power of
these tools much further. With these greater powers, however, come greater
demands on those that use these tools. Health care professionals now have to
standardize their data input in order to allow the tool to aggregate the data. Using
primary care data for billing, for research, for automatic fluid balances all
requires more work to disentangle these data from their primary contexts.
Crucial questions are who does this work, where the benefits end up, and
whether the added standardization and time effort do not in fact hinder the
ongoing work of health care professionals.