Health and Social Care - Related Papers
Policy issues
Complexity and Contradiction in IT Policy: The Case of the NHS National Programme for IT. Justin Keen
This chapter looks at the unintended consequences of a huge technology-based modernization project; the NHS National Programme for Information Technology in England. The project was envisaged by policy-makers in the Department of Health as a major rationalization of the NHS, gathering together all patient information in a single record for every citizen, accessible to health practitioners from across a range of services. But the NHS is a collection of organizations with a troubled history of failed information technology projects and a complex legacy of multiple systems for specific tasks, operating in parallel. There are also successes in some areas, where important links between systems have been developed and fostered over many years. Modernization plans introduced in the 1990s ignored these previous on-the-ground efforts, with policy-makers taking a fatalist view of the ad-hoc untidy nature of existing arrangements and the lack of integration between systems. Policies were aimed at ‘tying down the future’ with a new ‘gold standard’ of a centralised, integrated system which would radically simplify the organization of health information. Yet seven years after its conception, and a huge outlay of resources, the project remains only partially implemented and appears to have introduced additional complexity and uncertainty to the NHS information environment. A national ‘spine’ of basic information about citizens exists, but none of the stakeholders seem to know what kinds of patient information should be attached to it. The future is more uncertain than ever, as policy-makers continue to devote resources to the project, seemingly playing for time as they wait for an appropriate problem to fit the technological solution they have bought into.
Keen, J. (2009). Complexity and Contradiction: the case of the NHS National Programme for IT. In: C Hood and H Margetts (eds) Paradoxes of Modernization. Oxford University Press.Is an IT strategy possible? - or, will myths strangle our best efforts?. Justin Keen.
This paper argues that IT has a special quality in health care – myths cling to it. A myth, here, is a belief that suits certain interests. It is important that the belief is not scrutinised, precisely because the essential quality of a myth is precisely that there is nothing to back it up. The myths in IT in health care include: IT will save organisations money; IT will enable joined-up government; IT will improve patient safety; and IT will transform health care. The existence of myths would not matter if they could be stripped away during the policy making process. It is clear from policy documents in many countries, however, that the policies rest squarely on myths rather than evidence. The myths are identified, and the reasons why they persist discussed.
Keen, J. (2007). Is an IT strategy possible? - or, will myths strangle our best efforts? In: Healthcare Computing.Medical records
Implementing an HIS project: everyday features and practicalities of NHS project work - Dave Martin, John Mariani and Mark Rouncefield
This article considers some of the everyday practicalities of delivering an electronic health record project within an NHS hospital trust. Using ethnographic, observational data we document how and in what ways the orderly character of project work is achieved against a background of battles and negotiations to deliver the project within and despite various organizational contingencies and constraints.
Martin, D., Mariani, J. & Rouncefield, M. (2004). Implementing an HIS project: everyday features and practicalities of NHS project work. Health Informatics Journal, 10 (4). pp. 303-313.
Implementing an EPR Project: Some Everyday Features of NHS Project Work - John Mariani, Dave Martin, Mark Rouncefield, Mark Hartswood, Rob Procter, Roger Slack
This paper considers some of the everyday practicalities of delivering an electronic health record project within an NHS Hospital Trust. Using ethnographic, observational, data we document how and in what ways the orderly character of project work is achieved against a background of battles and negotiations to deliver the project within and despite various organisational contingencies and constraints.
Who and what are electronic patient records for? An ethnomethodological ethnography of system deployment in the NHS - David Martin
This paper reports on an ethnomethodological ethnography of a project to implement an electronic patient records (EPR) system in an NHS Trust in the North of England. The paper provides an introduction and reflection on the use of ethnographic studies for the purposes of computer system design and deployment through a discussion of the study. However, the paper also makes an more unusual turn for such work in computing by discussing the political import of the study, particularly focusing on policies related to accountability and governance and their impact on producing useful and workable EPR systems to support medical and care work.
Martin, D. (2006). Who and what are electronic patient records for? An ethnomethdological ethnography of system deployment in the NHS.
‘Working The Contract’ - Dave Martin, Rob Procter, John Mariani and Mark Rouncefield
This paper presents data and analysis from a long term ethnographic study of the design and development of an electronic patient records system in a UK hospital Trust. The project is a public private partnership (PPP) between the Trust and a US based software house (OurComp) contracted to supply, configure and support their customizable-off-the- shelf (COTS) healthcare information system in cooperation with an in-hospital project team. Given this contractual relationship for system delivery and support (increasingly common, and ‘standard’ in UK healthcare) we focus on the ways in which issues to do with the ‘contract’ enter into and impinge on everyday design and deployment work as part of the process of delivering dependable systems.
Martin, D., Procter, R., Mariani, J., & Rouncefield, M. (2007). Working the Contract. In: Conference of the computer-human interaction special interest group (CHISIG) of Australia on Computer-human interaction: design: activities, artifacts and environments. Adelaide.
Timing in the Art of Integration: ‘That’s How The Bastille Got Stormed’ - David Martin, Mark Rouncefield, Jacki O’Neill, Mark Hartswood, Dave Randall
This paper uses a long term ethnographic study of the design and implementation of an electronic patient records (EPR) system in a UK hospital Trust to consider issues arising in the multi-faceted process of integration when a customizable-off-the-shelf (COTS) system is configured and deployed in a complex setting. The process involves trying to artfully work out how disparate technologies integrate with existing and evolving patterns of work within developing regulatory requirements. We conclude by suggesting ways in which ethnographic interventions and user involvement may be timed and targeted to aid in achieving this process.
Clinical Narrative and Clinical Organisation: Properties of Radiology Reports - John Rooksby, Stephen Kay
Radiology reports, as a form of clinical narrative, are more than a repository of patient information but are active in patient care. They are not unique and individual to each patient but have structured content suitable for supporting the activities of care. We consider these activities of care and how they manifest in the report. This recognition of the infusion of clinical organisation in clinical narrative leads to the recognition of seven properties of radiology reports: labels, concepts, genre, structure, author, subject, reader. These properties exist across two relationships: the intertextual relationship between radiology reports and the interpersonal relationship between a radiology report and people.
Information provision
‘You’ve got to take them seriously’: meeting information needs in mental healthcare - Karen Clarke, John Rooksby and Mark Rouncefield
In this article we explore the practical aspects of providing mental health information over the telephone, and discuss how this may be used to inform the creation of a website. We draw from an ethnographic study of an ‘information and listening helpline’. By paying close attention to how the helpline operators ‘take seriously’ their callers’ problems and requests – indeed, by taking the work of the phone operators seriously – we show that the operators artfully talk, categorize and translate to help the individual caller and to satisfy organizational demands. A website is seen by the helpline in question as a logical move to providing accessible information to a wider audience. Whilst a web-based and phone-based service might both appear to function along similar lines for providing information, we question how a web-based system might afford or complement the kinds of services that can be done over the telephone.
Clarke, K., Rooksby, J., & Rouncefield, M. (2007). “You”ve got to take them seriouslyʼ: meeting information needs in mental healthcare. Health Informatics Journal, 13(1), 37-45.
Healthcare information giving services: technologies and everyday practicalities - Karen Clarke, John Rooksby, Mark Rouncefield, Rob Procter and Roger Slack
This paper presents findings from observational studies of work practice in two ‘information giving’ services – a poisons information service and a mental health helpline – as a precursor to informing the design of such services. Our work high- lights the interactions that constitute the requesting and giving of information and the role of intermediaries in the delivery of recipient-designed information. We propose a shift of focus from the logic of information in system design to one that encompasses the practicalities of information giving.
Clarke, K., Rooksby, J., Rouncefield, M., Rob, P., & Slack, R. (2004). Healthcare Information Giving Services: Technologies and Everyday Practicalities. Health Informatics Journal, 12(2), 153-164.
Patient Reports as Stories of Clinical Work: Narrative and Work in Neuro Radiology - J Rooksby, S Kay
Radiology reports recount a patient condition but also represent and influence clinical work. This paper describes the connections between the radiology report and clinical work and considers the implications for computerisation. A story representation is described that allows consideration of the radiology report as an active unit of narrative rather than a passive collection of data. This paper draws upon the results of a qualitative study of a Neuro Radiology department.
Social care
Software Co-design with Older People - G. Dewsbury, I. Sommerville, P. Bagnall, M. Rouncefield and V. Onditi
In a world that is orientated towards the healthy and the younger person, designers have been reticent to design inclusively. This is beginning to change due to the overwhelming evidence that older people are likely to be a considerably larger proportion of the population by the year 2020. The notion of ‘inclusive design’ emphasises the importance of social, human factors in system use. Designers should recognise that solutions devised on the basis of inappropriate investigative strategies and techniques can be debilitating and dis-empowering (Lebbon et al., 2003). Consequently, when considering technology design for older people, traditional technological approaches need to be complemented by detailed investigations into everyday life and user needs, involving the users themselves in the process of investigation and requirements specification as a feature of co- development or 'co-realisation' (Hartswood et al., 2002). Current practice still considers older or disabled people as specific groups set apart from the norm of society for which special demands are placed on the designer in order to produce one-off designs. This paper reports on the development of a person-centred approach to developing a communications and virtual games platform for older people to use in their own homes. We initially consider the methods and research process used in determining people’s needs and aspirations, and consider our adoption of cultural probes as a facilitator in this exposition. The paper reflects on the implications of the design in relation to inclusivity and demonstrates that the approach adopted by the research team considered the participants from a person- centred perspective.
The anti-social model of disability - Guy Dewsbury, Karen Clarke, Dave Randall, Mark Rouncefield & Ian Sommerville
Social theories are usually developed to enable a clearer understanding of a situation or problem. The ‘Social Model’ in various forms is currently the dominant model for researching disability, addressing disability from within a socio-political framework that draws substantially on a ‘social constructionist’ perspective. This article critiques some of the core sociological assumptions of the Social Model, questioning what ‘work’ this kind of theory does in informing a set of practical concerns around the design of assistive technologies, suggesting an alternative framework of analysis, supported by extensive ethnomethodologically informed ethnographic research
Towards a practical framework for managing the risks of selecting technology to support independent living - Andrew Monk, Kate Hone,Lorna Lines, Alan Dowdall, Gordon Baxter, Mark Blythe and Peter Wright
Information and communication technology applications can help increase the independence and quality of life of older people, or people with disabilities who live in their own homes. A risk management framework is proposed to assist in selecting applications that match the needs and wishes of particular individuals.
Risk comprises two components: the likelihood of the occurrence of harm and the consequences of that harm. In the home, the social and psychological harms are as important as the physical ones. The importance of the harm (e.g., injury) is conditioned by its consequences (e.g., distress, costly medical treatment). We identify six generic types of harm (including dependency, loneliness, fear and debt) and four generic consequences (including distress and loss of confidence in ability to live independently). The resultant client- centred framework offers a systematic basis for selecting and evaluating technology for independent living.
A Technique For The Client-Centred Evaluation Of Electronic Assistive Technology - Gordon Baxter and Andrew Monk
Electronic Assistive Technology (EAT) provides assistance and assurance for an increasing number of elderly and disabled people who wish to live independently. The technique described here aims to optimise the use of EAT by ensuring that it impedes as few aspects of everyday life as possible. The Post Installation Technique (PIT) is designed to be used by people with little technical or human factors knowledge to provide a client-centred evaluation of a recently installed EAT application. It systematically probes for aspects of their daily life that have been negatively affected by the technology. These problems are prioritised and passed to the EAT service provider so that it can be better tailored to client's needs.
This paper describes the development of the PIT through application in two small field studies and an expert evaluation.
Incident reporting
Sharing Incident Reports in Anaesthesia - Sangeeta Sharma and John Rooksby
Critical incident reports are stories of adverse events, used for learning and improvement of practice. There is a strong reporting culture in anaesthesia, where reports are usually encouraged and seen as a positive part of ensuring and improving safety. Reports are collected by an audit manager, and are discussed at regular meetings. Reports from one hospital can often be relevant to another, but they are not usually shared. To address this issue we have created a web-based system for sharing reports. Participative design methods were used to involve anaesthetists from six different departments in the design of the system. Four central requirements for the system were recognised: integration with existing practice, integration with existing reporting systems, support of educational value, and maintenance of trust. This paper discusses those requirements and describes how they are addressed by the system.
Rooksby, J. & Sharma, S. (2005). Sharing incident reports in anaesthesia.
Incident reporting schemes and the need for a good story - J. Rooksby, R.M. Gerry, A.F. Smith
Incident reporting is a central strategy for improving safety in the NHS (UK National Health Service). In this paper we discuss incident reporting in anaesthesia. We discuss four schemes for reporting: longstanding, departmental based schemes; newer, hospital wide schemes; a national scheme; and an inter-departmental scheme (developed by the authors). We also discuss an example report. We argue that this example report gives an expert ‘story’ of an incident, describing the incident in a way that is useful for the practical activities of maintaining and improving safety. We argue that stories are told and retold in reporting schemes. The reporting schemes are not just there to collect data but to afford the stories of what went wrong. In turn these schemes must be afforded stories by the anaesthetists, safety managers and the organisation at large. We consider how schemes can be designed to afford a ‘good’ story, one that is useful for the maintaining and improvement of safety.
Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia - S. Sharma, A. F. Smith, J. Rooksby and B. Gerry
In this qualitative study using observation and interviews, 10 anaesthetists from five Departments of Anaesthesia in the North-West region of England were enlisted to participate in the design of an online system to allow the sharing of critical incidents. Respondents perceived that existing schemes had differing and sometimes conflicting aims. Reporting was used for reasons other than simply logging incidents in the interests of promoting patient safety. No existing scheme allowed the lessons learned from incidents to be shared between members of the professional group from which they arose. Using participants’ suggestions, we designed a simple, secure, anonymous system favouring free-text description, intended to enable the on-line sharing and discussion of selected incidents. Seven incidents were posted during the 6-month pilot period. The practitioners in our study valued the opportunity to share and discuss educational incidents ‘horizontally’ within their community of practice. We suggest that large-scale reporting systems either incorporate such a function or allow other systems that permit such sharing to co-exist.
Sharma, S., Smith, A.F., Rooksby, J. & Gerry, R. (2006). Involving Users in the Design of a System for Sharing Lessons from Adverse Incidents in Anaesthesia. Anaesthesia, 2006; 61: 350-354
'Dasein of the Times': Temporal Features of Dependability - Karen Clarke, John Hughes, Dave Martin, Mark Rouncefield, Alexander Voß, Rob Procter, Roger Slack, Mark Hartswood
This paper is a modified version of a chapter in the PA2 ‘Trustbook’ (Clarke et al. Forthcoming) that uses our ethnographic studies of everyday work to illustrate sociological approaches to explicating some temporal features of dependability.
Clarke, K., Martin, D., Rouncefield, M., Hughes, J., Voß, A., Procter, R., Slack, R. & Hartswood, M. (2005). Dasein of the times : temporal features of dependability. In: 5th Annual DIRC Research Conference.
Using cognitive task analysis to facilitate the integration of decision support systems into the neonatal intensive care unit - Gordon D. Baxter, Andrew F. Monk, Kenneth Tan, Peter R.F. Dear, and Simon J. Newell
New medical systems may be rejected by staff because they do not integrate with local practice. An expert system, FLORENCE, is being developed to help staff in a neonatal intensive care unit (NICU) make decisions about ventilator settings when treating babies with Respiratory Distress Syndrome. For FLORENCE to succeed it must be clinically useful and acceptable to staff in the context of local work practices. The aim of this work was to identify those contextual factors that would affect FLORENCE’s success.
Baxter, G.D., Monk, A.F., Tan, K., Dear, P.R.F., & Newell, S.J. (2005). Using Cognitive Task Analysis to facilitate the integration of decision support systems into the neonatal intensive care unit. Artificial Intelligence in Medicine, 35, 3, 243-257.
A technique for the client-centred evaluation of electronic assistive technology - Gordon Baxter and Andrew Monk
Electronic Assistive Technology (EAT) provides assistance and assurance
for an increasing number of elderly and disabled people who wish to live
independently. The technique described here aims to optimise the use of
EAT by ensuring that it impedes as few aspects of everyday life as possible.
The Post Installation Technique (PIT) is designed to be used by people with
little technical or human factors knowledge to provide a client-centred
evaluation of a recently installed EAT application. It systematically probes
for aspects of their daily life that have been negatively affected by the
technology. These problems are prioritised and passed to the EAT service
provider so that it can be better tailored to client's needs.
This paper describes the development of the PIT through application in
two small field studies and an expert evaluation.
Baxter, G.D. and Monk, A.F. (2006). A technique for the client-centred evaluation of electronic assistive technology. In P. Bust (Ed.) Contemporary Ergonomics 2006. (pp. 236-240). London, UK: Taylor & Francis.