Medical Work and the ComputerBased Patient Record: A Sociological Perspective

Abstract

The computer-based patient record (CPR) is a tool likely to have great impact on the practice of medicine in the years to come. Yet, clinical settings with a fully integrated CPR are hard to find. This paper takes a sociological look at the attempts to construe and introduce CPRs. It is argued that part of the current trouble in getting these tools to work lies in the model of medical work that is inscribed in many (attempted) CPRs. A more sociological perspective on medical work should be able to offer points of departure for the construction of systems wh ich might fit the needs of health care workers better. Based on participatory observation, the paper outlines what it is medical work comes down to from a sociological perspective, and how the medical record figures in this work. Finally, some consequences this depiction has for current discussions on and (proposed) implementations of CPRs are described.

Keywords

Medical Decision Making - Computer-based Patient Record - Medical Sociology - Medical Data

• REFERENCES

• 1 Musen MA. The strained quality of medical data. Meth Inf Med 1989; 28: 123-5.
• 2 Dick RS, Steen EB. The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, D. C.: National Academy Press; 1991
• 3 Carpenter PC. The electronic medical record: perspective from Mayo Clinic. Int J Biomed Comput 1994; 34: 159-71.
• 4 Levitt J I. Why physicians continue to reject the computerized medical record. Minn Med 1994; 77: 17-21.
• 5 Kaplan B. The Medical Computing ‘Lag’: Perceptions of Barriers to the Application of Computers to Medicine. International Journal of Technology Assessment in Health Care 1987; 3: 123.
• 6 Collen ME. A History of Medical Informatics in the United States, 1950 to 1990. American Medical Informatics Association; 1995
• 7 Kaplan B, Duchon D. Combining Qualitative and Quantitative Methods in Information Systems Research: A Case Study. MIS Quarterly 1988; 12: 571-86.
• 8 Graves III W, Nyce JM. Normative models and situated practice in medicine. Towards more adequate system design and development. Information and decision technologies 1992; 19: 143-9.
• 9 Forsythe DE. Using ethnography to build a working system: rethinking basic design assumptions. In: Frisse ME. ed. 16th Symposium on Computer Applications in Medical Care. New York: McGraw-Hill;; 1992: 505-509.
• 10 Forsythe DE. Using ethnography in the design of an explanation system. Expert Systems With Applications 1995; 8: 403-17.
• 11 Nyce JM, Timpka T. Work, Knowledge and Argument in Specialist Consultations: incorporating tacit knowledge into system design and development. Medical & Biological Engineering & Computing 1993; 31: 16-9 (HTA).
• 12 Egger E, Wagner I. Negotiating temporal orders: the case of collaborative time management in a surgery clinic. CSCW 1993; 1: 255-75.
• 13 Schneider K, Wagner I. Constructing the ‘Dossier Représentatif: Computer-Based Information-sharing in French Hospitals. CSCW 1993; 1: 229-53.
• 14 Hanseth O, Thoresen K, Winner L. The politics of networking technology in health care. CSCW 1994; 2: 109-30.
• 15 Kaplan B. Objectification and negotiation in interpreting clinical images: implications for computer-based patient records. Artificial Intelligence in Medicine 1995; 7: 439-54.
• 16 Anderson JG, Aydin CE, Kaplan B. An Analytical Framework for Measuring the Effectiveness/Impacts of Computer-Based Patient Record Systems. In: Nunamaker JF, Sprague RH. eds. Twenty-Eight Hawaii International Conference on System Sciences, Vol. IV. Washington: IEEE Computer Society Press; 1995: 767-76.
• 17 Ball MJ, Collen MF. Aspects of the computer-based patient record. New York: Springer; 1992
• 18 Bleich HL, Lawrence L. Weed and the Problem-Oriented Medical Record. M. D. Computing 1993; 10: 69-72.
• 19 Shortliffe EH, Barnett GO. Medical data: Their Acquisition, Storage, and Use. In: Shortliffe EH, Perreault LE. eds. Mecical Informatics. Computer Applications in Health Care. Reading, MA: Addison-Wesley; 1990: 37-69.
• 20 McDonald CJ, Barnett GO. Medical-Record Systems. In: Shortliffe EH, Perreault LE. eds. Medical Informatics. Computer Applications in Health Care. Reading, MA: Addison-Wesley; 1990: 181-218.
• 21 Rector AL, Nowlan WA, Kay S. Foundations for an electronic medical record. Methods Inf Med 1991; 30: 179-86.
• 22 Rector AL, Nowlan WA, Kay S, Goble CA, Howkins TJ. A framework for modelling the electronic medical record. Methods Inf Med 1993; 32: 109-19.
• 23 Ebbesen EB, Konecni VJ. On the External Validity of Decision-Making Research: What Do we Know about Decisions in the Real World?. In: Wallsten TS. ed. Cognitive processes, choice and decision behavior. Hillsdale, NJ: Lawrence Erlbaum Ass.; 1980: 691-7.
• 24 Bell DE, Raiffa H, Tversky A. Descriptive, normative and prescriptive interactions indecision making. In: Bell DE, Raiffa H, Tversky A. eds. Decision making. Descriptive, normative, and prescriptive interactions. Cambridge: Cambridge University Press; 1988: 1-30.
• 25 Berg M. Turning a practice into a science. Reconceptualizing postwar medical practice. Soc Stud Sei 1995; 25: 437-76.
• 26 Clancey WJ. The Learning Process in the Epistemology of Medical Information. Methods of Information in Medicine 1995; 34: 122-130.
• 27 Berg M. Modeling medical work: on some problems of expert systems in medicine. ACM SIGBIO Newsletter 1994; 14: 2-6.
• 28 Berg M. Rationalizing Medical Work. Decision Support Techniques and Medical Practices. Cambridge: MIT Press; 1997
• 29 Strauss A, Fagerhaugh S, Suczek B, Wieder C. Social Organization of Medical Work. Chicago: University of Chicago Press; 1985
• 30 Young A. The Creation of Medical Knowledge: Some Problems in Interpretation. Social Science and Medicine 1981; 15B: 379-86.
• 31 Cicourel AV. The Reproduction of Objective Knowledge: Common Sense Reasoning in Medical Decision Making. In: Böhme G, Stehr N. eds. The Knowledge Society. Dordrecht: Reidel; 1986: 87-122.
• 32 Davis K. The process of problem (reformulation in psychotherapy. Sociology of Health and Illness 1986; 8: 44-74.
• 33 Silverman D. Communication in medical practice. London: Sage; 1987
• 34 Helman CG. Psyche, Soma and Society: The Social Construction of Psychosomatic Disorders. In: Lock M, Gordon DR. eds. Biomedicine Examined. Dordrecht: Kluwer Academic Publishers; 1988: 95-122.
• 35 Fisher S, Todd AD. The Social Organization of Doctor-Patient Communication. Washington D. C.: Center for Applied Linguistics; 1983
• 36 Bloor M. Bishop Berkeley and the adenoton-sillectomy enigma. Sociology 1976; 10: 43-61.
• 37 Lynch M. ‘Turning up signs’ in neuro behavioral diagnosis. Symbolic Interaction 1984; 7: 67-86.
• 38 Nyce JM, Graves III W. The Construction of Knowledge in Neurology: implications for Hypermedia System Development. Artificial Intelligence in Medicine 1990; 2: 315-322.
• 39 Hirschauer S. The Manufacture of Bodies in Surgery. Social Studies of Science 1991; 21: 279-319.
• 40 Berg M. The Construction of Medical Disposals. Medical Sociology and Medical Problem Solving in Clinical Practice. Sociology of Health and Illness 1992; 14: 151-180.
• 41 Garfinkel H. Studies in Ethnomethodology. Englewood-CIiffs, N. Y.: Prentice-Hall; 1967
• 42 Bowker G. Science on the run. Information management and industrial geophysics at Schlumberger, 1920-1940. Cambridge, MA: MIT Press; 1994
• 43 Whalen J. Accounting for ‘standard’ task performance in the execution of 9-1-1 operations. Annual Meetings of the American Sociological Association. Miami, August 1993; 1993.
• 44 Bosk CL. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press; 1979
• 45 Rees C. Records and hospital routine. In: Atkinson P, Heath C. eds. Medical work: realities and routines. Farnborough: Gower; 1981: 55-70.
• 46 Atkinson P. The Clinical Experience: The Construction of Medical Reality. Farnborough: Gower; 1981
• 47 Lave J. Cognition in practice. Cambridge: Cambridge University Press; 1988
• 48 Suchman L. Plans and situated actions. The problem of human-machine communication. Cambridge: Cambridge University Press; 1987
• 49 Heritage J. Garfinkel and Ethnomethodology. Cambridge: Polity Press; 1984
• 50 Timmermans S. The Paradox of Resuscitation Technologies. Philadelphia: Temple University press; 1998
• 51 Latour B. The Pasteurization of France. Cambridge: Harvard University Press; 1988
• 52 Lynch M. Art and artifact in laboratory science. A study of shop work and shop talk in a research laboratory. In: Garfinkel H. ed. Studies in Ethnomethodology. London: Routledge and Kegan Paul; 1985
• 53 Knorr-Cetina KD. The Manufacture of Knowledge. Oxford: Pergamon Press; 1981
• 54 Frohock FM. Special Care. Medical Decisions at the Beginning of Life. Chicago: University of Chicago Press; 1986
• 55 Anspach RR. Deciding who lives. Fateful choices in the intensive care nursery. Berkely: University of California Press; 1993
• 56 Fujimura JH. Constructing ‘Do-Able’ Problems in Cancer-Research: Articulating Alignment. Soc Stud Sci 1987; 17: 257-293.
• 57 Berg M. Practices of Reading and Writing. The Constitutive Role of the Patient Record in Medical Work. Soc Hea Illn 1996; 18: 499-524.
• 58 Heath C. Preserving the Consultation: Medical Record Cards and Professional Conduct. Soc Hea Illn 1982; 4: 56-74.
• 59 Smith D. Texts, Facts, and Femininity: Exploring the Relations of Ruling. London: Routledge; 1990
• 60 Hutchins E. Cognition in the wild. Cambridge: MIT Press; 1995
• 61 Latour B. Visualisation and Cognition: Thinking with Eyes and Hands. Knowledge and Society: Studies in the Sociology of Culture Past and Present 1986; 6: 1-40.
• 62 Hunter KM. Doctor's stories. The narrative structure of medical knowledge. Princeton: Princeton University press; 1991
• 63 Barrett RJ. Clinical writing and the documentary construction of schizophrenia. Cult Med Psyc 1988; 12: 265-99.
• 64 Schmidt K, Bannon L. Taking CSCW Seriously: Supporting Articulation Work. CSCW 1992; 1: 7-40.
• 65 Luff P, Heath C, Greatbatch D. Tasks-in-interaction: paper and screen-based documentation in collaborative activity. In: Turner J, Kraut R. eds. Proceedings of the Conference on Computer Supported Cooperative Work. New York: ACM Press; 1992: 163-170.
• 66 Nygren E, Henriksson P. Reading the medical record. I. Analysis fo physicians’ ways of reading the medical record. Comput Methods Programs Biomed 1992; 39: 1-12.
• 67 Engeström Y, Engeström R, Saarelma O. Computerized Medical Records, Production Pressure and Compartmentalization in the Work Activity of Health Centre Physicians. Proceedings of the Conference on Computer-Supported Cooperative Work CSCW ‘88. New York: ACM Press; 1988: 65-84.
• 68 van der Lei J. Use and abuse of computer-stored medical records [editorial]. Methods Inf Med 1991; 30: 79-80.
• 69 Atkinson P. Medical Talk and Medical Work. London: Sage; 1995
• 70 Cicourel A. The Integration of Distributed Knowledge in Collaborative Medical Diagnosis. In: Galegher J, Kraut RE, Egido C. eds. Intellectual Teamwork, Social and Intellectual Foundations of Cooperative Work. Hillsdale, NJ: Lawrence Erlbaum Associates; 1990: 221-42.
• 71 Macintyre S. Some Notes on Record Taking and Making in an Antenatal Clinic. Sociological Review 1978; 26: 595-611.
• 72 Bowker G. Lest we remember: organizational memory and the production of knowledge. 1995
• 73 Timpka T, Arborelius E. The GP's dilemmas: a study of knowledge need and use during health care consultations. Methods Inf Med 1990; 29: 23-9.
• 74 Kuhn TS. The Structure of Scientific Revolutions. Chicago: University of Chicago Press; 1970
• 75 Pickering A. Science as Practice and Culture. Chicago: University of Chicago Press; 1992
• 76 Button G. Technology in working order. Studies of work, interaction, and technology. London: Routledge; 1993
• 77 Bijker WE, Law J. Shaping Technology – Building Society. Studies in Sociotechnical Change. Cambridge: MIT Press; 1992
• 78 Greenbaum J, Kyng M. Design at work: cooperative design for computer systems. Hillsdale, N. J.: Lawrence Erlbaum Associates; 1991
• 79 Robinson M. Double-Levei Languages and Co-operative Working. AI & Soc; 1991. 5 34-60.