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Proceedings of the Conference on Computer Supported Cooperative Work, Boston: ACM Press pp. 354-363. 1996.
Documents and Professional Practice:
'bad' organisational reasons for 'good' clinical records

Christian Heath and Paul Luff
Centre for Work, Interaction and TechnologySchool of Social SciencesUniversity of NottinghamNottinghamUnited Kingdom ABSTRACT
(Landauer, 1995) . Moreover, more detailed studies of Despite the widespread introduction of information technologies in workplaces frequently reveal paper records technology into primary health care within the United continuing to be used despite new technologies having been Kingdom, medical practitioners continue to use the more introduced to replace them (e.g. Hughes, et al., 1988; Luff, traditional paper medical record often alongside the et al., 1992; Suchman, 1993b) It may be the case that our computerised system. The resilience of the paper document failure to achieve the dream of the ‘paperless office’ might is not simply a consequence of an impoverished design, but also be a consequence of our inability, on some occasions, rather a product of the socially organised practices and to build technologies which satisfactorily support the reasoning which surround the use of the record within day socially organised practices which underpin (previously to day consultative work. The practices that underpin the paper-based) collaborative activities. Indeed, in persisting use of the medical records may have a range of important with certain media, or failing to exploit the opportunities implications, not only for the general design of systems to support collaborative work, but also for our conceptions of technologies, ‘users’ may not simply be inflexible, ‘writers’, ‘readers’, ‘objects’ and ‘records’ utilised in those sluggish or worst still, Luddite, but rather attempting to reconcile the demands of a system with the intricate andcomplex organisation which surrounds even the most INTRODUCTION
mundane human (collaborative) activity.
Over the last few decades, of the many cited advantages ofcomputer systems, one of the most frequent has been the In this paper we wish to briefly consider one such setting technology’s capability to maintain records in an electronic where, despite the deployment of a computer system to format. This may be why, despite great innovations in the support record keeping and the distribution of information, participants still persist in using paper documents. The collaborative work, it appears to be the systems which setting in question is General Practice or primary health principally rely on the capabilities of a shared databases and care within the United Kingdom. Whilst providing new electronic mail that attract the attention of customers and capabilities, the information systems introduced to replace achieve some commercial success (e.g. Lotus Notes and traditional medical record cards, have not been wholly Windows For WorkGroups). These systems provide for successful and even after some years, there remains great accessibility to information by a large number of widespread use of the original paper documents. The case users and for the simple communication and transportation of General Practice does not simply provide a vehicle for of data, capabilities largely oriented towards the recording considering how the design of computer systems can and distribution of information. However, as has been undermine working practices, rather, it points to a recently noted, it is difficult to ascertain whether such potentially more profound and interesting issue which has a systems provide the support for collaborative work their strong bearing upon CSCW and our attempts to support adherents suggest (Orlikowski, 1992) . Indeed it is often collaboration. In particular, it allows us to consider how hard to determine the contribution even the most seemingly individual activities, such as reading and writing, conventional and widely deployed technologies have had for rest upon complex and systematic social practices which are more general bureaucratic work within organisations not explicitly concerned with the group, or interaction, or .
with the organisational, and yet do have relevance to documents. The records play an important part in day to day professional practices, not simply in providing abureaucratic dossier which documents the contact between THE TRADITIONAL MEDICAL RECORD CARDS
doctors and their patients, but actually in the organisationof the consultation. Both diagnosis and prognosis are often One has reached the conclusion that the key to inextricably linked to information which is documented in good general practice is the keeping of good clinical records. Time and again one has seen at aquick glance through a well kept record provide For example, before beginning a consultation the doctor either the diagnosis or an essential point in the glances at the patient's medical records normally turning to the most recent entry, this reading allowing the doctor to assess whether the patient is returning with an illnesswhich has already been discussed. If this is so, the The traditional paper medical record used in General document provides the resources with which to tailor the Practices in the United Kingdom consists of an A5 beginning of the consultation (cf. Heath, 1981). Or, for envelope containing a number of cards and various pieces of example, when faced with a problem the diagnosis of which paper such as referral and discharge letters, and notes is unclear or ambivalent, a doctor will often read the record containing the results from tests. On the envelope is in order to see whether there are any previous illnesses written the patients’ name, address, date of birth and which explain the current difficulties. As well as a resource National Health Service (NHS) number. The cards consist for hints or ideas, the records also provide the doctor with in large part of descriptions of consultations; each and every factual versions of the patient medical biography, so that consultation requiring a single entry on the medical record previous treatment programmes, allergies and the like can card. The records are stored and made available to the doctor be checked and confirmed by a brief glance at the record.
whenever he or she consults with a patient, whether it is in For doctors therefore, the records provide a reliable source of the surgery, at home or in hospital. The records follow the information which is adequate for the uses it serves in the patient, and only the death of the patient can result in the deletion of a record. Even then the record is kept for up tosix months in case any contingencies or enquires arise. The Doctors therefore rely upon the records to accomplish their following extracts are drawn from various patient records: professional work. They expect the records to containcertain sorts of information and to be adequate for the uses to which they are regularly put. Given that any doctor within a practice may see a particular patient, and that records follow patients if they happen to move, the documents must inevitably embody a powerful and generic body of practices which inform both the writing of therecord and their reading by 'any' general practitioner. In large part these practices, the social organisation which underlies the production and use of medical records, are not formally codified. Indeed, though there is a professional obligation, there is no legal requirement for doctors to actually keep medical records. We wish to suggest that thepractices which inform the production and intelligibility of the record are thoroughly embedded in the practical use within the consultation and that these practices and their practical application are highly relevant to the successful design and deployment of technologies to support collaborative medical work in primary health care.
Entries in the medical records consist of standardised elements, or better, classes of particular items. For example, consider the following relatively brief entry.
At first glance the entries in the record appear brief and unsystematic and one wonders why so much trouble is dedicated to their upkeep. Certainly researchers in the socialsciences and epidemiology have long complained about the This record consists of the following: the date and location quality of information kept in the records and argued that of the consultation (c. for consultation being held in the the records fail to provide a secure foundation for reliable surgery, v. for a home visit); the patient’s presentation of analysis. Despite the apparent quality of the paper records, the problem or symptoms; the practitioner's diagnosis or doctors go to some effort to maintain the medical assessment; and the treatment, its strength and the amount.
A single entry in the record can thus be seen to consist of INTERCLASS DEFEASIBILITY
distinct classes of items: the occasion of the consultation; Consider for example the following entries drawn from the complaint or illness; and the management of the complaint. These classes can include different items. Sofor example, the patient’s complaint can include such things as the patient’s presentation of symptoms or the doctor’s diagnosis, and the management of the complaint can consist of drug treatment, referrals, certificates, and thelike. None of this is to suggest that items are documented for each class for every consultation, however if an item is not recorded then various sorts of inferences can be drawn, for example the item could be inferred or its absenceconsidered relevant.
In the first instance, we find no details concerning thepatient's presenting complaint or symptoms. Tonsillitis An important feature in producing and making sense of the would be treated as the diagnosis, especially given the next medical record cards, is the ways in which entries are item. Antibiotics are rarely prescribed unless there is organised both in relation to each other and internally.
evidence of an infection. However, any competent reader Each entry follows a former with some break between. The confronting this entry would be able to infer the symptoms order of entries reflect the temporal organisation of the suffered by the patient from the diagnosis, namely sore consultations; the most recent consultation being the last throat, temperature and perhaps associated headaches and entry in the record. The geography of a single entry is also drowsiness. As for 'fed up' in the second entry, its character important. The respective items are presented across and coupled with the single inverted commas would lead one to then down the page, providing a serial or even sequential assume that it is a description of a complaint presented by order. How they are positioned with regards to each other the patient. The absence of a diagnosis and any treatment, provides an important resource with which to recognise or referral, allows the reader to assume that following the what the particular items mean. For example, 'depressed' in appropriate medical enquires, the practitioner was unable to the previous entry gains its status as an assessment or formulate an assessment or diagnosis. Indeed, standing diagnosis by virtue of its position following 'feeling tired'.
alone, the item suggests that the patient has not only If 'depressed' was the first item, and say 'paranoid' the presented a deeply trivial complaint, but is potentially second, then paranoid would constitute the assessment someone for colleagues to be wary of. Finally, 'Depressed' whereas 'depressed' would become the presenting complaint constitutes the professional assessment and diagnosis, or symptoms. Similarly 'paranoid' could be the patient's further confirmed by the treatment that the practitioner has presentation of the complaint, if followed by for example recommended to the patient, an antidepressant. The 'exam tension' as the professional assessment. patient's symptoms are largely excluded, however 'feelingsick' is documented, since such a symptom would not The various items which constitute entries therefore do not necessarily be associated with the diagnosis in question.
have a fixed and determinate sense. Rather their meaning isgenerated, in part, through their position within a entry.
In writing an entry therefore, practitioners are sensitive to The geography of items within in the record is a critical the inferences that colleagues can draw from particular resource in both reading the entry and making sense of its items. They can rely upon those inferences not only to include information which might otherwise seem relativelytrivial, but to exclude particular items (or even categories of D E S C R I P T I V E E C O N O M I E S
object) knowing that any competent reader would be able to In writing entries in the records, doctors orient to a certain, make sense of the entry and retrieve the relevant descriptive economy. They largely avoid repetition of information. The descriptions are designed for a particular particular items and information and exploit a competent class of recipient, namely general practitioners. Doctors readers’ ability to draw inferences from particular items and orient to, in the production of the records, the uses to which their configuration within the entry. An adequate the information is regularly put and the knowledge and description of a consultation relies not so much on an competencies that suitable qualified colleagues will bring to extended description of the event and its findings, but rather from a few short remarks assembled with regard to aparticular impression. The adequacy of a description relies THE DESCRIPTION AS A WHOLE
upon what is both recorded and retrievable by a competent The defeasibility of items may not only occur within reader, that is, a fellow general practitioner. To enable us particular classes, but also across classes within an entry.
to discuss the ways in which practitioners assemble a As noted above, for example, that the presence of an coherent and economic description and provide readers with antibiotic in an entry gave further support to the impression a particular impression, it may be useful to introduce the that 'tonsillitis' was the professional diagnosis rather than expression 'defeasibility'. The term has been widely used in simply a characterisation presented by the patient. Consider pragmatics and jurisprudence to describe the ways in which the following instances which include various forms of any rule or law, no matter how precise its formulation, will inevitably confront circumstances, where despite theirpotential relevance, it is inappropriate. Between the parts or constituents of a Gestalt contexture there prevails the particular relationshipof Gestalt coherence defined as the determining and conditioning of the constituents upon each other, In thoroughgoing reciprocity the constituents add to, and derive from one another, the functional significance which gives one its qualification in a The first entry is rather curious, 'badly bruised' in invertedcommas is the patient's presenting characterisation ratherthan an assessment by the practitioner. There is no INTRA-ENTRY DEFEASIBILITY
treatment for bruising and no confirmation of the patient's Entries are not only produced with regard to the mutual claim provided. However, whilst the practitioner appears to dependence of items within an entry, but also with suggest he could not find evidence of the bruising, the consideration to other entries within the patient's medical recommended management gives a slightly different flavour.
record cards. For example, in the following entry, it can be The Brook Centre, to which the patient was referred 'r/f', is noted that there is neither presenting complaint nor a hostel for battered women. So, whilst the doctor appears professional assessment or diagnosis. Furthermore whilst to have been ambivalent as to the evidence of the patient’s treatment is mentioned, namely eye ointment, it does not 'claim', he was obviously concerned enough to refer the provide an adequate basis with which to infer the symptoms woman in question to the Centre. The practitioner has deliberately built in ambiguity and uncertainty into hischaracterisation of the consultation. The second example is interesting as it looks as if the doctor is avoiding a diagnosis. Despite the relatively trivial symptom he doesgive the patient a treatment, which would suggest that he is The absence of potentially relevant information within the treating the patient's problem seriously. Perhaps the most entry, would encourage any general practitioner to turn to significant item, in terms of a potential assessment of the the previous entry to see whether it casts light on the problem, is ‘r/f AA’ namely Alcoholic Anonymous.
consultation. In the case at hand we find: Finally, ‘tired and weepy’ would undoubtedly be treated asrelatively unimportant, especially since the practitioner avoided any diagnosis or treatment. ‘r/f GC’ is a referral to the psychiatric social worker in the practice which leads thereader to believe that the doctor has decided to have an Given the proximity of the two events, some eight days expert see the patient. The referral is locally relevant in between each consultation, the reader could assume that the that it is only doctors in the practice which would most recent entry reported a return visit; a consultation which was principally concerned with the progression of aproblem which patient and doctor had discussed on a The production of an entry therefore, does not involve previous occasion. In such circumstances, the practitioner applying a set of clearly formulated rules as to what items knows that the diagnosis and the treatment details may be and information should be gathered into an entry. Rather found in a previous entry and that there is no point entries are assembled with respect to the overall impression (re)documenting the same information at each consultation.
they provide. It is not so much a précis of what went on, In the case at hand, the reader might also assume that the but rather a sketch, drawn through a few elements which eye was taking some time to clear up, and this would provide a certain sense or impression of the event. The account for the change of treatment during the subsequent consultation is drawn by interrelating components in such a way as to provide a certain impression. Each item isdependent for its sense on the other items, and the sense of the whole emerges from the interrelationship of the parts.
The process is not unlike a hermeneutic circle suggested byHusserl or the Gestalt contexture described by Gurwitsch perhaps difficulties at homeDepression Valium 10mg (30)cert 1/52 are written with regard to each other and provide acompetent reader with the resources to retrieve theinformation that they can ordinarily find within a singleentry. The very brevity of the entry, the omission of .
certain categories of item, coupled with the presence of changes to the ways in which diagnostic and prognostic some mentioned treatment, serve as an embedded instruction information is documented and presented to the general to the reader to turn to previous entries in order to retrieve practitioner. Whilst these appear trivial, they are the relevant information. The practices that doctors use to consequential to the ways in which doctors are able to use assemble the records are a resource both for documenting the new clinical records within the consultation: information and for inference and discovery; they provide fora delicate and subtle range of inferential work through Unlike the paper record, the details of each which conventional sorts of information concerning consultation are no longer written into a single consultation can be routinely assembled. entry. With VAMP, diagnostic and prognosticinformation are stored separately in distinct locations The defeasibility of items across two or more entries is not which cannot be accessed simultaneously. One file, simply a matter of saving the doctor time in producing a called the "medical history", contains details of the description of a particular consultation. By designing an type of consultation, a description of the problem entry so that a colleague turns to read other, related, and outcome, the results of tests, and any comments entries, a practitioner provides a sense of the career or by the doctor. The other, called the "therapeutic course of a particular illness and the ways in which various history", contains details of drugs, appliances and consultations featured in its development. It also provides a dressings that have been prescribed.
resource, as mentioned earlier, for a practitioner todetermine wherever an upcoming consultation is itself an The medical history file stipulates both the type of event within the progression of an illness. In such information which is entered and the amount of circumstances the beginning of the consultation and its information. It is divided into two sections. The overall shape is very different from occasions where the assessment or diagnosis and a section for 'free text'.
patient is presenting a new difficulty or problem. By In the original version of the system, each section defeasing items across entries and assembling the text with could consist of no more than one line of ten regard to an impression as to how this event is related to characters. The information entered into the previous meetings concerning the particular illness, doctors diagnostic section has to use a fixed set of diagnostic produce careers or trajectories of illness. The records reflect categories drawn from established system known as and embody the routine progression of particular problems Oxmis (though this has recent been replaced by an and the ways in which the proper management of illness by alternative system known as Reedcoding). Free text the members of the profession attends to, and of course can be entered alongside if the practitioner wishes to (re)produces, the routine progression and cure of particular elaborate the assessment or diagnosis, but as troubles. The design of the text therefore, the ways in mentioned above, the original system allowed for no which items are described and assembled, provides more than one line or ten characters.
instructions as to its span of potential relevancies and whatinformation within the document potentially features in this The therapeutic file is itself divided into two gestalt of the particular illness. As Garfinkel (1967) components. One details information concerning suggests however, on any subsequent occasion, the record repeat prescriptions, for example, relating to chronic may be examined with regard to the contingencies which difficulties, the other details treatments for acute demand a retrospective re-characterisation as to what is problems. With the VAMP it is not possible to indeed relevant to some (emergent) particular trouble The system also includes a number of other features which, THE COMPUTERISATION OF CLINICAL
whilst seemingly insignificant, are consequential to the use of the computerised clinical records in the consultation.
The computer system most widely deployed in general For example, information entered into the system through medical practice in the United Kingdom is known as the keyboard is organised in terms of a series of prompts VAMP ‘Value-Added Medical Products’. This is available which require the practitioner to move progressively on standard personal computers and is intended to be placed through the options in a particular sequence. For instance, on the doctor’s desk and used during consultations. VAMP in order to issue a prescription, the doctor must first enter the relevant component of the system. Subsequently the documentation and retrieval of medical biographical system displays details of past prescriptions and a series of information and a facility for issuing prescriptions. It also prompts for details of the new prescription. The prompt includes a database for information concerning available line requires such details as the name, form, strength, drugs and treatments. The system is aimed to be a dosage and quantity of the item(s) being prescribed. In each replacement for the paper medical record cards whilst also field the doctor normally uses the alphanumeric keys to providing the advantages of computer technology, including type in abbreviations of the relevant information; for enhanced access to and distribution of information. It was example, to enter a names of drugs, appliances or dressings, assumed that within a year of its deployment, that the the doctor need only type the first three or four letters of system would largely replace traditional paper record.
each word. After details of the form and strength have beenentered, the system will then attempt to match the details to However, in order to rationalise certain aspects of the paper check whether the appropriate quantities are available the records, the system has made a number of relatively small on-line dictionary of drugs, appliances and dressings.
Alternatively, the doctor may summon a list of the items contingent use of the technology and the doctors’ ability to contained in the treatment dictionary and choose an item delicately coordinate system use with the real time from this list. This facility is most frequently used when contributions of the patient (Greatbatch, et al., 1993). doctors are uncertain about what to prescribe. If the systemfails to recognise input, or two or more names in the Handwriting also provides a rich array of resources to dictionary match an abbreviated entry, then it will request practitioners which are precluded by the computerised for clarification or correction of the input. In working system. For example, it has long been argued that the through the sequence of prompts, the doctor presses the doctors’ ability to recognise the handwriting of their carriage return key to move to a subsequent field or the colleagues, and therefore who saw which patient for what, control key in conjunction with a character key to return to is an invaluable resource for making sense of the a previous field. After exiting the final field, the system consultation. The system also precludes various stylistic prints out a prescription and displays and updates the devices commonly used by practitioners to give a certain flavour to statements that they included in the medicalrecords. So for example, we saw earlier how inverted DEPLOYING THE TECHNOLOGY:
commas were used to attribute an item to a statement CONSIDERATIONS FOR GENERAL PRACTICE
uttered by a patient, but other sorts of punctuation, such as Whilst reproducing and rationalising the classes and commas, exclamation and question marks, underlinings, categories of information ordinarily documented in the paper crossings out, and the like are also commonly used by medical record, and providing various additional facilities, doctors to flavour the ingredients which make up an entry.
small changes to the ways in which details are documented In addition, there are some practices which whilst remain or made available to doctor have inadvertent consequences possible with the system no longer appear with such frequency. This may be a consequence of the ways inwhich the system inevitably standardises the information it the separation of files into medical and therapeutic holds. A case in point are the liberal use of amusing means that information which might normally be anagrams and abbreviations that one would find in the paper defeased across the two classes of entry is no longer records, for example, SEFN (Sub-normal Even for possible, since both fields have to be completed, and Norfolk), AWF (Away with the Fairies), and CTL (Close can only viewed independently. In consequence the to lay-lines - an area in Southern England where some of economies of intra-class defeasibility are removed by the more peculiar Churches have established centre). the system, as are the ways in which doctors cangenerate particular inferences by omitting or The system therefore removes the sorts of economy, including particular diagnostic or assessment items; gestalt, and tailorability which is critical to the productionand practical use of the paper records during the the separation of acute and chronic treatment files can also be significant. Whereas with the paper recordsdoctors could draw a range of inferences concerning These problems however are not simply the product of a the patient by glancing at the variety of treatments poorly designed system. Indeed, one can see that the that he or she is receiving, the separation of the acute system was designed to carefully reproduce properties of the and chronic treatment files means that this sort of paper record. It reproduces the classes and categories of inferential work is more difficult to achieve, since items within an entry which are ordinarily used on the traditional medical records. It builds in a certain economyto an entry, restricting the amount of free text and providing the limited diagnostic and assessment categories abbreviations for pre-specified diagnostic categories. It also which the practitioner is now constrained to use, provides an important distinction between treatment for coupled with the limitations on space allowed for chronic and acute troubles so that the general practitioner free text, forces the practitioner to actually nominate can differentiate the status of the various illnesses that a one of an admittedly large set of pre-specified patient might be suffering. However, the system diagnoses and precludes certain recurrent forms of understandably attempts to formalise the components which interclass defeasibility. It also undermines the were traditionally recorded, or retrievable from the record.
doctors’ ability to embed a certain ambivalence in the This rationalisation includes differentiating classes of object diagnosis or assessment of the complaint or to avoid and the necessity to document categories of items within a diagnosis in order, for example, to generate a more each class. The system attempts to clean up, or polish the reliable assessment on a future occasion. records, to make sure that each entry does indeed include theinformation that practitioners routinely expect to find and A number of further potential difficulties are also generated ordinarily rely upon in everyday professional practice. In so by the system. As suggested, the system pre-specifies a doing, the system also provides the possibility of providing certain series of moves for any activity, such as issuing a a more reliable database concerning diagnosis and treatment prescription, the doctor has to respond to system prompts which can be then used to inform research, policy decisions even when the specific categories are not appropriate. Since and even the allocation of financial resources. the system is largely used whilst the doctor issimultaneously interacting with the patient, then these In trying to improve the medical record however, the design preset response sequences can undermine the flexible and of the system ignores some of the practical reasons which .
account for the messy and apparently unsystematic character It should be added that there remains an ambivalence in of the original paper documents. In a sense, the design of General Practice as to whether the computerised record the system reflects a rigorous, but limited requirements constitutes a professional and legal report of the analysis. The relevant classes and categories have been consultation; some practitioners believing that a hand- identified, but the practices through which the document is written entry should still be made for each consultation. As written, read and used within the consultation have been one might expect however, attempting to maintain the largely ignored. By ignoring why the record is as it is, the paper records alongside the computerised system has not design has failed to recognise that the very consistencies proved particularly fruitful, in a sense the very existence of which have been identified, are themselves the products of the alternative document undermines the reliability of the systematic and socially organised practices. By ignoring original cards. In particular, general practitioners can not these practices, the design not only discounts the rely upon their colleagues turning to the paper document as indigenous rationality oriented to by the doctors themselves well as the computerised system, so that whilst they might in the producing and reading the records, but fails to document an array of potentially relevant information, it recognise that such practices are themselves inextricably may not necessarily be accessed. These problems are embedded in the day to day constraints of in situ medical exacerbated by the commitment to using the VAMP system work. This is not to suggest that doctors cannot change the to issue prescriptions and thereby log treatment details.
ways in which they produce and read records, indeed that is Doctors also do not necessarily enter treatment details on just what they are trying to do in using the system at the the patient record, so that intra-class defeasibility and the present time. Rather, it is to suggest that the troubles they gestalt of the traditional entry is not necessarily available.
encounter in using the system may themselves be a Sadly, therefore, despite attempting to preserve the consequence of attempting to introduce procedures which are traditional record in the face of the difficulties encountered insensitive to the local, practical constraints of professional by the system, the possibility that some information may to have documented undermines their potential usefulnessfor consultative practice. The VAMP system was developed and deployed at a timewhen there has been a growing emphasis within the United CONSEQUENCES FOR REQUIREMENTS AND
Kingdom in supporting an outstanding public service, the National Health Service, with private money. In Taking together the foregoing observations of the use of consequence the funding for VAMP and its deployment was medical record cards and the VAMP computer system not provided by the Government but rather, indirectly, by suggests some fairly basic requirements for new the pharmaceutical firms. The system was designed and technologies to support medical interactions. For example: deployed not only to serve general practitioners, but providea database, which VAMP could then sell, duly anonymised, the length of entries should be left to the writer and to pharmaceutical companies. Little needs to be said about the potential value for marketing drugs of a database whichdetails the diagnostic and prescribing practices of general diagnosis and treatment information should be practitioners throughout the United Kingdom. The design of the system therefore was subject to various practicalconstraints, only one of which was the day to day demands it should be possible to read an entry in relation to a of consultative medical practice. For various financial and bureaucratic reasons, it was important to formalise the dataheld on the patient medical record, in particular concerning the entries should be maintained in relation to a the nature of treatment currently being provided to patients.
potential course of a treatment i.e. in chronological It is certainly the case that the computerised record does order and it should be possible to read details of provide a more rigorous database, whether it is more chronic and acute treatment together.
reliable or accurate than the original document, especially inthe area of diagnosis, may be a moot point. Despite the Furthermore, the analyses of the use of both medical record system providing an important resource for more innovative cards and computer systems within medical consultations strategic marketing by the pharmaceutical companies, at (Greatbatch, et al., 1993; Heath, 1986) would suggest least as it is currently conceived, it fails to support the sorts some more fundamental properties that are required of a new of practical uses to which the information is put within the technology. First, the system should allow for the consultation. The practical demands which bore upon the collocation of reading and writing. Ideally reading and design of the system therefore, demands which were writing should not be spatially separated, as in the case extraneous to the practical, day to day, circumstances in with a standard keyboard and monitor. Instead, text should which the documents are used, perhaps undermined the be retrieved, entered and read in the same general location.
development and deployment of a useful and innovative Second, the technology should allow documents to be read at a glance and entries to be written with economicconciseness. Doctors need to be able to make a variety of One way in which a number of practitioners have attempted marks and annotations on the document and to enter to deal with some of the shortcomings of the computerised information at various levels of completeness. Third, the record is to continue to use the paper cards both to technology should allow for the records to be accessible document, and retrieve information, during the consultation.
whilst being used in relation to a variety of other activities, .
including the diagnosis, the physical examination, The foregoing analysis of the documenting of records may discussing issues with the patient and when prescribing suggest why some systems for bureaucratic work have been treatment. Therefore, records may have to read by the seen to be constraining’, ‘restrictive’ or ‘unusable’. The doctor when he is away from the desk, when he is on the practices surrounding the writing (and reading) of paper phone and when he is talking to the patient. Some idea of records provide for the defeasibility of items. The use of the mobility required can be gleaned from examining the the paper record can thus be sensitive to the contingencies use of the medical record cards. They can be propped up to facing both the reader and writer. This could have be viewed whilst the doctor is examining a patient, they can implications for the general development of systems, by be lifted off the desk to be read at an angle and the doctor pointing out how consequential to the activity-at-hand are can place a record on his knee and towards and away from the ways in which the information is ordered and where items are located. The design of particular interfaces couldthen be sensitive to: the visibility of entries so that items It could be possible to envisage a variety of technologies can be read alongside one another; to whether entries need to that could fulfil both these specific and general be complete so items can be defeasible, and to the range and requirements, for example, systems that preserve the constraints on items that can be entered so that information possibility of using paper documents in relation to can be recorded using a variety of marks and methods.
electronic ones or devices that project images of documents Needless to say, the consequences of such decisions go in a variety of orientations in a range of locations (e.g.
‘beyond the interface’ relying on flexible and open computer Newman and Wellner, 1992; Wellner, 1992) . However, architectures and, perhaps, transforming how records can be perhaps a more straightforward solution would be to adopt a mobile technology which maintains the general format ofthe medical record cards whilst augmenting these with In CSCW particular attention has focused on the various computational capabilities (cf. Luff, 1992).
development of flexible computer architectures and Utilising a stylus as the input device for the ‘notebook’ infrastructures to support different ways of collaboratively computer may also allow for the production and accessing (information, or computer) objects. These aim to support a range of capabilities from the simple exchange of possibility of preserving some of the distinctiveness of a objects, through the sharing of objects and to common colleague’s handwriting. It may also be possible, in the views of the same object. However, when considering even design, to preserve some of the geographical features of the the case of the simple record card, this range appears to be paper medical cards, for example, the ‘open area’ for unduly limited. This may be due to the rather static recording entries and the ability to locate one item close to conception of the object that pervades most current CSCW another, independent of class or type. The principal focus platforms. The practices which support the writing and of the technology, therefore, would not be on trying to reading of the paper record cards relies on a complex maintain a formally consistent document for various interrelationship between the items in an entry, the entries bureaucratic and financial purposes, but rather to give and the collection as a whole. This relationship is more doctors greater ecological flexibility and the freedom to than a simple hierarchy leading from the single component adapt their use of documents to the varying circumstances through to the record as a whole. It also relies on more and contingencies that arise as they conduct verbal and than just providing more ‘links’ between items and entries, physical examinations and prescribe treatment. as in some complex hypertext system. The entries on thepaper record card, are tightly interweaved, they rely on a It may be that some of these requirements apply to similar certain ambivalence to the recording of categories, particular domains where co-participants interact and collaborate over vaguenesses in the entries and flexibility in the type of documents, for example, other service enquiries and advice components which are entered. This flexibility is required giving activities. However, this study could have more so that readers can read the record ‘as a whole’ and ‘at a broad implications for the design of more wide-ranging glance’. Formalising and categorising records, required for systems. It has been frequently noted how computer financial and bureaucratic purposes not only places systems appear to constrain the ways individuals carry out additional demands on the users of systems which are activities previously accomplished by other means. Indeed, designed to satisfy these requirements, but also on any Landauer (1995) has recently questioned whether the designer considering more sensitive support for individuals increased use of computers over the past 25 years, having to accomplish such record keeping activities (cf.
particularly for office work, can be shown to have actually Bentley and Dourish, 1995; Goguen, 1994; Jirotka, resulted in any significant improvement in productivity.
He points to the ‘usability’ of computer systems as thecritical factor in impeding their effectiveness. Others have The practices surrounding the writing of a paper record are offered more detailed analysis, revealing how new sensitive to the ways in which colleagues, at other times, technologies can be seen to constrain the ways in which will read the records. These practices then have certain work is organised, stipulating, for example, pre-defined parallels to particular uses of systems designed to support orderings of activities and restricting the flexibility by ‘asynchronous’ collaborative work. The utility of such which these can be achieved (e.g. Bowers and Button, 1995; systems has often been accounted for by their capability to Button and Harper, 1993; Suchman, 1993a). provide information to colleagues who may either beremote or may require information at some other time. Theuses of the medical record card reveal how individuals can .
also be sensitive to the potential circumstances in which a collaborative. Particular features of this social organisation reader may have to read that record, they preserve a certain can be revealed by paying close attention to the nature of economy of description, and are designed with respect to the texts produced in the course of everyday activity. This may professional competencies of the reader. The range of ways suggest a reconsideration of how not only how ‘writers’, in which records can be flexibly assembled to facilitate readers’ or ‘users’ of such documents may be considered, but reading may not only provide for particular options for also how ‘documents’, ‘records’ and ‘objects’ are conceived interface design, but may reveal why contributing to of within CSCW and system design. The shortcomings groupware systems can be problematic. For shared with the VAMP system appear to derive from the ways in databases and the like to be more than repositories or which 'use', 'user' and ‘record’ are embodied in its design.
archives, and for contributions to be appropriate for some The use of the medical records is an essential part of the practical purpose by colleagues and co-participants, the successful accomplishment of the consultation. Indeed entries have to be tailored for the demands, or ‘designed’ for given it is a critical aspect of diagnostic and prognostic their recipients and sensitive to their circumstances. The activity, it has does not appear to have been given the case of the medical record card reveals how in one domain primacy in the design that it deserves. Rather, the this work can be done. It relies on a set of practices document has been conceived primarily as presenting a produced and recognised by both writers and readers. One retrospective version of events rather then an essential challenge for designers of ‘asynchronous CSCW systems’ resource in the production of the consultation. The 'user', would be to provide capabilities which allow for individuals the general practitioner, has been conceived as a rule to both flexibly design their contributions and to facilitate 'follower', a 'judgmental dope', rather than an active, their reading. The layout, ordering and appearance of entries reasoning and situationally sensitive participant in the on a simple paper medical record - its geography, and the production and use of the document. In consequence, the practices underpinning its organisation - might suggest doctors’ practical reasoning, their flexible use of the features, at least at the interface, which may be useful to document in day to day circumstances and the whole array of competencies and skills that they rely upon, were largelytreated as epiphenomenal in the system's design. As a D I S C U S S I O N
consequence, whilst the system appears to have provided a In the case of VAMP, choices in the design, particularly in more accurate and reliable record for extraneous and the ways in which information can be categorised, appear to bureaucratic purposes, it has failed to enrich medical have constrained the flexible ways in which professionals practice, and the use of the paper records persists. To could both enter and examine their records. Attention has reverse the title of Garfinkel's (1967) famous paper on the recently focused on the practices surrounding documents in apparent inconsistencies in clinical records, in the case at similar domains and revealed that, despite the specification hand we find perhaps 'bad' organisational reasons, for 'good' of formal procedures for completion, which items are entered and how these are classified can be subject to a greatrange of variation (e.g. Bowker and Star, 1994). This has REFERENCES
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