Patient care information systems and health care work: a sociotechnical approach
Introduction
‘Developing a comprehensive medical information system’, Morris Collen concluded in his historical survey of medical informatics in 1995, appears “a more complex task than putting a man on the moon had been” ([1] p. 464). Although we hear much more about successes, certain benefits and the need to implement patient care information systems (PCIS)1 in health care, the fact is that most applications to date have failed. Large numbers of systems never make it off the drawing table—and if they do, they do not appear to be transportable out of the specific context in which they were developed [1], [2], [3], [4], [5], [6], [7]. Although precise data are lacking, a general handbook on management information systems estimated that from the large systems that end up being used as much as 75% should be considered to be operating failures. They might be in operation, but they are too cumbersome, too expensive or too functionally deficient to be even remotely called a ‘success’ [8]. And in a recent overview of clinical data systems, Jeremy Wyatt mentions a staggering figure of 98% of software built for US government use that was ‘unusable as delivered’ [9].
Those who are facing the enormous difficulties of developing useful PCISs often stress the importance of ‘organizational issues’ [10], [11]. Building upon recent sociological insights in the construction and use of information technologies for (health care) work, this paper underscores the importance of these insights for the development and evaluation of these systems.2 A ‘sociotechnical approach’ to PCISs in health care will be outlined. After introducing the central starting points of this empirically grounded approach (Section 2), two implications of this approach for the practices of developing and evaluating IT applications in health care organizations are outlined (Section 3). First, getting such technologies to work in established practices appears to be a politically textured process of organizational change, in which users have to be put center stage. This requires an iterative approach, in which the distinctions between ‘analysis’, ‘design’, ‘implementation’ and ‘evaluation’ blur. Second, a sociotechnical approach sheds new light on the potential roles of IT applications in health care practices. It is critical of approaches that denounce the ‘messy’ and ‘ad hoc’ nature of health care work, and that attempt to structure this work through the formal, standardized and ‘rational’ nature of IT systems. Optimal utilization of IT applications, it is argued, is dependent on the meticulous interrelation of the system’s functioning with the skilled and pragmatically oriented work of health care professionals. These implications will and cannot take the form of ‘formulas’ for successful system development. Rather, the sociotechnical approach is inherently critical of overly methodical ‘guidelines’ promising success. The implications this paper will sketch are intended to reorient the way we tend to investigate and manage these processes. It attempts to offer new perspectives rather than a list of ‘critical success factors’; it engages in constructive critique rather than in delivering yet another set of guidelines for design and implementation. This does not mean that the sociotechnical approach is ‘philosophical’ or merely academically, research oriented. To the contrary: we claim that for a successful management and realization of concrete development processes, such an approach will ultimately prove to be more useful.
Section snippets
The sociotechnical approach: starting points
Some 20 years ago, the term ‘sociotechnical system design’ was used to indicate design approaches that stressed the importance of job satisfaction, workers’ needs, and skill enhancement [12], [13], [14]. These approaches put people and their working relationships center stage and formed a long-needed antidote to the technology-centered and top–down approaches that dominated system development. In current times, the term has drifted from this direct focus on workers’ emancipation. Embracing a
Implications of a sociotechnical approach
Adoption of a sociotechnical approach has implications for a range of issues within the development and evaluation of IT applications in work practices. It changes the way we think about the very concept of medical information [55], [70], [71], it transforms our view of the way IT is embedded within organizations [72], [73] and it problematizes any suggestions of a ‘formula’ for successful system development [3], [11], [37]. It is impossible to do justice to all these implications in the scope
Conclusion
The sociotechnical approach cannot be seen as a simple ‘solution’ to the many problems haunting PCIS development. It does not automatically yield a list of superior system requirements, nor does it answer the everyday problems of a manager in charge of an implementation project. The approach raises several issues that have no easy answers: how to find the optimal form for the iterative development process in an environment full of economic pressures for ‘fast results’, divergent interests, and
Acknowledgements
I would like to thank Emilie Gomart, Els Goorman and Berti Zwetsloot for the inspiration and comments that led to this paper. This research has been made possible by a grant from the Netherlands Organization for Scientific Research (NWO).
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